MOH Budget Speech 2005 (Part 2) - Putting Top Brains to Work

09 Mar 2005

By Mr Khaw Boon Wan, Minister For Health

Venue: Parliament

Speech By Mr Khaw Boon Wan, Minister For Health In Parliament: March 9

"Putting Top Brains to Work"

I thank Dr Michael Lim for his comments on our ambition to become the regional medical hub, an initiative which we have codenamed SingaporeMedicine. I share his dream, not every single detail, but at least the larger plot.

SingaporeMedicine

The Economic Review Committee felt that we could succeed in SingaporeMedicine. Years ago, we were a clear leader in the region. But as Dr Lim has pointed out, our competitors have quietly narrowed the gap with us. It is not just Parkway in Malaysia, or Bumrungrad in Bangkok. It is also Apollo, Escorts, Max Healthcare and Fortis in India. If we are not careful, it will soon be Shanghai, Beijing and Dubai.

Securing Our Lead

Dr Lim asked if MOH is ready to make his dream come true. SingaporeMedicine is not strictly an MOH portfolio. But from MTI where I was for 7 years, I knew that without MOH's support, SingaporeMedicine will be so much harder to achieve.

To secure our lead, we have many things to do: increase supply, step up training, let in more foreign talent, bring our cost down and work more actively with world-class partners.

Supply-Induced Demand

MOH's past ambivalence on SingaporeMedicine is not without good reasons. As increased demand would have to be supported by more specialists, there were concerns that more specialists in turn would lead to higher demand. The assumption is as what Dr Tan Sze Wee has noted that supply could induce demand in healthcare. The end result is higher healthcare cost.

Supply-induced demand is real but is not unique to healthcare. Wherever there is market failure and unequal powers between provider and consumer, the potential for supply to induce demand exists.

For example, where there is information asymmetry, where sellers know more than buyers, an irresponsible seller can creatively induce spurious demand.

Look at motor repair workshops. Most of us know how to drive, but know little about how engines work, let alone be able to fix any car problems. This is a classic case of information asymmetry between the mechanic and the car owner. If a mechanic is irresponsible, he will say: fix this or fix that, this is the bill. Very few car owners will know if they have been taken for a ride. And if insurance is going to pick up the tab, most car owners may not even care. They are more interested in how soon they can get the car back in good shape.

Control Supply Control Demand?

The way to address such market failures is not to restrict supply and expect demand to be moderated. The correct response is to make as much information available to consumers, to reduce the information asymmetry and allow them to make informed choices. If they cannot digest the information, they can seek third party advice, for instance from their family physicians or their insurers. That is why it is so important for every Singaporean to have a good family physician. Equally important, we need to put in place a framework which generates incentives for hospitals to provide good basic healthcare with minimum resources.

For some time now, we control the supply of specialists as a policy, on the premise that this would moderate healthcare demand. But from an economics point of view, this logic may not be entirely correct.

As I said just now, it is wishful thinking to hope that with fewer specialists, demand for their services will shrink. This is particularly so when demand is largely driven by exogenous factors: in the case of Singapore, for example, by our ageing population and aspirations to be a regional medical hub. Over-restricting supply in the face of independently-rising demand will simply drive up healthcare costs, as prices adjust to the excess demand. This is Economics 101.

That is why I favour taking a more market-based approach to manpower planning. We must respond to market demand and adjust supply accordingly. Yes, there are valid concerns about supply-induced demand. We will watch the situation carefully. But at the same time, we must take care not to rigidly control numbers and overly-choke supply to create a severe excess-demand situation. After all, if SingaporeMedicine makes progress and we still restrict the training of specialists, queues will lengthen, and charges will go up.

Train Our Competitors

We must also step up training, and not just for ourselves. We should help train our neighbours, particularly Malaysia, Indonesia, Thailand, Vietnam and China. Many are keen to learn from us. Annually, our hospitals play host to thousands of such visitors.

We should welcome such trainees, even from countries we may not have traditionally recruited from. The best amongst them we hope will stay to eventually become Singaporeans; the rest will return to be our links to the region. With a larger patient base, we can train our own doctors better and faster.

