Healthcare: Tale of two nations
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A recent BBC programme discussed the healthcare problem of two developed economies: Britain and Germany. I think there are lessons there for us with regard to health economics.
The UK has doubled its healthcare budget since Tony Blair came into power. They have introduced strict audit standards, placed on administrators the absolute requirement to balance their accounts and put priority on clearing waiting time and the backlog of surgeries. To achieve that, they have paid doctors alot more to work additional hours beyond the contract stipulations and have hired additional nurses and doctors from all over.
Their problem now is that they have run out of money. Encouraged by the pay, hospital consultants are working longer hours and clearing the backlog, but the hospitals are running out of money. One by one, a number of hospitals have gone bankrupt and closed their wards.
In contrast, Germany went for cutting healthcare costs. They were strict with the bottomline, limited doctors' pay and forced them to work longer hours for the same amount. The result is an exodus of doctors to other nations, particularly to UK. Half of their medical student cohort in Germany leave to work as junior doctors in the UK and other countries, where their pay is doubled and they work shorter hours.
As a result, Germany now is facing shortage of doctors, long waiting times and a queue for operations, something that they had never encountered before.
Singapore will face a similar dilemma. Our doctors are well trained and our specialists have internationally recognized qualifications that enable them to work in many places overseas. At the moment, the number of Singaporean doctors who work overseas is small. In the region, the only Asian country that pays better would be Hong Kong and indeed a number of our doctors have gone there (Japan is not an option because of language difficulties).
We have to strike a balance between the experience of Britain and Germany. That is the challenge facing us and there are no easy solutions. -
Well doctors and nurses in Singapore are also going to Australia to work . More so for nurses because the workload is lighter and the profession is far more well paid (not to mention more respected) than in Singapore.Originally posted by oxford mushroom:A recent BBC programme discussed the healthcare problem of two developed economies: Britain and Germany. I think there are lessons there for us with regard to health economics.
The UK has doubled its healthcare budget since Tony Blair came into power. They have introduced strict audit standards, placed on administrators the absolute requirement to balance their accounts and put priority on clearing waiting time and the backlog of surgeries. To achieve that, they have paid doctors alot more to work additional hours beyond the contract stipulations and have hired additional nurses and doctors from all over.
Their problem now is that they have run out of money. Encouraged by the pay, hospital consultants are working longer hours and clearing the backlog, but the hospitals are running out of money. One by one, a number of hospitals have gone bankrupt and closed their wards.
In contrast, Germany went for cutting healthcare costs. They were strict with the bottomline, limited doctors' pay and forced them to work longer hours for the same amount. The result is an exodus of doctors to other nations, particularly to UK. Half of their medical student cohort in Germany leave to work as junior doctors in the UK and other countries, where their pay is doubled and they work shorter hours.
As a result, Germany now is facing shortage of doctors, long waiting times and a queue for operations, something that they had never encountered before.
Singapore will face a similar dilemma. Our doctors are well trained and our specialists have internationally recognized qualifications that enable them to work in many places overseas. At the moment, the number of Singaporean doctors who work overseas is small. In the region, the only Asian country that pays better would be Hong Kong and indeed a number of our doctors have gone there (Japan is not an option because of language difficulties).
We have to strike a balance between the experience of Britain and Germany. That is the challenge facing us and there are no easy solutions.
There is no balance which can be striked. Health professionals move around globally because there is always a shortage and greener pastures elsewhere. The African countries are pleading for WHO to prevent richer developed nations not to take their health professionals away but ultimately it is the choice of the person.
All you can hope is that by training more - there will be some left to stay in the country. Most people stay to work in their country because it is somewhere they call home. I didn't stay in Singapore to work as a nurse because I felt it was not home at all and not from the crap i got from working in the singaporean hospitals for a sh*t pay or being target practice for doctors in a bad mood throwing folders about . I could work for the US but I didn't like the guns there. I could work for UK but being in Singapore was bad enough - I don't fancy being a folder fetcher anymore. So I stayed in Australia since 2002 and it is my home now.
Even in Australia, they are also facing a problem of shortages . Their nurses and doctors are moving to USA for the money or canada or just to see the world.
So no real way to solve this. Bond your doctors and after the bond they will still run if they want to . Pay them more but there will be someone else who is really willing to up the pay to get them there. Make them feel home and they will stay home.
So what does Singapore do? Make sure health is the responsibility of everyone and I think that is a good concept with the exclusion of genetic related diseases. -
Are you looking for good solutions or easy solutions?Originally posted by oxford mushroom:A recent BBC programme discussed the healthcare problem of two developed economies: Britain and Germany. I think there are lessons there for us with regard to health economics.
The UK has doubled its healthcare budget since Tony Blair came into power. They have introduced strict audit standards, placed on administrators the absolute requirement to balance their accounts and put priority on clearing waiting time and the backlog of surgeries. To achieve that, they have paid doctors alot more to work additional hours beyond the contract stipulations and have hired additional nurses and doctors from all over.
Their problem now is that they have run out of money. Encouraged by the pay, hospital consultants are working longer hours and clearing the backlog, but the hospitals are running out of money. One by one, a number of hospitals have gone bankrupt and closed their wards.
