Healthcare: Tale of two nations

last SG · 2006-04-12T21:15:58+00:00

Originally posted by oxford mushroom 12 April 2006 04.20AM I wonder where Atobe isCongratulations for some good responses to your thread, and surely you c...

fymk SG

Snow Leopard

Let's take it this way :
At least I don't attack you on a personal level like you did by calling me "intellectually challenged " . Don't need to get too frustrated if you don't like my questions. Just because I don't agree with you doesn't mean anything. You have to understand it has nothing to do with you when I state my questions or opinions.

Some of the ideas you given - nurse practitioners ? Doctors to specialise? It is neither original nor thinking of the box too . Australia already has nurse practitioners and I know the australian system better than I would know singapore since I have been in Australia for quite a while now. Pharmacists? Australia already let them give some prescription drugs without doctors prescription such as ventolin. But nothing further.

I admit not a know it all . I only stated my opinions from my personal and professional experience.

From all the discussions - you sound really sore about doctors earning money and you want to complain about the good old affordable polyclinic in terms of travelling times despite the fact consultation fees are 8 dollars. Look something have to give . this is my personal opinion.

I don't know what's your problem but it does seem you keep focusing on doctors profitting or something. Then again that's my opinion and yes you seem keen on a vendetta rather than actually discussing constructive , just judging from the way you answer.

If you don't like what I say , then disprove it with something solid. At least Atobe is giving me something substantive to look at and he does try to get his point across which I might or might not agree with.

oxford mushroom SG

Is healthcare about the "Quality of Life" or about "Life Expectancy" ?

Both...in general there is a good correlation between the two.

Are we being idealists to find the elixir of life for terminally ill patients, or should we help them to have a more comfortable ending ?

What is your point? Are you suggesting that instead of giving the cancer patient another year or two of life with expensive treatment, it will be more cost-effective to0 give him morphine and let him die painlessly? Sure it's more cost-effective...

Are you advocating that to Singaporeans? I have known patients willing to take a 40% mortality risk just to prolong their life by another 6 months. Shouldn't they have a choice then?

oxford mushroom SG

Not being a doctor does not necessarily mean that one cannot appreciate the advances that technology has transformed healthcare - similar to a doctor not being trained in electronics, does not necessarily prevent him from appreciating the advance in electronics to help in his work.

You seemed to be fixed on the idea that we do not need to provide patients with the benefits of cutting edge medical technology, which is unfortunately, expensive. This certainly suggests you are not aware of the numerous breakthroughs that have been in recent years, particularly in cancer treatment.

The Japanese Tax system is not punative in its DIRECT Personal and Corporate Income Tax, nor in its INDIRECT Tax schemes covering a whole host of consumption tax, inheritance tax, stamp duties, and with exemptions even granted on domestic transaction of assets.

The Japanese have an income tax rate of up to 40-50% That does seem alot more than what I am paying. The top income tax rate here is only about 22%. In any case, there is a danger of using taxes to finance a healthcare system. You have not addressed the problem of an aging population...with a lower tax base, you will have to raise taxes to meet the needs of an aging population which increasingly consumes more healthcare.

oxford mushroom SG

Even if the "average wages" do not give a better picture, surely you will not deny that the doctors' earnings are above the average Singaporean blue and white collar workers - 90% of whom live in HDB flats.

Of course doctors' salaries are above average. Does the average Singaporean blue and white collared worker have the ability to get into and pass the medical school course? Can the average worker do what the doctor does? There is a difference between repairing a car and restoring health.

Even in the People's Republic of China, the Health Care System maybe backward by Western Standards, but it is in no way lower than the standards of Singapore when looking at the vastness of the country and the size of its population

I don't know what you are talking about, but I do know that patients in Singapore with cancer get proper treatment. Many in China are just turned away to die at home.

What about the earnings from the PUBLIC FUNDS that have been invested by GIC and Temasek Holdings ?

I have been saying quite a few times that part of the earnings can be used to fund Singaporean needs, instead of ONLY paying the MILLION DOLLAR SALARIES of those who manage the funds.

I have no objection with that argument, although the government may well say that's exactly what the progress package is all about. That money came from government surpluses like those you mentioned. If people who manage the funds can earn billions, then yes, they deserve their millions or else they will go elsewhere. Will I be willing to pay Warren Buffet a million a year if he were to manage Temasek Holdings? You bet!

oxford mushroom SG

we don't have the same practice here and someone from the clinic once told me that certain medication for coughs are controlled items that cannot be dispensed from pharmacies. so a lot can be changed here really ...

