You CAN put a price on everything...

This news story made me smile:

Police to measure "the cost of crime"

SINGAPORE: In what will be the first study of its kind here, the Singapore Police Force (SPF) will commission an academic study to calculate the cost of the different types of crime committed here.

Modelled after a United Kingdom (UK) government research paper - The Economic and Social Costs of Crime - the study plans to use a "social cost approach" to measure the cost of crime in Singapore.

In response to Today's queries, police spokesperson Choo Hong Xian said the study "would provide valuable insights into operational policy-making, resource reallocation and police's strategies to deliver the mission".

The police release statistics on the overall crime situation here every six months but they relate usually to the number of cases, identifying key crime concerns and providing crime prevention advisories.

According to tender documents released last week, the study aims to derive the annual total cost of crime last year and "a preceding period stipulated" by the police. The final report from the study is expected to be delivered to the SPF within four months of the award of the tender, which closes on July 18.

Overall crime here fell by 0.6 per cent last year but the police highlighted three key crime concerns - cheating cases involving rental scams and phone scams, fighting youth crime and outrage of modesty cases.

The study aims to calculate the costs incurred as a consequence of crime, which includes "monetary loss in traditional terms" and "monetising the loss of life and trauma suffered by victims".

Costs of crime prevention and enforcement will also be tallied. The study seeks to find out costs borne by private entities - such as security expenditure and insurance - as well as costs borne by public bodies such as proactive police patrols in anticipation of crime.The police also intend to calculate the costs incurred in response to crime - investigating cases, apprehending suspects as well as the costs expended by the State in prosecuting, convicting and incarcerating suspects.

Several Members of Parliament had previously raised concerns over police resources being stretched. During the Committee of Supply debate in March, then-Home Affairs Minister K Shanmugam pointed out that while police resources will be increased, "they are not limitless".

While costs of crime prevention - such as installing alarm systems - and the State's response to crime could be measured, sociologist Paulin Straughan felt it might be "impossible" to measure the social costs of a spate of violence on a community. Social isolation and mistrust from these crimes would impact social capital on a community which would be difficult to estimate, she argued.

However, the former Nominated Member of Parliament felt calculating the cost of crime would serve as "a reality check" for any society.

"We live in a world that is driven by economics," Associate Professor Straughan said. "We can't understand or appreciate unless it is documented in dollars and cents. So, this is one way of documenting it (crime) in dollars and cents to show you that every burglary cost you this (amount) … and highlight the importance of crime prevention."

The UK study, published by its Home Office in 2000, found that crime in England and Wales cost society £60 billion (S$118.8 billion) a year, or more than £1,000 for every person.

Every murder cost the country an estimated £1.1 million, vehicle theft and robbery £4,800 and criminal damage £510 pounds, according to the Home Office report.

Assistant Professor Irene Ng Yue Hoong, who researches on youth crime and poverty at the National University of Singapore, felt any study on the costs of crime control should take into consideration the benefits from a decrease in crime.

"Do the marginal costs of crime control justify the marginal benefits from the marginal decrease in crime?" she wondered. "It will be interesting to study whether Singapore's crime control is at an optimal level in terms of the marginal benefits net of marginal costs."

As with healthcare and other valuable services, police work costs money; but as the cost is not borne by the user, the true cost is hidden and abuse occurs. Does this study by the SPF signal a desire on the part of the government to shift the cost of security from the public to the direct consumers? I certainly hope so. Now there will be people who will tell you that you cannot put a price on security (and health) - the truth is, you can: they just don't want to pay for it.

Scarlet fever, Hong Kong

For the past few days, an increasing number of Hong Kong children have been diagnosed with scarlet fever, with two deaths to date. The Hong Kong Centre for Health Prevention now posts daily updates here. So far, one kindergarten in Sha Tin district has been closed, while two other schools in Kowloon and Yuen Long districts have reported cases.

Scarlet fever is caused by Streptococcus pyogenes (or Group A streptococcus for those of you who remember the antiquated Lancefield groups), a bacterium that is better known in the media as the "flesh-eating bug" because it can rarely cause necrotizing fasciitis. Residents (got to get used to this word!) know it as the bug that most commonly causes cellulitis (although hardly ever cultured), while those going for medical clinical exams remember it best as the cause of rheumatic fever and rheumatic heart disease.

But on a more prosaic level, it is carried in the throats of about 10% of school-going children (some reports put this as high as 28%), where it doesn't generally cause any disease. S. pyogenes is spread via contact, and better hygiene will help prevent transmission (always difficult in young children hence more schools in HK will probably be closed).

Given the unusual virulence and scale of this outbreak, it is likely that we are seeing a novel clone of S. pyogenes, as was the case with the Escherichia coli causing the huge outbreak in Germany recently.