In contrast, Germany went for cutting healthcare costs. They were strict with the bottomline, limited doctors' pay and forced them to work longer hours for the same amount. The result is an exodus of doctors to other nations, particularly to UK. Half of their medical student cohort in Germany leave to work as junior doctors in the UK and other countries, where their pay is doubled and they work shorter hours.
As a result, Germany now is facing shortage of doctors, long waiting times and a queue for operations, something that they had never encountered before.
Singapore will face a similar dilemma. Our doctors are well trained and our specialists have internationally recognized qualifications that enable them to work in many places overseas. At the moment, the number of Singaporean doctors who work overseas is small. In the region, the only Asian country that pays better would be Hong Kong and indeed a number of our doctors have gone there (Japan is not an option because of language difficulties).
We have to strike a balance between the experience of Britain and Germany. That is the challenge facing us and there are no easy solutions.
Easy solution is to open the floodgates loh.
Actually already in implementation, some Philippine website listed TTSH as one of the top employers of Filippinoes leh.
Replace all the quitters with foreign talents loh --- what's new?
Declining birth rate, declining marriage rate, increasing cost of living -- what else can you expect? -
Foreign talents are also quitters from their own countries if you want to term those who went out from Singapore ,out of their comfort zone in search of a better future,quitters.Originally posted by ObviousMan:Are you looking for good solutions or easy solutions?
Easy solution is to open the floodgates loh.
Actually already in implementation, some Philippine website listed TTSH as one of the top employers of Filippinoes leh.
Replace all the quitters with foreign talents loh --- what's new?
Declining birth rate, declining marriage rate, increasing cost of living -- what else can you expect?
There will be no solutions to the matter. Some other country will always top the salary of the other country for labour they need. It is the way of the world. Who can pay more and give more benefits will get the people they need. It is only when a person thinks it is a country worth settling down then they will stay -
i believe in training more doctors - lots more. we currently train about 200 doctors a year. if we can increase the number to 2000, flood the market with doctors, doctors' wages will go down, health care costs will go down, more doctors around means improved services.
given the extremely high pay doctors are getting right now, the pay can be depressed quite substantially without affecting their lifestyles or pushing them overseas. -
hmm, the number 2000 is too big, if so, i think many quacks will surface, we certainly dun want that to happen.Maybe the school could start expanding (or lax its stringent requirements by abit). Certainly, we may need more doctors (and nurses too, right?), but not an exponetial increase in numbers ... n Quantity without quality is of no use ...Originally posted by snow leopard:i believe in training more doctors - lots more. we currently train about 200 doctors a year. if we can increase the number to 2000, flood the market with doctors, doctors' wages will go down, health care costs will go down, more doctors around means improved services.
given the extremely high pay doctors are getting right now, the pay can be depressed quite substantially without affecting their lifestyles or pushing them overseas. -
Just treat them like the PRC student. U need to work in the country where u study medicine for at least 20(PRC student 6) years before u can move out. By the time they will have raise in rank and by transfering to another country their pay might not be so great.
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I was not harping on that issue of migration, for the matter.Originally posted by fymk:Foreign talents are also quitters from their own countries if you want to term those who went out from Singapore ,out of their comfort zone in search of a better future,quitters.
There will be no solutions to the matter. Some other country will always top the salary of the other country for labour they need. It is the way of the world. Who can pay more and give more benefits will get the people they need. It is only when a person thinks it is a country worth settling down then they will stay
However, i cannot do anything if you are sensitive to it!
What i did point out is in fact true.
Healthcare is regulated in many countries.
Many nations have a quota for foreign medical workers.
Singapore's medical profession is in fact highly regulated.
There is a quota to the number of people studying medicine every year.
Oxford Mushroom was saying that there are no easy solutions.
I am saying that there is a easy (not necessarily good) solution.
My own experience tells me that supply of labour is always greater than demand if good job opportunities are available.
How many people come to Singapore to work as maids and general workers for a few years and return back to their countires rich? If medical jobs are made available to foreigners, do you think they will come?
Think about it --- this issue is not about healthcare alone.
Like PM LHL said, Think BIG! This is an election issue lah. -
Good...some of you have already made the suggestion I was going to make, so this makes my life easier.
First, one must understand that there are many levels of healthcare. For most people, their contact with the healthcare system is for minor medical problems or chronic illnesses that can be handled by a primary healthcare attendant, ie. a general practitioner, either in a private clinic or in the polyclinic.
There is a secondary level of healthcare, for those who require treatment in a hospital context but the level of expertise required is low to intermediate. I would include in this category common operations like mastectomy without reconstruction, colectomy for cancer,etc.
Beyond that, we have tertiary level healthcare that is expensive and labour and technology-intensive. This will include intensive care treatment, oncology services, transplant services and the like.
We need different solutions for different levels of healthcare. At the moment, there is no clear distinction between the secondary and tertiary levels of healthcare. Hospitals that do separation of siamese twins also perform breas_t resections, which can be done in a secondary healthcare facility. My proposal is a clearer separation between primary/secondary versus tertiary levels of healthcare.
