MOH Budget Speech 2005 (Part 3)

09 Mar 2005

By Dr Balaji Sadasivan, Senior Minister Of State For Information, Communications And The Arts and Health

Venue: Parliament

Speech By Dr Balaji Sadasivan, Senior Minister Of State For Health

Sir, I would like to thank the honorable members Mdm Halimah, Dr Tan Sze Wee, Dr Chong Weng Chiew and Dr Lily Neo for their comments. Mdm Halimah and Dr Tan asked about the medical manpower situation.

Manpower Planning

Manpower planning in healthcare is not an exact science. We recently announced that there will be a second medical school. This school will take 25 students in its first batch in 2007. They will be housemen in 2011. They would finish their advanced training around 2017. They would become specialist consultants around 2020; that is, about 15 years from now. Likewise, the number of doctors and specialist we have today was influenced by the admission policies of the last 30 years. Fortunately the number of doctors is not solely dependent on rigid manpower planning. This is because a significant number of Singaporeans study Medicine abroad and a number of them return home to work. We also take in foreign doctors who have augmented our numbers. But we also have Singaporean doctors who leave to work abroad in the US, UK or Hong Kong. They reduce the local supply but they are an asset to Singapore because they form a Singapore network around the world that we can link up with. Just as Singapore hospitals recruit foreign doctors, foreign countries try to recruit our doctors. Some time ago, there was a team from UK which visited Singapore. It was led by a distinguished surgeon and they were trying to recruit surgeons for the NHS. Two years ago, three of my former neurosurgical trainees who became consultant neurosurgeons were offered salaries of US$500,000 each, tax-free, to work in an oil-rich country. They turned down the offer.

Global Market

Today there is a global market for skilled medical manpower. Our healthcare system works within this market. The global market helps us import doctors in the areas where there is a shortage and allows our doctors to work abroad if there is a temporary oversupply in any specific area. In the same way, there is a global market for nurses and the health sciences professionals like physiotherapists and radiotherapists. Our nurses are targeted by foreign recruiters. I am told that the recruiters hand out leaflets to nurses at the bus-stops and MRT stations serving the public hospitals. The existence of a global market means that we have to pay globally-competitive wages if we are to hold on to our healthcare workers. But it also means we can meet shortfalls in our manpower requirement by recruiting foreign-trained workers.

The Contribution of Foreign Doctors

Of the 7,000 doctors registered by the SMC, about a fifth are foreign-trained. They have been a plus to our healthcare system. Let me give two examples of foreign-born foreign-trained doctors who have contributed to our healthcare system. Prof Abu Rauff and Dr K.C. Tan did not graduate from the local University. Prof Rauff was Chief of Surgery at NUS and was teacher to many of the top surgeons in practice today. Dr K.C. Tan is, of course, Singapore's liver transplant surgeon who saved both Ms Andrea D'Cruz and Mr. Suleiman when their livers failed.

No Discrimination

By welcoming talented foreign doctors, our healthcare system has been able to deliver better care to the public. There is no reason to discriminate against them. In answer to Dr Tan, there is no difference in the pay structure between foreign-trained and locally-trained doctors. The starting salary for medical officers is around $3,500 a month. Temporarily-registered doctors receive less because they have to be supervised. Those on temporary registration who perform well should eventually be given full registration.

Specialization - Creating Silos, Building Walls

In looking at medical manpower, we need to also consider the distribution of doctors between the various specialties. Specialization makes it difficult to redeploy medical manpower. The United States, which has a sophisticated training system, has 24 specialties and includes family medicine as one of the 24 specialties. Singapore has 35 and we exclude family medicine. Specialization creates silos with walls that prevent the movement of work or doctors across specialties. Even within specialties, doctors sub-specialise further and are reluctant to be deployed elsewhere within the specialty. This can create a relative over-supply or under-supply within the specialty. For example, since the number of deliveries in our public hospitals has dropped from an annual peak of about 40,000 to less than 20,000, the number of neonatal beds should be halved. Instead, the neonatal specialists tell me the number of beds remains the same and that they are working at 110%. When there were 40,000 births, the neonatal specialists had the modest goal of reaching a standard equal to that found in a good hospital in UK or Australia. Now, they want to be one of the top three centres in the world. With more than enough skilled manpower, relative to deliveries, they can set themselves this goal. The neonatal specialists are a dedicated and hardworking group, and they may achieve their goal. I am proud of their work. But this is an example of supply-induced demand. Since the supply of neonatal specialists has increased greatly in relation to the number of deliveries, they have set higher standards for themselves.

