Healthcare issues: "No-Go Zone"

Several local health care issues were raised at a prior blog post. The truth of the matter (I am refraining from using the much-abused "hard truth") is that it is better if health care is not brought up as an election plank, beyond cheap soundbites about sending the former Health Minister to JB. It is a complex issue that is well beyond the scope of a 10-day campaign period.

The cost of health care will only go up in the next several years, no matter whether PAP sweeps the House or several GRC's fall to the opposition. This is because of an aging population, the advance of medical technology and influx of new, expensive drugs for chronic diseases and cancer. Keeping health care expenditure at 4% of GDP (note that the government's share is only about a third of this) is well-nigh impossible in the medium term, as health care costs outstrips GDP growth.

Some, including fellow bloggers at SingaporeMD, have argued that it is necessary for individuals to take greater personal responsibility for their own health. This is certainly a persuasive line of thought, and the government has never held back from promoting this point of view, election or no. The whole business of cost-sharing and "health care subsidies" is an attempt at avoiding moral hazard and indirectly driving home the point of personal responsibility. Yet in all fairness, we recognize that personal responsibility can only go so far. Catastrophic illness can occur even if one lives a life of moderation. For lower- (and perhaps even middle-) income families, circumstances prevent many from leading healthy lifestyles. The health care system is also not structured in a way that promotes health, i.e. focusing on primary and preventive medicine, even though efforts are underway to do so.

Catastrophic illness, as the term suggests, can be devastating not just for the patient, but also for his/her family. If one depends on the 3M's, one cannot avoid paying far more than $8 for any major operation or hospitalization. Private insurance plans are available that can cover hospitalization and even outpatient treatment costs, but these are less well advertised and perhaps the majority are still unaware that anything other than the 3M's are required - until it is too late to apply. Or perhaps the cost of the premiums is too much of a burden in addition to the other costs of living.

What policies can we adopt or tweak that can reduce the burden of chronic and/or catastrophic illnesses on the lower- and middle-income households? Without becoming a welfare state or raiding the reserves, that is?

Doctors and Politics III (Local)

Dr Tan Cheng Bock's and Dr Kanwaljit Soin's respective articles in 1999. Still worth a read. A similar point of view published in 2007 in the Hong Kong Medical Journal. We must wonder what Dr Tan and Dr Soin would make of the recent clumsy and divisive politicking by their medical colleague, Dr Balakrishnan, the ophthalmologist and current Minister for Community Development, Youth and Sports (Update: well, Dr Tan has made his views clear). Perhaps we can count it a small blessing that there were no other doctors on the Holland-Bukit Timah slate.

Healthcare issues: Singapore general elections

It is interesting to observe the pre-election activities and exchanges that are taking place now. Are there any healthcare issues that might concern the small minority of the electorate that are interested/directly involved? Or the way the healthcare system is being (re)tweaked in Singapore? Here are a few possibilities that have been raised - please rebut or add:

1. Insufficient hospital beds - being belatedly addressed. "Slightly under-supply" being better than oversupply.
2. Medical tourism and its impact on healthcare costs and resources (and also the possibility of importing more infectious agents into our hospitals).
3. Cost of healthcare (Mr Leong Sze Hian is right on the money here). Means testing does not help to bring this down.
4. Shoving through the new residency training scheme with little consultation or discussion.
5. Private primary healthcare - more GPs becoming aesthetic doctors rather than dealing with an expanded scope of medical work like chronic diseases, etc.
6. Class system - do patients suffer only from reduced "hotel services"? Note that Prof Roy Chan carefully did not state whether subsidized patients with non-urgent skin conditions had to wait longer for an appointment compared to private patients.

On the other hand, there are more hospitals being built now (the next one will be up in 2014), the country still spends less than 5% of its GDP on healthcare, and the healthcare system ranked No. 6 in the world when last surveyed in 2000 by the WHO. And patients are seemingly more satisfied with the public healthcare system by the year.

Patient Satisfaction Surveys

The results of the 2010 patient satisfaction survey - performed by an independent survey company (not sure which one) - was published recently. Overall satisfaction with the public health sector remained high compared to previous years, although the larger hospitals (SGH, TTSH and NUH) play musical chairs for the bottom spot (SGH is "it" for 2010) regularly. The detailed scores for the service quality attributes (i.e. care coordination, skills of health professionals, care and concern shown, etc) are not published, but presumably dedicated teams at each hospital pore over these results in search of areas of improvement each year.