Singaporeans want cheaper medical services for their flu and common chronic illnesses like hypertension and diabetes, for which they need medication frequently. These conditions are simpler to treat and common complications including amputations for foot gangrene in the case of diabetes can be handled in secondary level facilities.
My solution is to greatly increase the number of primary and secondary level facilities. Open the floodgates to hire more cheap doctors from Malaysia, Thailand, India and Pakistan; nurses from China and attendants from Bangladesh. Training our own doctors will not decrease heathcare costs much, since they also have a family to feed, a car and HDB flat to pay off in Singapore.
If Singaporeans want cheaper healthcare for 'simpler' medical ailments, then we have to take in more foreign talent. As the Minister has already done so, radiology in the polyclinics are outsourced to India. Alas! we cannot outsource our patients to Thailand and Malaysia for their monthly checkup, so the solution must be to bring the mountain to Muhammad...bring in MORE foreign talent.
Mind you, we will not get the best doctors from India and Pakistan...those who do well enough in their PLAB or USMLE examination (qualifications for medical graduates to work in the UK and US respectively) will move to London and the USA, where the pay and prospects are better. We will have to settle with 'second rate' doctors but as these are simpler medical conditions, they should suffice in most instances.
Singaporeans cannot expect to have a doctor that speaks their language and there will be initial pain as these foreigners adjust to the local working environment but in time, they will become used to our culture. Someone complained to the Forum page recently about doctors from Myanmar with thick accents. We cannot oblige them their choice of doctors if this is to work.
Yes, we will have to relax the stringent regulations we now have that only recognizes top foreign medical schools. You don't seriously expect a graduate from Harvard Medical School or Oxford University to settle for a starting salary of below 2k? For the salary of a local graduate 2 years' post-housemanship, we can employ two doctors from India or China. But obviously you cannot expect the same quality...sometimes you get lucky and you hire a good doctor...sometimes, not so good.
Secondary healthcare institutions will not be required to satisfy the stringent accreditation standards by which tertiary institutions have to abide. Lab tests can be outsourced to Malaysia but obviously you cannot expect their labs to be accredited by international bodies. Test results may vary more, they may be less accurate and they will take longer to come back (because it is economical to batch tests) but they will be cheaper.
Such institutions will not have intensive care or full emergency services...but Singapore is small enough for patients to travel to tertiary institutions.
The range of services will be more limited, only generic medicine will be prescribed and as a rule, surgical implants and appliances will be older models where the patent has run out (generally 20 year patent protection).
Patients have to accept that you may have to take 2 tablets 4 times a day instead of a capsule once a day. Instead of taking your gallbladder out with three holes in the abdomen, you will have the traditional long scar and stay a day or two longer in the hospital but the fees will be lower. Your prosthesis is more likely to loosen than more expensive models and you may have to come back for a revision (repeat surgery) earlier. Obviously, you might be lucky and yours might give you no problem as well...we are talking about statistics here...
I will talk about funding for basic (primary/secondary healthcare) later. The point I am making is that there is a price to everything. We can make your visit to the doctor cheaper, but you cannot demand to have the best doctor, the best medication, most accurate lab results and the most comfortable consultation room.
If Singaporeans are prepared to accept that, this model can lower healthcare costs. We will still not be cheaper than a hospital in JB for the simple reason that even if we were to hire all their staff, why should they come over unless we pay more than what they are currently getting? No, we will not be cheaper than a JB hospital unless (touch wood) our economy falls way behind theirs.
However, basic medical care will be cheaper...would Singaporeans accept this? -
Originally posted by oxford mushroom:
I sense sarcasm . With all due respect, what is the real reason behind this post and posting the most ludicrous, nonsensical model I ever read about ? In general whereever you are in developed nations, people won't accept these type of conditions. Australia already had have a big hoo ha over some indian doctor of death. So what is the real issue you are addressing here?
Good...some of you have already made the suggestion I was going to make, so this makes my life easier.
First, one must understand that there are many levels of healthcare. For most people, their contact with the healthcare system is for minor medical problems or chronic illnesses that can be handled by a primary healthcare attendant, ie. a general practitioner, either in a private clinic or in the polyclinic.
There is a secondary level of healthcare, for those who require treatment in a hospital context but the level of expertise required is low to intermediate. I would include in this category common operations like mastectomy without reconstruction, colectomy for cancer,etc.
Beyond that, we have tertiary level healthcare that is expensive and labour and technology-intensive. This will include intensive care treatment, oncology services, transplant services and the like.
We need different solutions for different levels of healthcare. At the moment, there is no clear distinction between the secondary and tertiary levels of healthcare. Hospitals that do separation of siamese twins also perform breas_t resections, which can be done in a secondary healthcare facility. My proposal is a clearer separation between primary/secondary versus tertiary levels of healthcare.
Singaporeans want cheaper medical services for their flu and common chronic illnesses like hypertension and diabetes, for which they need medication frequently. These conditions are simpler to treat and common complications including amputations for foot gangrene in the case of diabetes can be handled in secondary level facilities.
