Promoting Clinical Research In Public Hospitals

26 Mar 2008

By Khaw Boon Wan

Venue: Merchant Court Hotel, Singapore

1. Over the past 40 years, the standard of our healthcare services has gone up from third world to first.  We achieved this at a relatively low total cost to society.  While other developed countries spend at least 7% of their GDP on healthcare, our spending at 4% puts us in the same band as the developing countries. 

We Have Done Not Too Badly

2. How was this possible?

3. First, we waste less.  As patients co-pay their fair share of the cost, there is less over-consumption. This link between payment and consumption is a fundamental pillar of our healthcare financing policy.

4. Second, there is less over-servicing and our doctors generally do not over-treat their patients.  The recent public debate over questionable aesthetic treatments by some doctors suggests an exception but over-zealous consumers are part of the cause.

5. I was reading the Sunday Times over the weekend and the Sunday Times did a good job of surveying a range of opinions on patients who have used some of these treatments like mesotherapy and the opinions expressed not surprisingly covers a wide range. While many agreed with the decision the MOH has taken, but as you can see, there are some who wanted us to do even more than we should - ban it and prevent people from putting out such treatments.

6. But on the other hand, there are others who think we should just leave things alone and leave the doctors to decide for themselves and the government should not interfere.

7. So there lies the difficulty of regulating this business called the beauty business. It is thankless job. But all I know is if tomorrow a bad accident happens and some patients end up with severe complications, all these people who expressed different opinions will gel together and condemn us for not regulating more tightly and say: “I told you so.” So that’s our karma.

8. I take a practical approach. Let us focus on where safety potentially can be compromised and regulate tightly those areas and leave the rest of the treatments to the professional bodies such as academies like the college of family physicians.

9. The professions ought to self regulate. As they do, I hope everyone sees the larger picture that one of the strengths of Singapore healthcare is our pool of ethical doctors. The vast majority practice ethical medicine and as a result there is trust and confidence of Singaporeans looking up so the medical profession remains respectable and people look at it with great respect.

10. I think it would be a pity if the profession for whatever reasons began to erode those ethical values and therefore the profession as a group must start thinking about how to regulate this very tricky area of beauty business. Do not allow a small minority who do this for personal financial reasons tarnish the reputation of the entire community. 

11. Third, public hospitals are dominant players and we actively prescribe lower-cost alternatives, whether it is generic medicine or standard implants. We do so without compromising clinical quality.  

12. But there is constant pressure to change the status quo.  Patients demand higher subsidies to lower their co-payments.  Doctors would prefer greater freedom to practice medicine without having to worry about the cost of treatment.

13. I once had a very good discussion with this professor from St Jude in the US. They are so well endowed with charity funds that he said for doctors working with St Jude, its like heaven. We never need to worry about how much things cost. Do as you wish, as you think best for your patients, he said. And often for the patients’ families, they fly in the families to visit the patients, with hotels and flights all paid for. So that is heaven. But we are not in heaven. Certainly not in Singapore. Many consumers equate the latest drugs and high-tech equipment as better care.

14. In healthcare, the fundamental problem is that of demand exceeding supply.  But demand is not always necessary. Hence public expectations have to be managed to reduce unnecessary demand. We have not done too badly in this regard.

Policies Need Regular Adjustments

15. First, we evolved our own healthcare financing model based on the 3Ms framework to support the co-payment philosophy while keeping healthcare affordable to all.

16. Second, we systematically rebuilt our hospitals and clinics and brought them up-to-date with the practice of modern medicine.

17. Third, we modernized hospital management, corporatised the hospitals and subjected them to greater commercial discipline.

18. Fourth, we re-organised the hospitals and polyclinics into vertical clusters to promote greater integration of care between the specialists and polyclinics and GPs. Patients will benefit if healthcare can be delivered more seamlessly.  Vertical integration is the way to go, but it has taken time and will take us some more time to execute this well.

19. Going forward, we will continue to make adjustments and refinements in response to changes in the external environment.  Tonight, I want to discuss a recent policy change and that is our decision to promote clinical research in public hospitals. I thought its worth discussing the implication of this recent change.

Promoting Clinical Research

20. Clinical research is not a new activity.  We have always dabbled in it and all hospitals have included it as part of their core missions.  There have been some success stories.  Prof SS Ratnam’s research on infertility in the old KKH was exemplary.  In more recent years, Prof Ariff Bongso’s pioneering work on human embryonic stem cells helped pave the way for stem-cell research globally.  There were many other examples.  But clinical research in public hospitals was largely confined to a small group of doctors whose achievements were due more to their passion rather than the active support of hospital administrators. There was an important consideration which underpinned such a tight-fisted policy in MOH. 