Mdm Cynthia Phua expressed concern about the high cost of drugs and diagnostic tests. The clusters buy in bulk and this has reduced the cost of medicines. With regard to radiological tests, there are many new diagnostic machines. In countries like the US, rules have been relaxed so that other specialists are allowed to own and operate these diagnostic machines. This is not yet the case in Singapore. Our regulations reduce the supply of specialists who are allowed to operate the machines to only radiologists. The cost of radiological investigations in Singapore is sometimes twice that of neighboring countries. This is not a problem restricted to the private hospitals. The MRI and CT scan charges at our restructured hospitals may, in some cases, be higher than the private sector. Patients bear this cost. MOH will study how to safely deregulate and introduce more supply and more competition so that the unit cost for radiological tests is brought down. This will benefit patients.

I have given these examples to show that market principles apply in healthcare and, at the same time, to show how supply can create its own demand.

Market Competition

For the market to work, our hospitals must have autonomy in making decisions on how they employ their doctors and what new services they wish to provide. So in answer to Dr Tan on the differences between the clusters: NHG and Singhealth do not have identical practices, because they have the autonomy to make their own management decisions and compete with each other. This gives patients choice and the competition between the two will lead to better service and lower costs. They have different manpower recruiting strategies and different plans for future expansion. The CEOs of the clusters, hospitals and polyclinics are on the ground and they are in the best position to make decisions. I believe MOH should not try and micromanage the polyclinics or hospitals.

Doctor-Patient Ratio

Madam Halimah wanted to know what the doctor patient ratio is - it was 1:720 in 2000. It is now 1:650. The second medical school will increase the supply of new doctors starting 7 years from now. At the same time, we are going to need more doctors as our population ages. So looking ahead, I think supply will match demand but even if the two did not match up exactly, any shortfalls or excesses will be evened out by the global market place in healthcare manpower.

Health Sciences Professionals

Madam Halimah asked about health sciences professionals. There has also been an increase in demand for health sciences professionals. Fortunately many Singaporeans trained abroad in these areas and fill these positions in our health system. Where Singaporeans cannot fill the positions, our hospitals have recruited from abroad.

Body-Part Specialist

Dr Lily Neo highlighted the problems of chronic diseases in the elderly. Looking after the chronic diseases of the elderly will become the biggest sector in healthcare. With our high healthcare standards, Singaporeans can look forward to living into their 80s and 90s. This is good news. But it also means many will develop one of 6 chronic diseases in their lifetime, namely - hypertension, diabetes, heart disease, stroke, cancer or dementia. We must therefore be able to manage these diseases better and in a holistic manner. Unfortunately many think that specialist care is better than the care of a GP or polyclinic doctor. Perhaps this is because of the word "specialist", which is derived from the word "special". So patients think they get ordinary care from a GP and special care from a specialist. This is not so. The "special" refers not to special care but to a special part of your body. The part of your body considered special is not really special - it could be your liver, or your lung or your colon or skin. It is considered "special" by the doctor because that is the usual part of the body he treats. So depending on the number of parts your body is divided into, you will need that many specialists to look after you. A specialist is therefore a body-part expert and not a whole-body expert. I have said there are 35 specialties in Singapore. If we exclude pediatrics and obstetrics, which I presume a man will not need, a man may need 33 specialists for his care. So that is why many patients in our hospitals end up seeing multiple doctors which costs them a great deal. Even then, sometimes things are missed because there will be gaps between the body parts covered by the specialists looking after the patient.

Holistic Care - Whole-Body Specialist

We need to educate the public that GPs, family physicians and polyclinic doctors are experts in looking after the whole body just as specialists are experts in looking after one part of the body.

The chronic sick often have multiple problems and they need holistic care. The polyclinics will be piloting specialist Family Clinics to look after chronic diseases. They will start with clinics that will look after hypertension and diabetes. They will announce the details when they are ready to roll out the service. If the pilot is successful, then GPs can be brought into the system to provide holistic care. We will study how best to model this scheme, possibly similar to the PCPS scheme, as suggested by Dr Lily Neo. Similarly, we can study how VWOs can be involved in chronic care as suggested by Dr. Chong.

The Role of the People Sector

Looking after the elderly requires a "many helping hands" approach. The grassroots can take the lead. If community groups need technical assistance with regard to healthcare issues in the setting up activity centres for the elderly, my Ministry will help. Perhaps this is a project that can be piloted at a constituency level in one constituency in order to see its feasibility. I agree with Dr Chong that VWOs can play an important part in looking after the chronic sick. Like MOH, VWOs can employ competent doctors to provide primary health care. But there is a difference between MOH and a VWO. The great strength of the VWO is that it is a people-driven organization, and that means it is an organization with a heart that beats in tune with the community.