There is a very good reason for that: certain cough mixtures contain opiates (opium-like substances) which supresses cough but as you know, are often abused by drug addicts. I have known drug addicts who accumulate bottles of such cough mixtures and people have been known to die from drinking litres of it..

you're not encouraging people to take a rest when they really need to take a rest, especially when they are having a flu and in danger of spreading to everyone else.

No discrimination here and sick people should take a rest. Their salaries won't be cut...we are talking about an additional bonus if you stay healthy.

if it's cough or flu you go straight to the pharmacist. no need to waste time, a short interview by pharmacist and you're off with your medicine.

As I said, if you have a cough and want some cough mixture, you can just get it from Guardian Pharmacy. The reason why you would go to the polyclinic is to get an MC...I have worked in 3 polyclinics before and I can tell you that I have seen patients who just collect the MC and go next door to buy a better cough mixture from the private pharmacy.

Are you suggesting to let the nurse give out MCs instead? Might as well abolish the MC system in that case.

so what will happen is that they will pursue the specialist route instead of opening up a clinic, which will be made less profitable. so instead of being paid less, they will end up being paid more and we end up having more specialists that would ease the acute shortage,

By the way, not every doctor who wants to specialize succeeds. The average pass rate for many specialist examinations like radiology and pathology is only about 40%. And those who make it will obviously want to charge a rate that is commensurate with their skills and knowledge. Since Singaporean specialists have internationally recognized qualifications and can go elsewhere, we have to pay them first world salaries. So what happens when a poor citizen has cancer or heart failure instead of a cough and needs a specialist?

If he can afford the private sector, that's not an issue. If he cannot afford it and has to see someone in the public sector, then will he find the specialist he needs there? If the public hospital pays doctors much less to cut healthcare costs, how can they afford the specialist who demands the same salary as the private sector?

The way we do it at the moment is to give doctors a bond to specialize overseas. But of course, since the private sector pays so much better, doctors simply break their bonds when they return. Another way is to employ foreign specialist doctors who do NOT have internationally recognized qualifications. (Those who do will demand the same high salaries as local specialists). They cannot work in UK or the US and so will be willing to accept lower salaries. But are we willing to accept that?

if we allow nurses the licence to providing cleaning services for us all, you can be sure that $80 fee will plummet like a shooting star.

I agree and I am sure the Minister for Health will absolutely agree as well. Let more dental nurses do teeth cleaning for those who only want to have their teeth cleaned. Of course don't expect these nurses to be able to pick up subtle gum or root canal disease unless you complain about a toothache. But yes, I agree with you that we should deploy our dentists to do higher value jobs.

Unfortunately, you know, my colleagues are telling me that you can earn more giving botox injections to perfectly healthy people than treating sick diabetic patients with a mountain of complications. Why are doctors doing the job of beauticians instead of focusing on our true mission to help the sick? Because that's where the money is...

oxford mushroom SG

really? they use nurses in the UK and aussie? my goodness, my idea's not that bad after all eh? so you see? it doesn't matter if it's the nurse or the doctor who treats you as long as he/she is properly trained. how do you know there is no demand if you don't even supply it? how can you say it is not efficient when it's being practised elsewhere and we used to have it too?

Haha...just because I disagree with you on some points does not mean I think all your arguments have no merit either Smile I totally agree that if we can expand the scope of nurses, we can lower healthcare costs. But our nurses have to be better supported.

There must be access to doctors for consultation when they encounter something beyond their expertise. I think that's why we don't have more dental nurses who can do cleaning and polishing work. Most dentists in Singapore no longer work in the public sector and those who do are highly trained dental surgeons and oromaxillofacial surgeons who handle complex cases. I was told NOT to go to the National Dental Clinic for my teeth to be cleaned...they want to see complex cases only.

There are hardly any dentists left in the public sector to supervise dental nurses. But yes, I agree with you that we should have more dental nurses in the public sector to do cleaning and polishing work...but then most of the dentists in the private sector will go bankrupt...

For medical problems, we can have nurse practitioners who handle patients with chronic illnesses. In fact, we do have them....more than 10 years ago I used to refer my stable diabetics and hypertensives to our nurse practitioners who will see them for their monthly medication, unless their condition changes.

Can we get nurse practitioners to see cough and cold? Apart from the problem with MCs, I have no objections and I think with training, they can do quite a good job. The biggest fear is to miss a pneumonia but now that we have X-ray machines in the polyclinics, it is easier to diagnose these cases as well. But yes, they will have to buy malpractice insurance like doctors. Wonder what fymk think of this...