Look at India and China. The number of organ transplants, coronary artery bypasses and joint replacements that their doctors get to work on is mind-boggling. What our trainees get in a year, their trainees can get in a month. Coupled with their vast pool of talent and hungry ambition, it is a matter of time their skills will surpass ours.

We should not be afraid that we are training our competitors. The strength of Singapore is our ability to get things to work and maintain operational efficiency over time. We are good at operating complex systems.

Look at Changi Airport and PSA. Others can buy the same hardware, the same cranes, the same IT equipment and so on. But we stay ahead of competition by operating what we have, effectively and efficiently. Likewise, our regional healthcare competitors can buy the same technology that we have. But I am confident that our hospitals have what it takes to stay ahead of competition.

Vision

Dr Lim has painted his dream. Let me share my vision. It is that our hospitals can be the best in Asia and be clearly acknowledged as such by our peers.

Let me clarify what "the best" means. To be the best does not mean tall, shiny buildings or expensive equipment. "Best" means we have the best clinical outcomes, the lowest morbidity and mortality, the lowest complication rates, the fastest recovery, the lowest usage of resources. We come up with new productive devices, new effective techniques, and new processes.

Not all specialties can achieve this. But hopefully, a handful can produce results within a few years. This will encourage the others.

Can We Make It?

It is a tall order. But we have proven our abilities in other areas before.

Just now I spoke about our SMs healthcare funding model. It is totally made in Singapore. Our response to SARS was world-class, and again made in Singapore.

With some of our best students in medicine, and some of our best talent in healthcare, we must put these top brains to work.

Dr Lim spoke obliquely about "bureaucratic hurdles, turf protection and harassment through government agencies", all of which could turn his dream into a nightmare. He spoke from his own experience. I listened carefully and I understand his "coded" message. Let me encourage him not to lose his passion. Changing mindsets overnight is not possible. But there are people within the Ministry who share his dream. Count me as one. Together, let us make it happen.

I have shared the vision with the medical leadership. They are keen to work towards it, while acknowledging the challenges. If we stay focused and are prepared to be bold in our approach, with determination, I think after 5 to 10 years, we should be able to produce significant results. But we must be prepared to change, re-engineer our processes, and work with the best.

East + West = Best?

Since Dr Chong Weng Chiew mentioned TCM, let me use that as an illustration. It is a difficult subject, given our lack of domain knowledge. There is a certain mystique surrounding TCM because we do not know what we do not know.

Take the regulatory regime for TCM herbs as an example. We have two options: do nothing, keep them largely unregulated and hope that it does not become a problem, or proactively engage the TCM experts and industry to see if we can develop a regulatory and certification system which can in fact be a global model.

Consumers have problems differentiating real herbs from fakes and are often conned. Can we develop the standards and the tests to help certify authentic TCM products? Can we aim to be the certifying body for the world market? Singapore has a trusted brand. That will create a new industry here.

Ten years ago, Minister George Yeo planted a seed in AMKH when he started acupuncture there as a pilot. There have been some developments since. Even our Zoo finds application for TCM - Ah Meng has apparently benefited from acupuncture!

Booster Shot

I am giving TCM a booster shot. That is why I said "yes" to Dr Chong Weng Chiew'yyyys request to bring the full range of TCM services into AMKH. My hope is that the local TCM practitioners will take this opportunity to climb up the ladder.

Success is likely to come if they actively partner with the best in China. We must acknowledge that our TCM is not as developed as in China, and see how we can bring the best in TCM here, to help us evolve a model which can bridge east and west. We should jointly conduct scientific studies and clinical trials of TCM practices and TCM herbs. We should publish the results in international scientific journals and actively contribute to a better understanding of this ancient art of healing.

They should invite the best TCM physicians to come here regularly to conduct clinics, treat patients, give lectures and teach. They can come as experts on temporary registration. To achieve best results, we must not be protectionist or fear that such foreign talent would take away our lunches. They can already do so, operating from China. It is far better that they are with us here, even if only temporarily.

At the same time, as Dr Chong pointed out, the local TCM community must continue to upgrade and professionalise.

TCM Orthopaedics: "Die-da"

That is why I am not sure if I can accept Mr Ong Ah Heng's approach of allowing "die-da" practitioners to continue with their traditional way of training, often from father to son.