My solution is to greatly increase the number of primary and secondary level facilities. Open the floodgates to hire more cheap doctors from Malaysia, Thailand, India and Pakistan; nurses from China and attendants from Bangladesh. Training our own doctors will not decrease heathcare costs much, since they also have a family to feed, a car and HDB flat to pay off in Singapore.
If Singaporeans want cheaper healthcare for 'simpler' medical ailments, then we have to take in more foreign talent. As the Minister has already done so, radiology in the polyclinics are outsourced to India. Alas! we cannot outsource our patients to Thailand and Malaysia for their monthly checkup, so the solution must be to bring the mountain to Muhammad...bring in MORE foreign talent.
Mind you, we will not get the best doctors from India and Pakistan...those who do well enough in their PLAB or USMLE examination (qualifications for medical graduates to work in the UK and US respectively) will move to London and the USA, where the pay and prospects are better. We will have to settle with 'second rate' doctors but as these are simpler medical conditions, they should suffice in most instances.
Singaporeans cannot expect to have a doctor that speaks their language and there will be initial pain as these foreigners adjust to the local working environment but in time, they will become used to our culture. Someone complained to the Forum page recently about doctors from Myanmar with thick accents. We cannot oblige them their choice of doctors if this is to work.
Yes, we will have to relax the stringent regulations we now have that only recognizes top foreign medical schools. You don't seriously expect a graduate from Harvard Medical School or Oxford University to settle for a starting salary of below 2k? For the salary of a local graduate 2 years' post-housemanship, we can employ two doctors from India or China. But obviously you cannot expect the same quality...sometimes you get lucky and you hire a good doctor...sometimes, not so good.
Secondary healthcare institutions will not be required to satisfy the stringent accreditation standards by which tertiary institutions have to abide. Lab tests can be outsourced to Malaysia but obviously you cannot expect their labs to be accredited by international bodies. Test results may vary more, they may be less accurate and they will take longer to come back (because it is economical to batch tests) [b]but they will be cheaper.
Such institutions will not have intensive care or full emergency services...but Singapore is small enough for patients to travel to tertiary institutions.
The range of services will be more limited, only generic medicine will be prescribed and as a rule, surgical implants and appliances will be older models where the patent has run out (generally 20 year patent protection).
Patients have to accept that you may have to take 2 tablets 4 times a day instead of a capsule once a day. Instead of taking your gallbladder out with three holes in the abdomen, you will have the traditional long scar and stay a day or two longer in the hospital but the fees will be lower. Your prosthesis is more likely to loosen than more expensive models and you may have to come back for a revision (repeat surgery) earlier. Obviously, you might be lucky and yours might give you no problem as well...we are talking about statistics here...
I will talk about funding for basic (primary/secondary healthcare) later. The point I am making is that there is a price to everything. We can make your visit to the doctor cheaper, but you cannot demand to have the best doctor, the best medication, most accurate lab results and the most comfortable consultation room.
If Singaporeans are prepared to accept that, this model can lower healthcare costs. We will still not be cheaper than a hospital in JB for the simple reason that even if we were to hire all their staff, why should they come over unless we pay more than what they are currently getting? No, we will not be cheaper than a JB hospital unless (touch wood) our economy falls way behind theirs.
However, basic medical care will be cheaper...would Singaporeans accept this?
[/b]
UK NHS is not the best system to quote , neither is the german system. Of course they are the better known ones to most.
Try looking at the Finnish health system - they have a better idea and their life expectancy is excellent. In fact , the scandinavians have a generally good idea of how to run a health care system - it comes with a price - heavy price tag on taxpayers. However I don't see much scandinavians moving out of their countries to practice somewhere - and they can speak english perfectly fine too. They must be doing something right ....or they could just love their saunas in finland.. -
They relaxed their quotas on Singaporeans studying medicine overseas though.Originally posted by ObviousMan:I was not harping on that issue of migration, for the matter.
However, i cannot do anything if you are sensitive to it!
What i did point out is in fact true.
Healthcare is regulated in many countries.
Many nations have a quota for foreign medical workers.
Singapore's medical profession is in fact highly regulated.
There is a quota to the number of people studying medicine every year.
Oxford Mushroom was saying that there are no easy solutions.
I am saying that there is a easy (not necessarily good) solution.
My own experience tells me that supply of labour is always greater than demand if good job opportunities are available.
How many people come to Singapore to work as maids and general workers for a few years and return back to their countires rich? If medical jobs are made available to foreigners, do you think they will come?
Think about it --- this issue is not about healthcare alone.
Like PM LHL said, Think BIG! This is an election issue lah.
Think BIG? Sure ..I can think like him .....when I am rich and able to afford AMERICAN healthcare - of course I cannot lah. Too poor. -
Try looking at the Finnish health system - they have a better idea and their life expectancy is excellent. In fact , the scandinavians have a generally good idea of how to run a health care system - it comes with a price - heavy price tag on taxpayers. However I don't see much scandinavians moving out of their countries to practice somewhere - and they can speak english perfectly fine too. They must be doing something right ....or they could just love their saunas in finland
I welcome criticism but you must argue logically. What is your alternative? How do you resolve the problems? The failure of the WP manifesto is that they do not offer any cogent solutions..it is easy to say that everything is cheap or free, but how do you fund it?