I doubt that kiasu Singaporeans will accept it though, especially if it involves children. Although I think to the ah peks, seeing a Hokkien-speaking nurse practitioner is probably much better than an English-speaking Indian doctor for his high blood pressure.

oxford mushroom SG

Surely you would have heard of "Living Will" ?

Society has to be educated to know of the consequences of their health conditions, and be given enough choices to decide in advance - once their terminal condition is diagnosed.

Very few people have actually signed an Advanced Medical Directive. Fymk is saying that Singaporeans generally do not accept it even when treatment is futile. Such persons are the last to write a living will.

Not being a health practitioner and not having worked in a hospital, Atobe has no idea of the stress upon medical and nursing staff when relatives insist that their loved one be given a mechanical ventilator instead of letting them go peacefully.

Sometimes doctors resort to 'trickery'. If you have a terminal cancer patient who has collapsed, you must rush to the bedside with all the lights flaring and resus tray in tow, draw the curtains and then.....do nothing. Relatives need to think that medical staff are trying their utmost to save their loved ones, even when expensive treatment is going to be futile.

No, contrary to what Atobe thinks, our society is not that mature yet...

oxford mushroom SG

From all the discussions - you sound really sore about doctors earning money and you want to complain about the good old affordable polyclinic in terms of travelling times despite the fact consultation fees are 8 dollars. Look something have to give . this is my personal opinion.

I agree with fymk that $8 consultation fee in the polyclinic is really very low and I don't think most Singaporeans can really find fault with that. It's the cost of hospitalisation and medication for chronic illnesses that's the problem.

There was an article in the straits times recently about a diabetic patient who has to pay $450+ for 3 months' worth of medication (from a public hospital). The problem is that doctors are prescribing the best medication with the least side effects for each patient. The price is set by the drug company, not the hospital and not the government. We cannot make it cheaper unless doctors do not prescribe patented drugs. If we want the best, we have to pay more for it. It's either we pay directly or indirectly by taxes.

Atobe talks about using surpluses. I have no objection with that but what happens during years when the economy experiences a downturn? What if we have a deficit for that year? What will we do with the patients then?

I don't know what's your problem but it does seem you keep focusing on doctors profitting or something. Then again that's my opinion and yes you seem keen on a vendetta rather than actually discussing constructive , just judging from the way you answer.

Most doctors did not come into this profession for the money. We know we can earn much more in finance or law. Most people started out wanting to be doctors to help people and in return, society renders healthcare staff a special place in society and respect. The terms 'missy' and 'lau goon' were once honorifics sufficient for many to aspire to be a nurse or doctor. Medical school education was almost completely subsidized by tax payers and medical staff enjoy free medical benfits. In return, doctors have the moral obligation to serve the public even if they do not earn as much as their skills and training command.

Unfortunately, that 'social contract' has been eroded. When I entered medical school, my fees were heavily subsidized by taxpayers and so I have a social responsibility to serve the public even though I can earn three times more in the private sector. Nowadays, medical students are expected to pay the bulk of the fees and end up with a $100k debt when they graduate. We do not enjoy any special medical benefits even though we are exposed to the risks of deadly infections like the SARS virus, which killed a number of our colleagues. The government and society now considers medicine as a commercial transaction like any other.

Do you not expect doctors to demand remuneration as someone would in a purely commercial transaction? It is sad that we have come to this state of affairs, but the clock cannot be turned back.

snow leopard SG

Originally posted by fymk:
Snow Leopard

Let's take it this way :
At least I don't attack you on a personal level like you did by calling me "intellectually challenged " .

similarly, i don't constantly misconstrue what you're saying so your lack of comprehension of what i'm saying comes across as intellectually challenged. nothing personal, just a matter of fact statement of your responses.

Don't need to get too frustrated if you don't like my questions. Just because I don't agree with you doesn't mean anything. You have to understand it has nothing to do with you when I state my questions or opinions.

i'm not frustrated with your questions as they're not difficult to handle. what i'm frustrated with is your lack of comprehension.

Some of the ideas you given - nurse practitioners ? Doctors to specialise? It is neither original nor thinking of the box too . Australia already has nurse practitioners and I know the australian system better than I would know singapore since I have been in Australia for quite a while now. Pharmacists? Australia already let them give some prescription drugs without doctors prescription such as ventolin. But nothing further.

frankly if you didn't tell us, many of us wouldn't have know. so to people like us it is something out of the box. and since now we know it actually works well in another system, there is no reason to deny it here.

I admit not a know it all . I only stated my opinions from my personal and professional experience.

but you're too ingrained in your current profession to really step out of the box.