It is unclear what the results really mean, especially when the "flower hospital" (you have to click on the KTPH button on the banner at the top here) comes up tops. Well done, of course, when the former AH team duplicate their award-winning patient-pleasing ways in the new hospital. These surveys have gone on for a number of years, and a neutral and careful review of the pros and cons of such surveys in general can be found here (only the abstract). It is important to note that patients who are healthier tend to report higher satisfaction as opposed to those with improvements in health - a consideration for why tertiary hospitals tend to fare worse when placed in the same bracket as smaller secondary hospitals.

The other kind of surveys published by MOH are costs of procedures/hospitalizations for a fixed number of common clinical conditions. These may be useful for indirectly keeping costs down (or at least relative to the public sector standard) for the most part.

But surely it is time that we find out a bit more about technical quality? The data should be readily available for such reports by now. The US has had hospital rankings for ages. If I have breast cancer (touch wood), which center will provide me better and longer quality of life (hopefully without exotic and expensive chemotherapy)? If I need a knee implant, what are the infection rates at various hospitals? If I have leukemia (touch wood twice!), should I just go overseas for treatment? How likely am I to get unnecessary tests and treatment if I visit a public as opposed to private hospital (alright, data for this last question never gets collected or compared)? For a country that has one of the best reputations for healthcare in the region, such data are hard to find. But they can help drive competition in another important direction, i.e. by focusing on patient-centric clinical outcomes

Doctors and Politics II (Local)

Since the previous speculative post, the ruling party has completed introducing its new candidates for the upcoming election. Dr Tan Wu Meng and Dr Abdul Razakjr will not be fielded this time round. We may never know if this was a party decision or their individual decisions. Certainly, the response that Dr Janil Puthucheary received must have been an unpleasant surprise. He must have been perceived to be an ideal candidate in many ways: bright, young, articulate, a tireless doctor (who saves children's lives while teaching at Duke-NUS), a new citizen, the son of an estranged founder returning to the fold. Major miscalculation.

Well, there are other ways to serve for Dr Tan and Dr Razakjr. Neither will become too old by 2016.

World Health Day 2011

Yesterday marked World Health Day 2011.

The theme for this year is Antimicrobial Resistance: "no action today means no cure tomorrow".

The statement by Dr Margaret Chan (WHO Director-General) can be found here, while the WHO's policy recommendations are available for download or viewing here. In brief:

1. Commit to a comprehensive, financed national plan with accountability and civil society engagement.
2. Strengthen surveillance and laboratory capacity.
3. Ensure uninterrupted access to essential medicines of assured quality.
4. Regulate and promote rational use of medicines.
5. Enhance infection prevention and control.
6. Foster innovation and research & development for new tools.

Tan Tock Seng Hospital held an exhibition at its atrium from 5th April until today. The details - including an online pamphlet - are available here.

Donations for immortality

Yesterday's issue of the Straits Times carried an article reporting that Dr Tan Cheng Bock (former MP) had stepped down from the board of the upcoming Ng Teng Fong Hospital (formerly referred to as Jurong General Hospital) because he had moral issues with the idea that "a rich man could pay to have a public institution named after him".

I doubt most doctors/healthcare staff actually care enough - as long as they are paid on time - whether they are working at the Ng Teng Fong Hospital or the Middle-Earth Herbarium or the Dimwit Flathead Medical Center of Frobozz.

More to the point, this does not actually set precedence. Alexandra Hospital's replacement was named Khoo Teck Puat Hospital following a $125 million donation by the late tycoon's family, whereas the older local medical school was renamed the Yong Loo Lin School of Medicine (this is a particular mouthful) for a slightly less astronomical price of $100 million. Tan Tock Seng Hospital is also named after a man, but the circumstances were considerably different. He had contributed much more than just a once-off pay-out, as did Michael Bloomberg who has his family name on the John Hopkins Bloomberg School of Public Health (USD107 million in total donations over several years).

Should someone one day decide to contribute $150 million to any of the local hospitals/schools, will the current institutional names be replaced? That doesn't seem to speak very well of us, despite this creating sort of an incentive for huge public donations. Perhaps the practice should be reviewed and discontinued.