If I am reading you correctly, you are advocating the Scandinavian model of a welfare state to fund the healthcare system. Yes, places like Sweden has a very good healthcare system...and you are right about the cost.
Take Sweden as an example, they have a two step progressive tax scale with a municipal income tax of about 30% and an additional high-income state tax of 20-25% that kicks in when you earn more than about 300 000 SEK (S$63, 000) per year.
The tax is heavy for employers too. In addition to corporate taxes, the employing company pays an additional 32% of so called Employers fee.
In addition, a national VAT (equivalent to our GST) of 25% is added to many things bought by private citizens except food (12% VAT) and transports and books (6% VAT). Certain items are taxed at higher rates, e.g. petrol/diesel, new cars and alcoholic beverages.
If you are prepared to pay this sort of taxes, yes, we can have the Swedish healthcare system. Why don't you persuade the WP or other opposition parties to campaign for such a system and drastically raise taxes? If you think Singaporeans will support your idea, put it forward.
What I find objectionable is that people can promise the world but not prepared to count the cost. -
Point of the discussion : I didn't know the real issue earlier but now I do.Originally posted by oxford mushroom:I welcome criticism but you must argue logically. What is your alternative? How do you resolve the problems? The failure of the WP manifesto is that they do not offer any cogent solutions..it is easy to say that everything is cheap or free, but how do you fund it?
If I am reading you correctly, you are advocating the Scandinavian model of a welfare state to fund the healthcare system. Yes, places like Sweden has a very good healthcare system...and you are right about the cost.
Take Sweden as an example, they have a two step progressive tax scale with a municipal income tax of about 30% and an additional high-income state tax of 20-25% that kicks in when you earn more than about 300 000 SEK (S$63, 000) per year.
The tax is heavy for employers too. In addition to corporate taxes, the employing company pays an additional 32% of so called Employers fee.
In addition, a national VAT (equivalent to our GST) of 25% is added to many things bought by private citizens except food (12% VAT) and transports and books (6% VAT). Certain items are taxed at higher rates, e.g. petrol/diesel, new cars and alcoholic beverages.
If you are prepared to pay this sort of taxes, yes, we can have the Swedish healthcare system. Why don't you persuade the WP or other opposition parties to campaign for such a system and drastically raise taxes? If you think Singaporeans will support your idea, put it forward.
What I find objectionable is that people can promise the world but not prepared to count the cost.
Second point of the discussion : there was not so much of an argument.
Third point of the discussion: I am not in Singapore . Even if I am, I have private health insurance to cover my health needs , then again I have the healthcare backup in Australia - which is incidentally using a two tiered health system like Singapore but more welfare oriented. Medicare, PBS and the 30% rebate on private health insurance helps me along the way.
Fourth point of the discussion : I am not interested in WP policies- you and I know they will never win the elections. Put it this way - I rather be apolitical with an occasional jest of a jab at political parties.
Fifth point of the discussion : I am actually doing a comparative study of health care systems in OECD countries for a policy analysis paper. So yeah I thought if you might like to look in another direction - I could point you out in that way.
Sixth point of the discussion: I already gave a partial solution but it pertains to the environment of which the health care professionals lives in , works in , relax in. Why people stay in certain places for long when they can move off elsewhere? Because they call it their home . Goes for every single individual. -
Taxes are high in Finland as well and there are a number of taxes in addition to the income tax:
In 2005 the income tax rate (national tax) for an individual is between 10.5%-33.5%.
In addition to direct taxation there is also municipal tax (similar to the council tax in the UK or what you pay to your town council) in Finland. This tax is payable by an individual on his or her income and it fluctuates between 15% - 20% depending on the municipal authority.
Church tax is also payable, between 1% and 2.25%.
In addition to all that, there is VAT of 22%
The combined top marginal tax rate in Finland is about 57%.
Preventive medical treatment (eg. maternity care, immunization) is free but for other treatment and consultations, they can charge up to 20Euro (S$39) per visit.
The total healthcare expenditure on the Finnish system is 1,700 international dollars (a measure common to all currencies) compared to below 1000 international dollars in Singapore.
http://ucatlas.ucsc.edu/spend.php -
Those who are interested in this issue might find this link useful:
http://ucatlas.ucsc.edu/spend.php
In general, there is a correlation between increased healthcare spending and life expectancy but the correlation is not perfect. The US has the world's highest per capita healthcare spending but in terms of life expectancy, Cuba does better the the US on a much lower budget. There are many reasons for that but one of which is the extremely high medical professional insurance rates in a very litigious society.
Singapore does very well in fact. On this scale between life expenctancy and health care spending, Cuba and Singapore do better than most countries in the world, Switzerland is slightly below average and the US citizens get the worse deal in terms of cost-effective healthcare. -
You are absolutely right in having private health insurance. The fact is that most people in Singapore do not and they expect the State to pick up most of the tab.Originally posted by fymk:Even if I am, I have private health insurance to cover my health needs , then again I have the healthcare backup in Australia - which is incidentally using a two tiered health system like Singapore but more welfare oriented. Medicare, PBS and the 30% rebate on private health insurance helps me along the way.