From all the discussions - you sound really sore about doctors earning money and you want to complain about the good old affordable polyclinic in terms of travelling times despite the fact consultation fees are 8 dollars. Look something have to give . this is my personal opinion.

that's where your lack of comprehension lies. i have said for the unteempth time that despite $8 polyclinic fees, good doctors are being locked up providing basic healthcare that a nurse practitioner, perhaps with better training can do equally well. these doctors can be released to do better things and that has been the core of my opinion. i wonder if u would ever understand what i'm saying.

I don't know what's your problem but it does seem you keep focusing on doctors profitting or something. Then again that's my opinion and yes you seem keen on a vendetta rather than actually discussing constructive , just judging from the way you answer.

you see, you are missing the point yet again. after saying it for the unteempth time, you still don't get it. how not to wonder if you're not intellectually challenged? now u're saying i'm "keen on a vendetta", you're judging me equally aren't you?

it is about getting doctors to do what they are most needed for and from society's point of view is the most constructive.

If you don't like what I say , then disprove it with something solid. At least Atobe is giving me something substantive to look at and he does try to get his point across which I might or might not agree with.

you should turn this around and ask yourself. why have not come up with something solid to disprove what i'm saying. and you not equally guilty of shoving your points across?

snow leopard SG

Originally posted by oxford mushroom:

There is a very good reason for that: certain cough mixtures contain opiates (opium-like substances) which supresses cough but as you know, are often abused by drug addicts. I have known drug addicts who accumulate bottles of such cough mixtures and people have been known to die from drinking litres of it..

yes, it was the cough mixture that was a controlled item that i supposed couldn't get from the pharmacist. that's why i feel the role of the pharmacist can be expanded and enhanced so that he or she can perform diagnosis and prescribe particular cough mixtures in a controlled way. that way, we need not go back to the doctor and be charged a premium.

No discrimination here and sick people should take a rest. Their salaries won't be cut...we are talking about an additional bonus if you stay healthy.

yes, but everyone would want to earn maximum bonus by not taking MC at all, which would be detrimental to their health ...

As I said, if you have a cough and want some cough mixture, you can just get it from Guardian Pharmacy. The reason why you would go to the polyclinic is to get an MC...I have worked in 3 polyclinics before and I can tell you that I have seen patients who just collect the MC and go next door to buy a better cough mixture from the private pharmacy.

as we've discussed above, certain controlled cough mixtures aren't available over the counter from Guardian Pharmacy. but if the pharmacist at Guardian can be 'upgraded' to also hold a proper diagnosis role, he would be able to dispense the controlled cough mixture perhaps more cheaply than a doctor would.

come to think of it, if we allow pharmacists to give MCs, people would go to the pharmacists for MCs instead of bogging down the doctor who would then have more time for patients. isn't that good too?

Are you suggesting to let the nurse give out MCs instead? Might as well abolish the MC system in that case.

what's wrong with that? you don't trust the nurse's ability to read a patient's health condition or you don't trust his or her moral integrity to give out MCs?

By the way, not every doctor who wants to specialize succeeds. The average pass rate for many specialist examinations like radiology and pathology is only about 40%.

yes, like driving test, fail just try again.

And those who make it will obviously want to charge a rate that is commensurate with their skills and knowledge. Since Singaporean specialists have internationally recognized qualifications and can go elsewhere, we have to pay them first world salaries.

remember you said that some specialists earn millions? we're not making paupers out of them, just increasing the competition so that they perhaps earn a couple of hundred thousand dollars less. they would still command a significant premium over the masses, a premium good enough to make them stay.

So what happens when a poor citizen has cancer or heart failure instead of a cough and needs a specialist?
If he can afford the private sector, that's not an issue. If he cannot afford it and has to see someone in the public sector, then will he find the specialist he needs there? If the public hospital pays doctors much less to cut healthcare costs, how can they afford the specialist who demands the same salary as the private sector?

The way we do it at the moment is to give doctors a bond to specialize overseas. But of course, since the private sector pays so much better, doctors simply break their bonds when they return. Another way is to employ foreign specialist doctors who do NOT have internationally recognized qualifications. (Those who do will demand the same high salaries as local specialists). They cannot work in UK or the US and so will be willing to accept lower salaries. But are we willing to accept that?

it is fundamentally an issue of inbalance between demand and supply. we don't have enough surgeons so whatever few we have are readily lapped up by private hospitals which can afford to pay premium salaries. but the moment we churn out enough surgeons that more than meets demand, there is no way private hospitals can absorb all the extra surgeons and still pay them premium salaries. after all, singapore is only that big and can only support that many surgeons. so when that happens, the inequilibrium will slowly ease. but we can only make surgeons out of doctors, not out of nurses or pharmacists. as such, flooding the market with inexpensive clinic services will push doctors towards a higher level, a situation that benefits everyone.

we also need to remember that it is not just the pull factor of money but also the disatisfaction doctors have of govt hospitals that compels them to make the jump to private hospitals. in this respect, hospital management can be improved.

i do not rule out your suggestion although i am uncomfortable. one way is that, if these foreign doctors accept, we get them to go through some form of conversion course in our medical school and pass our exams set at stringent levels.