21. Research was not a priority in MOH. Our priority has been to deliver affordable healthcare through a lean and cost-effective system.  Cost control takes precedence over discretionary activities.  There was only a nominal budget for clinical research and we had to beg from the Tote Board and other charities to support our researchers. 

22. The concern was that clinical research would lead to more costly treatment options.  This would increase healthcare costs and also fan up public expectations for esoteric treatment which our society might not be prepared to pay.  We used to look at the huge NIH research budget in the US which runs into billions of dollars a year and concluded that we could not afford such a luxury.  Let the Americans do the research and we will send our doctors there to learn the new treatments and procedures after they have been established.  It is a cheaper way to raise our medical standards.

23. I wanted to stress that these considerations were neither frivolous nor trivial. Indeed, many aspects of those considerations remain valid today.

24. But in 2006, MOH revised the policy and obtained the Cabinet’s approval to include clinical research as part of MOH’s mandate.  MOH would henceforth promote clinical research in public hospitals and seek appropriate funding support for its researchers.  Why did we change the policy?

25. This is not because we think we have arrived, that we are now a developed country and we are rich enough to support clinical research. We are not.  Funding will remain tight and cost control will remain an MOH priority.  But we assessed that the time had come for Singapore to do more in the area of clinical research because such research, if suitably directed, could benefit healthcare. 

26. First, a decade of investment developing the life sciences in the Biopolis has laid a strong foundation for biomedical research in Singapore.  There are now more than a thousand PhDs actively working on various aspects of basic biomedical research, many of them of first-world standard and at the cutting edge.  But to deliver greater value from basic research, it has to be translated into actual clinical applications.  Bench research on animals has to be turned into better treatment protocols, therapies, diagnostic kits, or even drugs and devices, to benefit patients. Rather than having our researchers in Biopolis partner foreign clinicians in foreign hospitals, we should promote such collaboration in translational and clinical research (TCR) with our local hospitals instead.  Indeed, our international scientific advisors have strongly recommended that Singapore invest in TCR to close the missing gap between bench and bed. 

27. Second, a strong clinical research environment will support our philosophy to emphasizing a knowledge- and evidence-based approach to healthcare. This will raise the standards of medical care for Singaporeans and help manage medical inflation by identifying more effective ways to deliver care.  Our system is already highly productive in terms of service delivery, and there is little scope for major cost-cutting within the present approach.  Breakthroughs in cost management must come from applying knowledge.

28. Third, supporting clinical research and knowledge-driven care will help to draw and retain top doctors and medical talent within our public hospitals. I think anecdotally, you have heard this many times both from our own doctors who are interested in research as well as the newly recruited doctors from overseas whom we managed to persuade them to return to Singapore. Inevitably, all of them mentioned that there is a change in environment or at least they perceived that there is change in environment.

29. But I think there is more than perception and that it is real. This is an important point for our clinicians. By meeting clinicians’ aspirations for scientific discovery, they can develop professionally and be more intellectually engaged in their work. We therefore hope that participation in research programmes will help reduce the brain drain of our doctors to the private sector and to other countries.

30. In short, clinical research is a way to grow our medical capabilities and maintain our status as a regional medical hub.  It will differentiate us from our neighbours.  Our competitive advantage has to be based increasingly on better knowledge and stronger skills, grounded on scientific research. 

Responding To New Policy

31. But we must be realistic in our ambition to pursue clinical research.  Demand for research funding is bottomless and we can never hope to match the US budget for clinical research.

32. Nevertheless, we have committed a significant $1.55 billion, which to us is a lot of money. For years, we hardly get a few millions. Now at least, there is slightly more than a billion for the next 5 years. I have no doubt that very soon it will be more than $1 billion for the next 5 years of programme.

33. With this larger investment comes the need for more strategic management of, as well as accountability to the public for, the use of these funds.  We should only fund high quality, competitive research that will deliver concrete results in improving healthcare for Singaporeans. We must ensure that only the best proposals are funded.