Infectious Disease/AIDS Specialists

Both Dr Tan and Madam Halimah have asked about adequacy of infectious disease manpower. There are 18 infectious disease specialists of whom 15 are in the public sector. There are also over 70 trained public health specialists and 10 trainees in each specialty. Is this enough? Having more specialists is always better but I think our numbers are adequate.

The AIDS Epidemic

In November, I had forecast that the rate of increase of AIDS was such, that in 2004, we will cross the 300 mark in terms of new cases diagnosed. The final tally is in. Sadly, the total number of new cases for 2004 was 311. In 2003, the number of new cases was 242. This means there was a year-on-year increase of 28%. Currently 90% of these newly diagnosed patients are males, with 1/3 being gays. We had a low prevalence rate of HIV in the past, even in the gay community. We do not know the reasons for the sharp increase of HIV in the gay community. An epidemiologist has suggested that this may be linked to the annual predominantly gay party in Sentosa - the Nation Party -which allowed gays from high prevalence societies to fraternize with local gay men, seeding the infection in the local community. However, this is a hypothesis and more research needs to done. The reported new cases are only the tip of the ice-berg. In total, we have more than 2,000 HIV/AIDS patients. But for every AIDS patient we have diagnosed, there are possibly 2 to 4 undiagnosed patients with HIV in Singapore. That means there could be, anywhere between 4,000 to 8,000, undiagnosed HIV patients in Singapore. Last month, there was an alarming report from the US. The AIDS virus has mutated and the new virus is drug-resistant and kills quickly. Even those who are already HIV-positive can get infected by this strain.

Some Measures being Studied

We therefore have to make testing simpler for people at risk. MOH is currently studying the introduction of over-the-counter HIV test kits. These test kits are easy to use because they test the saliva. This will allow those at risk to test themselves. If those with HIV are diagnosed early, they could receive treatment early and hence minimise the development of complications.

Recently we made testing of HIV in pregnant mothers an opt-out option. This increased the overall screening rate from 37% to 77%. As a result of screening, in the last two months we have saved at least one child from getting infected. MOH is studying proposals to make testing of pregnant mothers compulsory so that we can achieve 100% screening.

Legislation on AIDS

Besides gays, the other major risk group are heterosexual men who have casual sex. In many cases, this puts the wife, at risk. Sir, in countries where the AIDS epidemic is full-blown, the majority of AIDS patients are women. This is because it is easier for the infection to move from man to woman than from woman to man. Currently, only 10% of AIDS patients in Singapore are women.

Sir, if we do not act to protect women, many women will get infected and we too will have a situation where women form the majority of AIDS patients. Do we want this to happen? There is a need to balance the right to confidentiality of the AIDS patient with the right to protect those at risk. The current legislation appears to be tilted in favour of the patient and exposes the spouse to the risk of catching AIDS. It also prevents the healthcare system from performing its public health duties. This is one reason why the AIDS epidemic is not coming under control. We need to treat AIDS like any other public health problem. We must give public health workers the tools needed to screen for the infection and contact-trace the infection.

There has been a reluctance to deal pro-actively with AIDS because of the fear that the AIDS patient will be discriminated. Hence many measures were put in place which hindered efforts to diagnose HIV. But if the HIV patient is not diagnosed and even the person who is HIV-positive does not know he has HIV, how can we effectively stop the transmission of the disease? We need to de-stigmatise testing and at the same time we must prevent discrimination against AIDS patients. Those who test positive for HIV should lead normal lives in society. MOH will consult with the public and stakeholders before proposing any legislative changes.

Block Budgets and Clinical Care

Finally, there was some fear expressed by Dr Tan over the block budget affecting clinical services. Minister Khaw has outlined to this House our approach towards Block Budgeting. There is no perfect health system. The health administrator has to work in a market-based system and is forced to be as efficient as he can. At the same time, the block budget ensures that the overall growth of the healthcare sector is moderated so that healthcare remains affordable. For the doctor, he must do the best for his patient with the means available to him. He should do what is reasonable and correct in the provision of care to the patient. The standard of care we expect is that set by his peers. There will be some tension between the two - the doctor and the administrator. But this is a healthy tension as long as both realize that the other is also working for the benefit of the patient.