"die-da" (TCM orthopaedics) is a branch in TCM dealing with injuries to bones and soft tissues. The practice of "die-da" (TCM orthopaedics), like the practice of any specialty in TCM, requires full knowledge of TCM. That is why we require those who wish to practise "die-da" (TCM orthopaedics) to undergo the complete training in TCM and be registered as TCM practitioners. This is also the regulatory practice in China and Hong Kong.

However, we are sympathetic to the incumbents who had no opportunity for such training in the past. So we made special provisions for them during the transition period of registration to allow them to continue to practice. But for all new practitioners, they will have to be fully-trained and registered as TCM practitioners

TCM Schools

Dr Tan asked about the enrolment in our local TCM schools. We have 2 schools. They offer 6-year part-time diploma courses and a 3-year full-time course. Both have tied up with TCM universities in China to offer undergraduate and postgraduate training in TCM.

Last year, about 100 graduated from the 2 schools. Currently, about 800 are in the 6-year part-time courses and about 200 are undergoing the 3-year full-time diploma course. This gives a total of about 1,000 students.

Dr Tan asked about the impact of TCM training on western primary healthcare. TCM has always co-existed with Western medicine, playing a useful complementary role. It has about 12% of our outpatient market share. This figure has remained stable for quite some time.

One, Two or Three

Let me now move West to our hospital clusters. Mr Alex Chan and Dr Chong asked whether cluster formation has achieved its purpose and whether excellence can be better achieved via a 3rd cluster.

Frankly speaking, the key to medical excellence is seldom due to organizational structure. I have seen various kinds of organizational structures among the top-performing institutions, from Cleveland to Stanford.

Top performance comes from leadership. Are the leaders serious? Are they clear of their goals? Are they able to attract like-minded people to join their cause? Are they ready to drop team members who get distracted or are distracting?

Whether it is one cluster, two clusters, or three, the more important question is whether we are clear about our mission and have good people who are passionate about our vision. Do we know when to co-operate, and when to compete? This is increasingly the key to winning the global competition.

We Are One Team

As I see it, the only way SingaporeMedicine can stay ahead of competition, is for all hospitals, public and private, to work together as Singapore Inc. when it comes to professional matters. We fight as one team.

Last year, I advised the clusters to stop organizing competing annual scientific meetings, but to jointly organize much bigger annual scientific meetings with far greater impact on the region. I am glad that they are taking up my suggestion.

They are planning to upsize the many small local professional meetings to include professionals from the region. They will share and consolidate their databases of conference participants so that we can market our meetings more effectively. They will also try to leverage on the many world-renowned scientists brought in by A*STAR, to help project Singapore as a thought leader for all things medical. I am cheered by this development.

Last year, one of my grassroots leaders had a mild heart attack. He was a former patient of SGH Heart Centre. But the ambulance brought him to TTSH as he lived nearby. After stabilizing him and discovering that he was an ex-patient of SGH, TTSH put him in an ambulance and sent him over there for admission, after alerting the SGH staff to expect his arrival.

All these transactions happened as per routine. After 7 days in SGH, he left the hospital and only then did he tell me about his positive encounter with the 2 hospitals. He was a subsidized patient, by the way.

I was very happy to hear his experience. The purported rivalry between the 2 clusters must have eased, and SGH and TTSH have been able to co-operate for the welfare of their patients.

Conclusion

In short, it is not about how many clusters we have. The key is our focus and leadership. What counts is how we take care of our patients at the front line, in our clinics and our hospitals.

If our clusters compete to have the latest equipment, inflating pay to poach staff from each other and shifting costs to each other, then we are headed for trouble.

But I am confident that we have enough sense to know that the competition is not against each other. The competition is against diseases. Our focus must always be on how to improve health, reduce illness and how to do better with less, for the sake of all Singaporeans.

Our success will depend on whether we have the right leadership at the front line: hospital CEOs who see the broader picture and share the vision, and yet at the operational level, are hands-on at the helm of a tightly-run ship. They serve the doctors, the nurses, the frontline staff, make sure that the right systems are in place, the right people are well-trained and well-deployed, and facilities and equipment are working optimally to enable our professionals to care for their patients in the best, least-costly manner.

If we stay focused on the right thing and have the right people in place, I see no reason why we cannot be the best in the region.