Is Singapore short of doctors? ‘Today’ Commentary 14 Feb 2013

Workload between public and private sectors

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?

http://www.todayonline.com/commentary/singapore-really-short-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.

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4 comments

  1. Jeremy,

    Will these projected expenditures bear out?

    Singapore healthcare expenditure market to hit US$ 22.3b in 2018

    Healthcare workforce will also jump by 50%.

    According to Frost & Sullivan, the Singapore healthcare expenditure market was worth US$ 11.7 billion in 2012 and will grow to US$ 22.3 billion by 2018, which represents a CAGR of 11.4% from 2012 to 2018.

    The growth of Singapore healthcare market will also set the increment in healthcare workforce such as doctors, nurses, dentists, pharmacists and allied health professionals by 50%, that is, 20,000 by 2020.

    The Asia Pacific healthcare market was worth US$369.9 billion in 2012 and is expected to reach US$ 752 billion in 2018, growing at a Compound Annual Growth Rate (CAGR) of 12.8% while global growth rates continue at less than 6% during the same period.

    Rhenu Bhuller, Vice President, Healthcare, Asia Pacific, Frost & Sullivan said, “Healthcare expenditure continues to experience growth as rising patient demands for better healthcare will result in healthcare reforms in Asia Pacific. Increasing urbanization is accompanied with growing consumer awareness and an expanding middle class, progressively skewing population density. This all translates to an increased demand for improved healthcare services.”

    She continued, “The increasing life expectancy in the region will also result in more elderly requiring long-term care. Asia Pacific will consist of over 2.3 billion people above 65 years of age and the average percentage of people above 65 will rise from 9.8% in 2013 to 11% in 2018 across the region. 68.5% of people will be in the working age of 15-64 years.”

    APAC has traditionally been a laggard in implementing technology in healthcare and this trend will continue into 2013. The revenue forecast for Healthcare IT in Asia Pacific is looked to reach at a CAGR of 13.1% from 2012 to 2018.

    Large scale implementations will generate better returns on investment for both healthcare providers and technology vendors.

    The most formidable challenge is around interoperability arising from the lack of uniform standards, protocols, data definitions and data sharing laws across APAC countries. Budget constraints also hamper adoption

    K

    1. Hi Mr Kim Chin,
      Thank you for the comments.
      Some responses:
      1. Healthcare spending will most certainly increase and fairly steeply over the next decade for three main reasons: aging, increased population and higher expectations. This will be over and beyond the baseline inflation due to technology, rising wages etc. Success in ‘bending the cost curve’ will depend on the ability to transform the care delivery model and emphasize greater productivity through cutting out ‘waste’ (This includes not just errors and re-work but unnecessary work), role substitution, especially that of physicians, and prudently introducing and adopting technology. I feel the role of political leadership is under-estimated and the role of the political leadership in getting the population to embrace new models of care and breaking professional cartels which stifle innovation is often not appreciated. There is tremendous willingness at this stage to spend more on healthcare and I expect this to continue for a while until finances become a little tighter and the trade-offs between spending on healthcare versus putting money somewhere else become starker.

      2. Yes, healthcare is a technology laggard for the reasons you raise but this can be reversed fairly quickly if a. Society and governments become ‘desperate’ enough to try new things such as tele-health, b. There are skilled negotiators in-country who can bring the diverse stakeholders together and bang out win-win road maps including agreement on standards and inter-operability, c. Government is prepared to invest upfront in the infrastructure needed (not just hardware but regulations, business models etc). It will be hard work and very slow moving initially but like most tipping point technologies, uptake will be very rapid once adoption hits the inflexion point.

      3. What can industry and the private sector providers do? Since Asian governments have little experience or expertise, human capital development of clinicians, IT specialists, payers and regulators becomes crucial. I do wish countries far more advanced in say tele-health come forward and offer to share expertise through training people, conducting workshops and conferences etc. Industry can take the long view and support governments in thinking through the national frameworks and implementing them. There is money to be made further down the road. The private sector healthcare providers can and should cooperate with governments and agree to national standards, common IT platforms etc.

      Early days but I think reality will force action…

      Warm regards,

  2. Hi Jeremy, one thing that was previously looked into but not emphasied enough, in my opinion, is the training of new physicians. Private enterprises in Singapore do not fulfill such role traditionally, especially in certain subspecialites such as ICU medicine / surgery for example.

    Sure, the way we train medical students these days have changed with improved technology / simulation / diagnostic imaging, these however will not replace clinical experience which is linked to case load.

    Can the “cost” be quantified if the system fail to provide quality training of our physicians to ensure we always have a core population of top quality Singaporean clinicians?

    1. Hi Lim Kai,
      Very relevant points. My views: Difficult for the private sector to offer training in all specialties but really no issues for the private sector to be active in medical student and specialist training in partnership with the public sector (This is not that unusual as the LKC School of Medicine needs to partner with KKH for pediatrics and OG training). I was at a forum for the private sector hosted by Minister Gan and a senior cardiologist rightly pointed out that because there are many more foreign patients in the private sector, the private setting offers young trainees opportunities to learn about pathologies they would not see in the public sector. There are also many more acknowledged excellent clinical teachers in the private sector who had won many accolades whilst in the public sector; no reason why they cannot continue to be tapped upon to train up the next generation.
      I don’t think your specific question on cost of not training the next generation can be answered. Perhaps we are already paying the price today for failing to produce enough doctors and from what I hear, there are some concerns around whether the residency program is delivering the superior training it was hoped.

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