I agree and I am sure the Minister for Health will absolutely agree as well. Let more dental nurses do teeth cleaning for those who only want to have their teeth cleaned. Of course don't expect these nurses to be able to pick up subtle gum or root canal disease unless you complain about a toothache. But yes, I agree with you that we should deploy our dentists to do higher value jobs.

glad you see the merit of the idea.

Unfortunately, you know, my colleagues are telling me that you can earn more giving botox injections to perfectly healthy people than treating sick diabetic patients with a mountain of complications. Why are doctors doing the job of beauticians instead of focusing on our true mission to help the sick? Because that's where the money is...

yes, doctors becoming beauticians isn't something we would respect very much. similarly, though to a lesser degree, doctors not taking up the scapel but instead sets up his own clinic, making comfortable living out of treating coughs and colds isn't very commendable either.

i suppose as long as we keep botox expensive, it remains exclusive to the rich and exclusivity means the demand remans small and can only support a small number of beautician doctors.

snow leopard SG

Originally posted by oxford mushroom:

I agree with fymk that $8 consultation fee in the polyclinic is really very low and I don't think most Singaporeans can really find fault with that. It's the cost of hospitalisation and medication for chronic illnesses that's the problem.

fymk kept badgering about $8 and i never bothered to reply. you know why? it never was an issue to me. what he constantly fails to understand is that i'm not concerned about the $8 per say but the fact that $8 plus govt subsidies is keeping the doctor in a clinic when he ought to be treating chronic illnesses. when we free doctors from clinics and put them in hospitals to treat chronic illnesses, we abate the costs of treating those illnesses.

There was an article in the straits times recently about a diabetic patient who has to pay $450+ for 3 months' worth of medication (from a public hospital). The problem is that doctors are prescribing the best medication with the least side effects for each patient. The price is set by the drug company, not the hospital and not the government. We cannot make it cheaper unless doctors do not prescribe patented drugs. If we want the best, we have to pay more for it. It's either we pay directly or indirectly by taxes.

yes if the patient cannot afford the best and the next best is good enough, why not? we do not have control over drug companies so i cannot suggest anything to improve costs other than lament that drug companies charge too much. but we can do something to increase our pool of doctors treating chronic illnesses by minimising their time spent in clinics prescribing cough and flu medicine.

Atobe talks about using surpluses. I have no objection with that but what happens during years when the economy experiences a downturn? What if we have a deficit for that year? What will we do with the patients then?

i suppose we need to use some and save some.

Most doctors did not come into this profession for the money. We know we can earn much more in finance or law. Most people started out wanting to be doctors to help people and in return, society renders healthcare staff a special place in society and respect. The terms 'missy' and 'lau goon' were once honorifics sufficient for many to aspire to be a nurse or doctor. Medical school education was almost completely subsidized by tax payers and medical staff enjoy free medical benfits. In return, doctors have the moral obligation to serve the public even if they do not earn as much as their skills and training command.

Unfortunately, that 'social contract' has been eroded. When I entered medical school, my fees were heavily subsidized by taxpayers and so I have a social responsibility to serve the public even though I can earn three times more in the private sector. Nowadays, medical students are expected to pay the bulk of the fees and end up with a $100k debt when they graduate. We do not enjoy any special medical benefits even though we are exposed to the risks of deadly infections like the SARS virus, which killed a number of our colleagues. The government and society now considers medicine as a commercial transaction like any other.

