Tuesday, January 13, 2009

Suggestions to improve specialist healthcare to subsidised patients

Hi friends,

I have written to the forum page with copy to Ministry of Health on how delivery of specialist healthcare for subsidised patients can be improved.
(It has been printed in one paper and MOH has also replied- see below)

Being from the private specialist sector, this letter is from that perspective. Some parts of the letter gets a bit "deep" and involved. I apologise for that.

Private specialists have taken flak ( and deservedly so) for being aloof and being far removed from the masses who are suffering and have difficulty in making ends meet.

Despite this, I feel that the Public (govt) and Private healthcare sectors can work together to better serve all Singaporeans.

Yes, there are many doctors ( not just in private sector) who may have forgotten their Hippocratic oath.

However, I do know many private specialists who have big hearts ( and I am proud to call them "friend" )and who treat poorer patients at reduced rates ( or even waive charges). Sometimes we put on leotards and become Robin Hoods.

We in private practice, often try to find ways to beat the Private hospital system in order to reduce patients' charges. The more obvious means include pleading with the hospital for discounts ( for patients) or even going to cheaper hospitals. Other ways cannot be divulged publicly.

Private specialists are human too- Most of us chose private practice for Work-Life Balance or just could not take the "office politics"anymore. Of course the money (usually) was not too bad also.

Dr. Lee Wei Ling has already mentioned some of the shameful acts of the Black Sheep of the profession. As a fellow doctor, I fully agree with what she has said ( on most things).


Dr.Huang Shoou Chyuan

The Letter to the Forum page ( cc MOH)

Dear editor,

Re:Enhancement of Public Private Partnership (PPP) in Singapore’s healthcare

I would like the Ministry of Health to consider expanding the partnership between the public and private healthcare to include specialist care in addition to primary healthcare (family medicine).

1.The present situation

From 1st January 2009, General Practitioners (GP) were roped in to see mainly needy elderly patients who were Community Medical Benefit (CMB) cardholders or Public Assistance (PA) scheme cardholders. This highly innovative scheme (called Primary Care Partnership Scheme- PCPS) is popular as it allows patients to be seen by their neighbourhood GP’s who receive similar or equivalent subvention from the government as when these patients go to the polyclinic. The patients co-pay either by cash or from the Medisave accounts (subject to caps).

Acute conditions (eg coughs and colds) and 3 chronic medical conditions viz.Diabetes Mellitus, Hypertension and Lipid disorders, are included in the PCPS.

Although Singapore’s healthcare has a well-deserved reputation for being of a high standard, there are gaps in the delivery of specialist care for subsidised patients. These are the patients referred by the polyclinics and (from Jan 2009) the PCPS-GP’s.

The main bugbear is the long waiting time to get an appointment at the government specialist clinics (eg SGH/NUH etc) which in turn translates to overworked specialist doctors who may not be able to provide optimal patient care.

2.My suggestion to plug the gaps in specialist care delivery

I advocate an expansion of the system to include private specialists and to expand the patient pool to include not just CMB and PA cardholders seen by PCPS-GP’s but also all polyclinic-referred patients.

These patients, when they have complicated conditions requiring specialised care, would have been referred to government hospitals where they will be seen by specialists.

However, when the specialist clinics have filled up all appointment slots and these patients cannot be seen by the recommended waiting time, my suggestion is that these patients be channelled to those private specialists who are willing to see them at subsidised rates.

For this to work, the government should ( as in PCPS) continue to pay similar or equivalent subvention ( with reasonable addition for different cost structure in private practice). This could even be made to work in private hospitals when these patients need surgery or other institutional care. Co-payment is as per the PCPS.

3.Benefits of PPP for specialist care

There are many benefits for considering this Public-Private-Partnership (PPP) for the whole chain of healthcare delivery in Singapore.

i.All patients (be they subsidised and non-subsidised) will get timely and optimal care from both primary care doctors or specialists.

ii.Specialists in government hospitals will have more time for teaching medical students and trainee specialists and for treating more sophisticated “tertiary-care” cases.

iii.There is no increased government spending as subvention remains almost similar. In fact less government hospitals may need to be built in the future.

iv.Allows private specialists to better participate in the treatment of all classes of Singaporeans. Believe it or not, most doctors (even private specialists) perceive Medicine as a calling and not as a way of “getting rich” .