34. The old scheme where MOH gives out block budgets to individual centers on the basis of trust that you will spend the money well, I think those days are gone. When it is a few million dollars, we can afford to take the risk. But when you start talking about spending a couple of billion dollars, I think that causal informal approach to research fund distributions can’t work. We need proper research grant applications, have them peer-reviewed and subject them to contest. Whoever has the best ideas will get the money.

35. Hence, it is paramount that we build in competitive peer review mechanisms into the grant allocation framework. In addition, we should maximize our returns through better coordination and integration to reap synergies.  We must not waste resources through silly duplication particularly where facilities are on the same campus.

36. My office is within the Outram Campus. I worry when I see Duke next door building up, much of it funded by Singapore taxpayers. And at the other side, we have SGH’s specialty centers. All want to build their own research laboratories and so on.

37. Let us think through carefully with each campus on what we can share. At the end of the day, money comes from taxpayers like you and me. For big ticket items where Singapore can only support one, we subject both campuses to contest and we decide where we want to put this facility.

38. Where we can have two, we will build one each. But within each campus, let us cooperate and coordinate and not duplicate because there just isn’t enough money to go round. For every hundred million dollars we save, we could fund so many more scientists, clinical scientists and researchers.

39. I hope our hospital clusters must grasp this significant policy change and its full implications, so as to take full advantage of it.  More of the same will lead to missed opportunities.  The cluster boards and their leadership will have to fundamentally review their corporate mission, tweak their governance and reform their HR and financial policies to meet this exciting new challenge.  There are significant upsides for their doctors and their patients, indeed for Singapore, if they respond well to the challenge.

40. The Kent Ridge Campus is off to a good start.  They have undertaken the first step by integrating the NUS-Yong Loo Lin School of Medicine, the Dental Faculty and the NUH into the National University Health System to catalyse the development of the Campus.

41. I am particularly happy about this move because it is something on my mind for many years. We have always wanted to do something like this. The more you can integrate, be it service, teaching and research, and this is regardless of entities: it could be MOH, hospitals, MOE or Universities. If we are in the same campus and if only we can synergise and collaborate and actively share a similar vision, the sky is the limit. But if you box yourselves into silos, a lot of opportunities will be missed. That is why I pushed this unfinished business and I hope this unfinished business can reap us some good harvest in due course. 

42. The Outram Campus has a great chance of success too. It has a strong talent pool and excellent clinical assets in SGH, the various national centers and the Duke-NUS Graduate Medical School. If we can further galvanise the talents, integrate clinical services, teaching and research in a holistic patient-centric manner, Outram can be unbeatable in this part of the world.

43. That is my vision and I believe the cluster’s board and professor Tan Ser Kiat shared that vision too. Harnessing its potential will require a carefully crafted strategy. It will require aligning the mission and values among its different stakeholders. It will require strong leadership and sound execution.  It can be done and I am determined to help them along this journey. 

Conclusion

44. I am confident that our two campuses will succeed in their new mission to exploit translational and clinical research to benefit our patients.  I am confident because we have many talented doctors.  Tonight, we pay tribute to a representative sample of this talent pool.  An ophthalmologist who pioneered many internationally groundbreaking surgical techniques to restore sight to the blind. A paediatrician who laboured for 20 years to develop the world-class National Paediatric Renal Replacement Programme. Teams of experts coming together to successfully treat debilitating chronic mental disorders and high-risk pregnancies. And two distinguished professors who are excellent role models and mentors to the younger generation of clinicians and researchers.

45. They have individually and collectively improved our healthcare. And that is the ultimate objective of the new policy to promote clinical research.  It is not the mindless pursuit of esoteric discoveries to score a world’s first.  It is to bring real health benefits to our people, to keep healthcare standards high yet affordable. 

46. We are more likely to succeed if we focus on common conditions that affect large numbers of our people such as diabetes and myopia.   Besides doing clinical trials on new drugs, we should also look at the effectiveness of treatment with different combinations of existing drugs and the effectiveness of behavioural modification strategies for different segments of our population.  Such studies may seem mundane but can potentially benefit large numbers of our patients. 

47. The advancement in genomics will also present many opportunities for improvement in the treatment of diseases.  For example, scientists are now identifying many different genetic variations associated with diabetes.  It will take many inquisitive scientists many years of hard work to uncover which treatment protocol would be more effective for which genetic variation of the condition.  Even the current controversy over aesthetic medicine shows the need to study effectiveness and health benefits of treatment procedures.  This is how the medical science makes progress, for the benefit of mankind.

48. My heartiest congratulations to the award recipients.