Do you not expect doctors to demand remuneration as someone would in a purely commercial transaction? It is sad that we have come to this state of affairs, but the clock cannot be turned back.

in case you think like fymk, who accuses me of having a personal vendetta against doctors, i say again categorically that my emphasis on doctors earning a good income prescribing cough mixtures is not a personal grudge against them because i've also said that i understand why they are doing it. the important thing is, from a society point of view, it does not make social, moral and economic sense for the govt to spend huge sums of money training doctors who eventually end up opening up a clinics to sell cough mixtures. isn't it such a waste that after spending so much time and money you end up doing only a fraction of what you are trained for. if that's the case you don't need to be trained that much in the first place.

it is not just the doctors but society as a whole has become very transactional and commercial. that is why we can only move things and people with money. when the money in the pot is no more (private clinics), you can be sure doctors would be nudged into those fields where they are most needed.

snow leopard SG

well, you've said it better than i did. even though we differ in the nitty gritty details, i'm glad we see the same fundamental problem and that our underlying solutions are similar.

oxford mushroom SG

certain controlled cough mixtures aren't available over the counter from Guardian Pharmacy. but if the pharmacist at Guardian can be 'upgraded' to also hold a proper diagnosis role, he would be able to dispense the controlled cough mixture perhaps more cheaply than a doctor would.

Then we will have to change the law to allow pharmacists to dispense controlled drugs...drug addicts out there, you know where to go Smile I have no objection in principle but that means there will be greater access to controlled drugs. If Singaporeans are happy with that, I have no issue.

Train pharmacists to make diagnosis? Sure, they will have to go through 5 years' of medical school to do that and become doctors themselves...we are back to square one.

if we allow pharmacists to give MCs, people would go to the pharmacists for MCs instead of bogging down the doctor who would then have more time for patients. isn't that good too?

Allow nurses and pharmacists to give MCs? That means they can distinguish the malingerers from those who are truly sick...same problem...you have to send them through medical school to learn how to make proper diagnosis. Of course they will have to buy medical liability insurance like doctors, which will cost them at least 1-2k a year. You will have to raise their salary then...how can you expect them to give up a month's salary for malpractice insurance?

But if they are willing to take the added responsibility and risk and not demand a higher salary, sure...why not? I have a feeling the number of MC seekers will rise though but if Singapore employers don't mind, I have no issue..

like driving test, fail just try again

Ya...I know of someone who has been failing since I met him 15 years ago...he has just given up. For some exams, two tries and you are out..It is not easy to even get in...very few are selected for specialist training. Of course, if we are willing to lower standards, we can let more in...

remember you said that some specialists earn millions? we're not making paupers out of them, just increasing the competition so that they perhaps earn a couple of hundred thousand dollars less. they would still command a significant premium over the masses, a premium good enough to make them stay.

Ya, the few surgeons who are making the millions will stay, but most of the specialists are NOT earning millions...they can easily move elsewhere and they will if we lower their salaries too much. The BBC has just reported that the average pay for a GP in the UK will be 100k GBP or S$300k a year. Even for a newly qualified consultant, the average pay is 72k GBP or S$216k. That is much more than what many other specialists are getting here. If our doctors have equivalent qualification, why should they stay here?

It is true that our surgeons are paid far more than other specialists and far more than their counterparts in the UK. That is an anomaly that should change.

it is fundamentally an issue of inbalance between demand and supply. we don't have enough surgeons so whatever few we have are readily lapped up by private hospitals which can afford to pay premium salaries. but the moment we churn out enough surgeons that more than meets demand, there is no way private hospitals can absorb all the extra surgeons and still pay them premium salaries.

You forget that they can go overseas..but our surgeons earn too much compared to UK surgeons. I agree with you about surgeons, but not for other specialties where our specialists are paid less than the first world.

It's not only an issue of demand and supply (which I agree with) but there is also the issue of a global market.

we also need to remember that it is not just the pull factor of money but also the disatisfaction doctors have of govt hospitals that compels them to make the jump to private hospitals. in this respect, hospital management can be improved.

i do not rule out your suggestion although i am uncomfortable. one way is that, if these foreign doctors accept, we get them to go through some form of conversion course in our medical school and pass our exams set at stringent levels.

Doctors are dissatisfied with the way management wants them to do alot more to cut costs. They can do less for an equivalent or more pay in the private sector.

You are right to be uncomfortable. Fymk has been talking about the mismanagement by foreign doctors in Australia. There have been similar concerns about doctors from Eastern Europe who work in the UK.

But if you make it so difficult for foreign doctors to work here, why should they come? If they are good enough to pass the stringent exams set by US and UK, do you think they will come here? Of course we are getting the second rate ones...what do you expect if you want them cheap?

i suppose as long as we keep botox expensive, it remains exclusive to the rich and exclusivity means the demand remans small and can only support a small number of beautician doctors.

Ha...point is people won't blink an eye spending $800 for botox treatment but complain about the $8 in the polyclinic. No wonder more and more GPs are going into this...they call it aesthetic medicine..

oxford mushroom SG

but we can do something to increase our pool of doctors treating chronic illnesses by minimising their time spent in clinics prescribing cough and flu medicine.