This thread is a continuation from a previous one in which some forumners argue that Singaporeans do not want high tech medicine and that the governmemnt should provide basic healthcare as cheap as those in JB and Thailand:
http://www.sgforums.com/?action=thread_display&thread_id=184999&page=1
My argument is that if indeed that is what Singaporeans want, ie. a cheap and basic healthcare without having to pay for all the patented drugs and new technology, the above post is how I foresee it can work.
A welfare system based on taxes will not work as our population matures. WE can see the lesson played out before us in Europe. With fewer babies and a longer life expectancy, we will have fewer tax payers supporting a larger number of retireees who consume healthcare. Taxes will have to rise tremendously or we will have to work much longer to support the system. The alternative solution is immigration but there is a limit as to how many we can squeeze on this island. -
honestly i really don't know if 2000 is too high. don't have the statistics to work out an optimum number. in any case, it is to make people realise that we need a whole lot more than we're currently churning out now.Originally posted by gd4u:hmm, the number 2000 is too big, if so, i think many quacks will surface, we certainly dun want that to happen.Maybe the school could start expanding (or lax its stringent requirements by abit). Certainly, we may need more doctors (and nurses too, right?), but not an exponetial increase in numbers ... n Quantity without quality is of no use ...
not all doctors are top notch candidates. the selection is quite broad to encompass the very smart ones as well as the not so smart ones. i would say in terms of raw abilities, doctors and engineers are very much on par so if you can transfer 500 to 1000 engineers to do medicine instead, that would be a good number. -
it will. the great majority of the population are already feeding families and paying HDBs with monthly pay of around $3,000. if this is all the doctor needs to be satisfied, then there is a lot of room to slash from his current $20,000 a month paycheck. with that we can have a lot more doctors and still give them HDBs and food for their families.Originally posted by oxford mushroom:Training our own doctors will not decrease heathcare costs much, since they also have a family to feed, a car and HDB flat to pay off in Singapore.
the problem is, which doctor would be contented with $3,000? they'd probably need at least $10,000 a month to be happy. so the supply can be increased until the average pay hits that threshold where doctors can still feel that they are in a priviledged and prestigious profession. -
Maybe because Singaporeans have been spoonfed too long? If you notice , most of the campaigns are spoonfeeding them on how they should behave like smile campaign, courtesy campaign etc .Originally posted by oxford mushroom:You are absolutely right in having private health insurance. The fact is that most people in Singapore do not and they expect the State to pick up most of the tab.
This thread is a continuation from a previous one in which some forumners argue that Singaporeans do not want high tech medicine and that the governmemnt should provide basic healthcare as cheap as those in JB and Thailand:
http://www.sgforums.com/?action=thread_display&thread_id=184999&page=1
My argument is that if indeed that is what Singaporeans want, ie. a cheap and basic healthcare without having to pay for all the patented drugs and new technology, the above post is how I foresee it can work.
A welfare system based on taxes will not work as our population matures. WE can see the lesson played out before us in Europe. With fewer babies and a longer life expectancy, we will have fewer tax payers supporting a larger number of retireees who consume healthcare. Taxes will have to rise tremendously or we will have to work much longer to support the system. The alternative solution is immigration but there is a limit as to how many we can squeeze on this island.
Singaporeans don't have any say on policies made. No empowerment no knowledge of how policies are economically rationalised into being - nothing at all. Government says Immunise , everyone immunises ( which is a good thing, not saying it is bad ) etc. There is no real consumer participation or grassroot decision making foundations at all. Every single decision on health policies is made by the Government . Not very much on transparent financial reporting on major healthcare expenditures like treatment, drugs, medical technology , upgrades needed, CEO salaries etc. Of course, singaporeans might think that with all the wonderful taxes that the Government is collecting , they could at least get the best care at dirt cheap prices but both of us know that healthcare never comes cheap at all. -
that is a good suggestion. similarly, we can elevate some of our pharmacists or nurses to a level where they can take on minor roles played by doctors, your so-called primary level.Originally posted by oxford mushroom:My solution is to greatly increase the number of primary and secondary level facilities. Open the floodgates to hire more cheap doctors from Malaysia, Thailand, India and Pakistan; nurses from China and attendants from Bangladesh. Training our own doctors will not decrease heathcare costs much, since they also have a family to feed, a car and HDB flat to pay off in Singapore.
i remember as kids, our teeth were extracted by nurses in the school dental clinic. many doctors learnt their trade from nurses during housemanship. a very experienced sergeant can be more capable in leading a platoon than his lieutenant and the army has in fact elevated their stripes to their shoulders so i don't see why it can't be done in the medical profession. it would enhance the image of nursing and encourage people to join the profession. -
You forgot the part about enhanced lithigation as well. And more nurses might run off since the pay for nurse practitioners are premium elsewhere compared to Singapore.Originally posted by snow leopard:that is a good suggestion. similarly, we can elevate some of our pharmacists or nurses to a level where they can take on minor roles played by doctors, your so-called primary level.
i remember as kids, our teeth were extracted by nurses in the school dental clinic. many doctors learnt their trade from nurses during housemanship. a very experienced sergeant can be more capable in leading a platoon than his lieutenant and the army has in fact elevated their stripes to their shoulders so i don't see why it can't be done in the medical profession. it would enhance the image of nursing and encourage people to join the profession.
