Commissioning private healthcare providers to care for public patients is controversial even in the best of times and I expect this commentary to elicit strong reactions. Perhaps controversy is a good thing; we do as a country, need to start thinking radically as the challenges we face are unprecedented and be ruthlessly pragmatic. The ideologies aside, Singaporean ‘subsidized’ patients are having their surgeries postponed and their care potentially compromised by the over-crowding in public hospitals. Is the situation desperate enough to consider what a decade ago would have been heresy?
I wanted to highlight in this commentary how stark the patient volume imbalances were and how we are far from optimizing as a system our entire healthcare workforce. Are we short of doctors? Probably. Are we doing the best we can with the doctors we have?
Published in ‘Today’ 14 Feb 2013: Is Singapore Really Short of Doctors?
Singapore’s healthcare system is creaking under the triple challenges of ageing, increase in chronic diseases and population growth. The National Population and Talent Division estimates the need for an additional 32,000 (a 70-per-cent increase from present) healthcare professional workforce numbers by 2030 to cater to the growing demands, while the Ministry of Health is building new hospitals in Jurong and Sengkang.
How do we measure up internationally? Singapore has 1.9 doctors per 1,000 population, which is the same as South Korea but lower than countries like Japan (2.2) or the United States (2.4). Yes, we have some catching up to do compared with other developed nations, but perhaps the more important question for the here and now is whether we are utilising our existing pool the best we can.
The chart shows the breakdown of cases for seven common surgeries by whether they are performed in a public or a private hospital. Superimposed on the bars are the proportions of specialists in the public and private sectors.
The data reveals the magnitude of the imbalance in our healthcare eco-system. Let us just take two examples from the chart.
In the public sector, 25 knee replacements were performed over an 11-month period for every orthopedic surgeon; in the private sector, it was only three. The public sector ophthalmologist performs on average over 234 cataract surgeries a year; her private sector counterpart? Only one third, or 80 cases.
SHORTEN THE WAIT
Deputy Prime Minister Tharman Shanmugaratnam declared two years ago that the private sector should be “taking on a share of the load to treat subsidized Singaporean patients”. While this has inched forward in primary care through the expansion of the Community Health Assist Scheme, efforts in specialist care have fallen woefully short.
This load-balancing is crucial to mitigate excessive waiting times and overstretched infrastructure in the public sector. It would be facetious to rebut by saying there is little waiting in the public sector for joint replacements, as the time freed up can improve care of other patients, such as those with hip fractures who can hopefully get into surgery within 24 hours of the fall as per international guidelines. Eye surgeons in the public sector reducing their commitments in cataract surgery can focus on research and teaching, as well as pay more attention to Singaporeans with complex eye diseases.
Why has this not happened? Amid the myriad calls to improve productivity, why have we not asked whether we can distribute workload throughout the entire healthcare eco-system to benefit Singaporeans?
Is it a question of administrative difficulties? Perhaps, but this answer is not good enough for the frustrated 80-year-old Singaporean waiting impatiently for surgery. We have a world-class public service and we should have every confidence that if political will is not lacking, it can be done.
Is it a function of money? Unlikely, as the Government has announced a doubling of the healthcare budget. I personally know also of at least two private specialist groups which have offered to treat subsidised patients for the same subsidies that the Restructured Hospitals receive from the Government.
What about the accusation that the private sector will “profiteer”? This boil down to trust, but surely private surgeons — at least some, if not all — can be trusted to do the right thing.
Many private surgeons were luminaries in the public sector — Dr Seow Kang Hong, a renowned orthopaedic surgeon, was deputy head in the Singapore General Hospital Department of Orthopaedics and Director of its Adult Reconstruction Service. Dr Chan Wing Kwong was formerly the head of the Refractive Surgery Service at the Singapore National Eye Centre. Furthermore, many private surgeons have assumed leadership roles in the political realm.
Can the issue be institutional inertia and turf issues? Let us put the welfare of Singaporeans at the forefront. We are struggling with an over-strained public healthcare system. Doctors in public hospitals are over-worked. Mr Tharman has exhorted: “We need all hands on deck.” What are we waiting for?
Dr Jeremy Lim has held senior executive positions in both the public and private healthcare sectors. He is writing a book on the Singapore health system. This is part of a series on health policies here.