I have already said I have no issue increasing the pool of doctors and we are already doing that with many more foreign doctors. Local doctors won't see chronic illnesses in the polyclinic for a 5k monthly salary. Foreign doctors will...but they don't speak dialects and they may not have equivalent qualifications. If you are happy with that, that's an option...

As for cutting out coughs and cold, if patients are happy to see the nurse instead, I have no issue. They probably want the MC only...but if we let nurses give out MC too, I have no issue with that too. As I said though, you can expect everyone to get an MC...patient will say he has headache and a nurse is not a doctor. He/she will not take the risk to deny an MC in case the patient is truly sick and sues later...

i suppose we need to use some and save some.

Do you know what is your salary in 3 years' time? We don't know how much surplus we will have next year or whether we might have a deficit instead. So how will you know how much to spend and how much to save?

You tell your patients the medicine is only $10 a month this year, but next year the economy is not doing well and so you have to tell your patient who has lost his job because of the poor economy that he now must pay $30, because we don't have a surplus to subsidize his treatment now.

when the money in the pot is no more (private clinics), you can be sure doctors would be nudged into those fields where they are most needed.

That is true to an extent. When the money is no more in medicine, they will go overseas and more people will go into law, finance or politics. You can still earn a million in the cabinet I think..

oxford mushroom SG

The recent move by the Minister of Health to open up Medisave to chronic illnesses is telling us where the government is likely to proceed.

They will indeed train more doctors, including a larger number of bright foreign students who may be given a bond in return for study grants. These additional doctors are meant for our biomedical industry, to conduct clinical trials, do research rather than manage cough and colds. They will provide cutting-edge medical services to make Singapore attractive for rich foreign patients. Increase in this group of doctors will not lower healthcare costs for Singaporeans but will be good for the economy. They will be highly qualified and you have to pay first world rates to see them.

For the heartlanders, there will be a shift towards more primary healthcare. Send to to be treated in nursing homes and small district hospitals that are cheaper and less skill-intensive.

More cheap foreign doctors will be recruited for our public hospitals and polyclinics. We are now accepting degrees from a larger number of Universities. For example, Malaysian doctors who studied in Sheffield, UK (the University of Sheffield has a joint degree program with Malaysian Universities) could not work in Singapore in the past. Now we recognize their degree and so avail ourselves of a source of cheaper doctors. They will be cheaper but not as cheap from doctors from India and China. If Singaporeans still complain that the polyclinics are too expensive, I suppose they can recognize even more Universities from India, Bangladesh and China. These doctors can be given limited license to work only in polyclinics and government hospitals.

The government will not go as far as I have suggested: to restrict non-patented drugs for polyclinics and public hospitals. It is just not politically acceptable...our patients will not accept having to take 2 pills 4 times a day when there is a once-a-day pill with less side-effects..

So the government is allowing people to use medisave to pay for them...It is not going to lower heathcare costs, just making it more affordable by letting people use their own savings. But what if those savings run out? What if there is not enough medisave?

That's Khaw Boon Wan's headache too...but hopefully by then he would have retired and that becomes another minister's nightmare Mr. Green

oxford mushroom SG

yes, but everyone would want to earn maximum bonus by not taking MC at all, which would be detrimental to their health ...

You cannot be a nanny state and tell people they cannot do what they want to do.. If the doctor tells you you should rest at home but you want to work anyway, that's your choice. If you have an infectious disease and told to stay at home, you can be prosecuted under the Infectious Disease Act if you choose to go out.

People in this forum talk about following western democracies...we do not have MCs in the UK...just call in sick. You decide if you feel well enough to go to work, unless prohibited by the doctor as provided for by the law.

fymk SG

I already told snow leopard repeatedly about the need to see whether the community will accept nurse practitioners. No point. He is adamant about it.

You want nurse practitioners? Fine : here is what australia is doing
http://www.dest.gov.au/archive/highered/nursing/pubs/duty_of_care/doc19.html
Each state has a different criteria but have a look. They are complex and most of the master of nursing (nurse practitioner) degrees are currently under review. All nurse practitioners are targetted at rural and regional areas.

This is the process

Registered nurse with a bachelor degree -> have to work minimum of 2 years to go on to post grad-> 1 year for post grad specialisation-> plus minimum of 3 years to qualify as a specialist nurse in the chosen area -> Master of Nursing ( Nurse practitioner) 2 years.

OK in the universities they set the criteria at

RNs must have at least 5 years' post-registration work experience;

must be recognised as an advanced practice nurse/midwife with a specified area of practice, and demonstrate excellence within that role;

must demonstrate a commitment to, and the capacity to contribute to innovation and leadership within their scope of practice;

must provide documentation of employer support necessary to undertake the extended clinical practice components of the course within their workplace or related agencies.