In Australia, nurse practitioners earn about 3.5k -4k per month after taxes. Try beating that. -
Both fymk and snow leopard are right... By increasing the responsibilities of our nurses we can reduce the workload of the doctors and lower healthcare costs, since doctors are paid more. We already have nurse practitioners but most nurses in Singapore are not prepared to accept a bigger role because of greater legal liabilities.
Fymk is right in that nurses will have to buy malpractice insurance if they are to have a bigger role. Incidentally, doctors in high risk specialties such as obstetrics and cosmetic surgery pay an annual premium as high as 10k, so it is not feasible to expect them to lower their fees too drastically either. If we pay nurse practitioners 3k a month like those in Australia, we will raise, not lower healthcare costs.
In any case, I doubt getting more Singaporean nurse practitioners will be any cheaper than bringing in more Indian and Chinese doctors, who are willing to work for around 2-3k a month. If you are willing to lower your standards, you can get them at below 2k as well. Doctors can take on more operative procedures but in the context of rehab medicine, geriatrics and convalescence wards, yes...it will be cheaper to get nurses and we should do so.
Along this vein, I understand that in some hospitals nurses are doing less than what they used to do when I was a houseman some 20 years ago. Following a few instances when nurses were found negligent for administering wrong dosages of medication, many nurses now refuse to give intravenous medications. Compared to the duties of nurses in the Uk, certainly our nurses can do more, but they would want more money.
We are already short of nurses and globally there is a shortage of trained, English-speaking nurses. If if we want them cheap, we have to get them from China and give them on the job training. -
Originally posted by snow leopard:
You must be joking! $20k a month paycheck? Where have you plucked your figures from? As a consultant with nearly 20 years' experience I barely get half that amount. But you have brought up the issue of doctors' pay, which I will address.
[b]it will. the great majority of the population are already feeding families and paying HDBs with monthly pay of around $3,000. if this is all the doctor needs to be satisfied, then there is a lot of room to slash from his current $20,000 a month paycheck. with that we can have a lot more doctors and still give them HDBs and food for their families.
b]
First of all, you are advocating a communist system whereby highly trained professionals like doctors are paid not more than the 'great majority of the population'. I have seen the effects 50 years of communist rule has done for China. Instead of attracting the best and brightest to medicine, the best of each cohort went into politics and nowadays, into business. Doctors in rural China are so poorly paid that many are corrupt and standards have remained what they were in the 1950s.
Why bother to slog so much, spend 6+4+2+5=17 years (2.5 years more for the boys in NS) of your life to qualify as a doctor (if you pass the first time)? Do not forget also that medical students now pay 18k per year for 5 years in NUS (again, provided they pass every year). During the additional year as a houseman they are paid just below 2k and if at the end of it all, you will not be paid much more than the average Singaporean and with a 100k debt from NUS, why would anyone bother with medicine?
It is too late to turn back the clock in any case. If we were to place a cap on doctors' salaries at the 50th percentile as you suggest, we will lose a large proportion of our doctors. Our qualifications are recognized in the UK and other Commonwealth nations where there is a shortage to meet the needs of their aging population.
There is another fallacy: that medicine obeys the economic principle of demand and supply. It does not....in fact, quite often, we see a supply induced demand in medical practice. We used to take out gallbladders by making a long incision in the abdomen but I do remember the days when we started doing laparoscopic surgery, making a few holes instead of a long cut. The patient could also go home earlier but it also costs more. The moment one patient in the ward had it, all the other patients waiting for the operation also wanted it. The more surgeons who can do this operation, the more such expensive procedures are undertaken.
When you want to buy a dress, you shop around for the best price and you decide what you need and pay what you consider to be a reasonable price. With medicine, it's different. Your doctors tell you what needs to be done and does it, you pay him whatever he charges. We know that the rate of caesarian deliveries and all surgical procedures is higher among private patients, if doctors get a cut of the operating fees. As medical students, we could almost predict who will need assisted delivery by just looking at the ward class of some patients.
With more doctors we will have more expensive procedures being performed, because everyone wants to earn more money as long as it is legal. That's a fact.
Wouldn't hiring cheap foreign doctors give rise to this problem as well? Not if we restrict them to work in public hospitals. They will not be licensed to work in private clinics/hospitals and so we can control their pay packet. In my proposal, primary and secondary healthcare institutions will only provide basic healthcare...no keyhole surgery until such time when the cost of such procedures is equivalent to older techniques. This will leave poor patients an avenue for treatment, even though it is not going to be the best available (and should not be).
I would indeed expect alot of Singaporean doctors to leave, because with the cheap foreign doctors, our local doctors have only two options left in Singapore:
1. Go private and compete with the ever-increasing pool of local doctors in the private sector if they want to earn more than the 2-3k a month paid to the foreign doctors
2. Upgrade, specialize and try to get a job in the ever competitive tertiary institutions, which will do high-tech medicine for the wealthy, private patients and foreign patients.