Restructured hospitals in online posts

There are probably many others, but I shall just focus on two today:

Alex Au blogged about the hospital bed crunch today, almost one year after his last post on this topic. His father, who apparently had a UTI, had to wait for four hours at the Emergency Department before being admitted. This is indeed a problem that is disturbing not only because it wasn't anticipated (or at least deemed not to matter), but because all the signs were present and the feedback available for the past several years. Restructured hospitals have become increasingly creative in dealing with this issue (mainly in terms of improving the time to actual care delivery and reducing the time where patients are stuck "in transit" in the ED observation rooms) - like NUH's aptly-titled "The Big Squeeze" - but the hospitals can only do so much with the limited number of beds relative to the growing population.

In the Temasek Review Emeritus, a Ms Serene XM Cai complained about the delays in her treatment at SGH, questioning whether she received 2nd class service because she was a B-class patient. Poor Dr Bok (her primary physician) must be wondering why he's suddenly notorious! But... I could not really find anything wrong with the way she was managed. She received an MRI within 24 hours of admission, and the ultrasound (TENS?) on the following day. How is that for speed of service in a public sector hospital for a subsidized patient?? Very few public hospitals worldwide can achieve this. Sure, Mt Alvernia specialists reached the diagnosis rapidly and prescribed treatment that was presumably successful, but then again, the last set of doctors patients see generally gets things right because of all that has gone on before. This is a case where the patient's expectations were much too high and they were perhaps not managed well.

GPs not "functioning"?

The subject of GPs doing aesthetics came up again recently when Dr Woffles Wu wrote a letter to the ST Forum, arguing that liposuction should only be done by specialists.

MOH replied today; while I have no opinion on whether GPs should be allowed to perform liposuction, the final paragraph of the letter disturbs me:

The ministry is in the process of strengthening our primary- care sector by enhancing the training of GPs so that more of them could function as family physicians. This will eventually help to improve our primary-care capability, especially in managing chronic diseases in our ageing population.

Now the 'problem' of GPs doing aesthetics has two parts to it: "why don't GPs do primary-care?" and "why do GPs do aesthetics"?

The answers to the two questions are largely related: to the first part it's because GPs do not see doing primary-care work as rewarding to them, and to the second part it's because they see doing aesthetics work as rewarding. However, it would be wrong to think that if we stopped them from doing aesthetics it will automatically mean that they will all turn to primary-care work, specifically to "managing chronic diseases in our ageing population". They can still make a living 'selling' MCs and 'lifestyle' medications (remember this?), or running a high-volume low-quality corporate contract practice, or doing "health screening", where "problems" are "diagnosed" but not treated (that's where the lucrative end of the business is, you see...).

In other words, 'GPs doing aesthetics' is not the root of the problem for 'GPs not doing primary-care', but a symptom. If you stop GPs from doing aesthetics, then they will likely find something else to 'do'. We can only hope that it's not something like Subutex...

So why don't GPs want to do primary-care then? Is it, as Dr Chern seems to suggest, that they don't know how to? That they need more "enhanced" training before they can even "function" as family physicians? Now bear in mind that we are talking about doctors who have invested the time and money into learning how to perform the various treatment modalities that aesthetics encompasses, not to mention the equipment cost. You do not wake up one morning and say to yourself: You know what? I think I'm going to do aesthetics today. Dr Chern tells us that to do liposuction, a GP has to "be accredited by the Accreditation Committee on Liposuction (ACL) and their medical clinics have to comply with specific licensing conditions". Are such people really incapable of functioning as family physicians?

Now even if that was true - let's just assume for argument's sake that a doctor who has gone through housemanship is not capable of functioning as a family physician (and they are not) - we have a situation where a new doctor has the choice between learning how to do aesthetics, and going through the "enhanced training" that allows him to function as a family physician. Which path do you think he will choose and why?

The bottom line here is that primary-care work, specifically the"managing chronic diseases in our ageing population" part, is not financially rewarding. Part of the problem lies with the fact that our healthcare system subsidises primary-care indiscriminately - you may not qualify for full subsidy under means testing in the wards, but you can still get full subsidy at the polyclinics, and be referred to a specialist as such, no questions asked. Such a situation distorts everyone's perception on what primary-care costs and is worth, and the result is what we are seeing today. (Ironically, SMA's effort in trying to encourage GPs to stay away from a high-volume low-quality care with the guidelines of fees was ruled anti-competitive.)

To a hammer, every problem is a nail. To a regulatory group, the solution to the problem is more regulations. The 'authorities', when presented to a problem, will always be tempted to 'do something'. Perhaps it's time MOH took a step back and looked at the economic realities that are present, and asked themselves whether their existing policies have made the practising of primary-care unattractive to GPs. If you can make it rewarding to them, the GPs will train themselves to become good family physicians (MOH don't provide enhanced training for GPs who want to do aesthetics, do they?); if you make it unrewarding to them, then why will they want to train to be a family physician at all?