Total years taken before becoming a nurse practitioner - 7 to 8 years minimum since the time the registered nurse is qualified.

Now tell me ,snow leopard, how do you propose to implement a nurse practitioner program ? What is the form of education for training nurse practitioners? How many years? What's the incentive? The costs of educating them? How much do you want to pay them per month? How many people will be willing to see them? What will it cost the person from the community to see a nurse practitioner? Most importantly , what are their limitations on treatment ( and no I don't want to hear coughs and cold again - I mean ALL treatment forms) Who pays for their indemnity ? In Australia , most nurses just join the union because they have professional indemnity insurance thrown in for about approx 400 dollars per annum (full time rate) .

I used to remember those Singaporean home visit nurses charge about 10-20 dollars per visit depending on the difficulty of the job and they have to use transport etc. What they did was not really close to the level of nurse practitioners and they had the support of the polyclinic doctors as well as nearby gps. Nurse practitioners practice on a semi- autonomic role at a level somewhere between a registered nurse and a general practitioner. So what will it cost the person from the community to see a nurse practitioner VS seeing a polyclinic doctor?

And I am just stating facts here.

Remember about what oxford mushroom said about kiasu singaporeans and lest not forget the kiasee ones as well.

fymk SG

Another question for snow leopard :

So what can nurse practitioners prescribe as well for the said coughs and cold? Or let's say pharmacists.

If you say antibiotics for coughs and cold , please address the problem of resistant pathogens like MRSA, resistant streptococcus etc. Resistant pathogens are actually increasing healthcare costs in developed nations . Would people readily accept symptomatic treatments for a viral cold from a nurse practitioner? How would the nurse practitioner be able to counter that problem?

I am all ears now.

geodome SG

This is already enforced. NUS Medical Fees are highly subsidised. All Singaporeans who study medicine at Singapore are required to serve in government hospitals for 6 years. whereas foreigners who study medicine at NUS are required to serve in government hospitals for 5 years.

fymk SG

Let's put it this way ,

Health of the population -> sick individuals -> demand of healthcare delivery -> healthcare costs

Acute illnesses - don't need to say so - they come and they will go . They won't affect the person for life. Of course lah , there are the big problems like SARS and avian flu everyone is scared about.

Chronic illnesses - affect the person for life and the largest burden on healthcare costs. Hospitalisation bills are usually the largest on the medical expenditure list not coughs and colds.

MOH :Better Health Outcomes for the Chronically-Ill Through Structured Disease Management Programmes

Chronic diseases are a major source of morbidity, suffering and misery to patients and their families in Singapore. They are also the major causes of death. This is a phenomenon common to all developed countries.

Four common chronic diseases affect about 1 million Singaporeans: diabetes mellitus, hypertension, hyperlipidemia (lipid disorders) and stroke.

For example :
You can have a diabetic person who does not control the diet -> unstable diabetes -> increased monitoring which includes blood tests and HBA1c tests -> need to see the doctor more who advises this person-> gets more prescribed medication since blood sugar is not controlled -> heavier burden on healthcare costs -> still does not control diet or do exercise or even check the feet regularly -> complications -> diabetic nephropathy ( kidney disease) , eyes affected , feet has sores -> see the doctor or nurse educator -> gets advised on diet again etc etc -> not listening -> may end up with renal disease , blindness or lower limb amputation -> heavier burden on the healthcare system since this fellow probably needs multiple admissions to the hospital , needs more specialist focus i.e. nephrologist, opthamologist , orthopedic surgeon etc as well as allied health support like dietitions, podiatrists etc -> might need insulin on top of the diabetic medications -> might need amputation -> loses the job probably because the person is too unhealthy to even work -> social costs on top of healthcare costs .

You have another diabetic person who controls the diet and exercises regularly . Less risk of kidney disease, and just needs to see the diabetic nurse educator regularly . Cost is not too bad - sees the doctor once every 3 month to get medications which might be just one or two types. Cost is kept low even though this person has a chronic illness.

Preventative health care will cut healthcare costs very efficiently and probably more than you think that the nurse practitioner policy might.

Specialist nurses are helpful in a way if you use them in a preventative type of setting in a chronic disease setting . Will help the costs to drop down. However to use nurse practitioners in diagnosis and treatment for Singapore might not help costs at all. First of all Singapore is small and the population is also small compared to larger countries . There are enough doctors going around for a community. You just need to refocus on preventative health strategies.

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