For sure, all stakeholders in Singapore healthcare will need a paradigm shift in mindsets so that all ( esply needy Singaporeans) can benefit from this mini healthcare revolution.

Getting a pool of willing private doctors in each specialty and getting private hospitals to participate in the scheme should not be too difficult in view of the dire economic climate and the impending glut of private hospital beds in the near future.

Perhaps the government hospitals should remain gatekeepers and the system can be implemented in stages with close monitoring to prevent abuses.

Needless to say, private specialists who only want to cater to select class of patients need not apply.

Yours Sincerely,

Dr.Huang Shoou Chyuan

Addendum (14.1.09) 4.50pm: Reply from MOH

Dr. Huang:In essence, MOH ( or Alxxx who represents it ) said, " Ya, sure" but in 98 words!

So here goes ( for those who enjoy standard bureaucratic "cut and paste" answers).

I wonder if this letter even got past the first guy who read it? Am I just wasting my time and energy trying to write a succint and cogent piece about how the system can be improved?


Oh- BTW, one paper has printed the letter, one rejected it and one has not said anything (yet).

Reply from MOH (Reply - PQ-09-000116):

Dear Dr Huang,

We refer to your suggestion to include interested private specialists under the PCPS.

As you are aware, GPs are able to refer patients who require specialist care to the restructured hospitals' specialist outpatient clinics (SOCs) under the current PCPS.

Although there are no plans to involve the private specialists at this point in time, we are definitely open to explore such collaborations in the future when the need arises and we would hope to garner your support then.

Thank you for your suggestion.

Yours sincerely,

Alxxx Hx
for Quality Service Manager
Ministry of Health,


tony said...

"Sometimes we put on leotards and become Robin Hoods." Hilarious! But seriously,though, with the current crunch and bailouts, it seems to me that those in power are robbing the poor to pay the rich...

nofearSingapore said...

Hi tony,
Ya, they doing the opposite of what we do, ie "rob the rich to pay the poor", but please keep these comments to yourself or else my more well-to-do patients will stop coming or pretend to be poor go to polyclinic and get a referral and hope they get channelled to me! haha.

Yes tony, I really empathise with the poor ( esply the elderly poor).
I see around the neighbourhood, poor men with bowed legs - barely able to walk, ramaging through the rubbish bins!

I think the govt is obsessed about not causing a "crutch" mentality so that they don't even provide a crutch to those very ones who need them!

The elderly cleaners around the hospitals- I think they would druther be spending time with their grandchildren or just whiling away their time over a cuppa- but they are pushing trolleys ( or is it the trolleys are pulling them along) and trying to pick up trash or mop the floor!

What's happening?

tony said...

Yes, Doc, I agree with you, this is a terribly tragic situation. Even here in supposedly rich Switzerland there are people now rummaging in dust-bins looking for food. A recent documentary about this created a furor over here. (The Swiss, nice as they are, usually tend to close their eyes to anything that’s unpleasant, hoping that the problem will go away.) And when I think of the children in Gaza, Zimbabwe, Haiti, etc., eating toxic roots, rats and mud, it really drives me mad. What the f…

soon said...

Hi Dr Huang,

Interesting proposal you have there.

But sadly, i doubt the guy on the other side even read it.

Anyway, i thought, if we carry out your idea, wouldn't that load the polyclinics system even more?

And as far as i know, in the past, the government used to subsidise the GPs to care for the public but only in the recent years, they decided to take everything by their own hands. I never got to figure out why. But i suppose they are not thinking of going back that path anytime soon.

soon said...

Regarding the working elderly, its all part of our dear govt's grandmasterplan to keep all our elderly working till they die like LKY.

But i think they fail to realise that our elderly has important societal roles to play as well like caring for our kids. And anw, who has incomes like them to justify working till they die?

nofearSingapore said...

Hi soon,
It won't overload the polyclinic cos the polyclinic will continue to send cases requiring specialist care to govt hospitals who will act as gatekeepers. The govt hospitals decide how many and which subsidised patients to farm out to private specialists willing to see subsidised cases.