In other words, we will create a bigger gap between the salary scale of our doctors. Currently GPs earn anything between 3k to 10k, but I would think the average is about 5-7k a month. If we flood the polyclinics with foreign doctors, GPs will see their salary drop to probably 3-5k a month. Top doctors with skills that are highly sought after will still command salaries above 10k in tertiary institutions. But you have to be the best to be there...
Back to your point about 20k salaries. There is a big problem in the wage discrepancy among doctors. Your neighborhood GP is probably getting 5k a month and the hospital consultant psychiatrist will be extremely luckly if he can manage 10k with performance bonus added in. But surgeons in Singapore are paid more highly than their counterparts in the UK, and that is not linked to their skills or experience either. The pay scale for surgeons is much higher and yes, they get a cut from the operations they do.
Remember when Dr Ng Eng Hen joined politics, the PM pointed out that he lost a big chunk of his salary by becoming a cabinet minister. Now we know the salary of a cabinet minister is close to a million or so, if Dr Ng has lost a huge chunk of his salary, he must have been earning at least a million a year as a brea_st surgeon.
I think by bringing in foreign doctors, we will force local GPs to lower their fees to some extent (but not much as their pay is not as high as Snow Leopard suggests). However, the biggest impact will be to increase the competition for tertiary institutions as we have never seen before. Surgeons in tertiary institutions will also have to lower their salaries in that case.
If it is at all possible, I would propose that the salary scale of various medical specialities should not vary so much. When a consultant psychiatrist gets 10k a month and a surgeon gets 100k a month, we will see a diversion of our best talents in one or two specialties. There will be good people who specialize in poor-paying discipline because of passion, but we are not being fair to them. -
Healthcare funding
How do we find the funding for our heathcare system so that Singaporeans can afford it despite an aging population that will consume more services?
Medical insurance is the way to go to even out risks and make it affordable for all. For this to work, we need a compuslory system that everyone has to buy into. The reason is simple: unless it is compulsory, why should the young want to pay in to support the old? Why should the healthy athlete want to pay in for the benefit of the neighbour with renal failure?
Premiums for a national medical insurance scheme have to be paid through the medisave and we already have that to some extent. The problem is that the coverage is not enough. The reason for that is the pot of money for premium is not sufficient and healthcare expenses can rise exponentially. For this to work, we have to curb the expenses as well.
If we define primary and secondary healthcare institutions in the manner I have mentioned...cut out all the patented drugs and new surgical procedures that are expensive, hire loads of cheap foreign doctors and nurses, it might be possible to make a medical insurance policy cover say, 80% of all costs in primary and secondary healthcare institutions. I say 80% because I do agree with co-payment to discourage abuse of the system. Patients must pay something out of pocket, unless they are truly destitute.
Patients who want to take one capsule instead of 8 a day can get a prescription to buy out of their own pocket. But those who cannot afford any medication otherwise will get it. And no, HIV patients will not get the anti-retrovirals and brea_st cancer patients won't get Herceptin...not for another 10-20 years at least.
The medisave currently covers only hospital inpatient expenses but this is clearly inadequate. I welcome the recent news that the Minister for Health has opened it to chronic illnesses such as hypertension and diabetes. It is certainly a very big change and indicates that he is aware of the limitations of medisave. Obviously he is concerned that patients might exhaust their medisave accounts quickly and that is also quite possible with chronic illnesses. That's why I would advocate a national insurance scheme paid through medisave that will cover all basic hospitalisations and outpatient treatment in primary and secondary healthcare institutions.
For this to work, it is essential that our basic healthcare is truly basic although extensive. If you need to get that colon cancer out, consider the cheapest way to do it...from the type of suture you use to the kind of bowel preparation. Although a truly efficient conveyor-belt type surgery is not possible, if we can hire alot of cheap foreign surgeons from Eastern Europe and the Indian subcontinent, they can be made to specialise in just one type of surgery. You gain lots of expertise quickly if you only remove colons and nothing else, day in and day out. Local doctors will not want to do that because they quickly become incompetent in other types of operations but with hired foreign surgeons, we can forced them to do that.
If the expensive surgeons we have currently are worth their salt, we may see higher failure rates and infection rates when these operations are handled by cheaper, less skilled foreign surgeons who cannot get jobs in the UK or the US. But they are cheap and as long as the drop in standard is not too much, perhaps Singaporeans will accept it rather than not being able to afford the operation at all? Who knows? Perhaps there will not be a drop in standard...perhaps surgeons like Dr Ng, Dr Balaji and Dr Balakrishnan were overpaid for their services.
I wonder where Atobe is. If Singaporeans are prepared for this sort of system, it will be possible to lower healthcare costs. But it will not be reasonable to ask for cheap hospital fees and demand that Ng Eng Hen removes the brea_st lump! -
Originally posted by oxford mushroom:
finally i just want to say that i am not against you and i enjoy our discussions. you have shown yourself to be a gentleman who doesn't resort to insults or crude language.
You must be joking! $20k a month paycheck? Where have you plucked your figures from? As a consultant with nearly 20 years' experience I barely get half that amount. But you have brought up the issue of doctors' pay, which I will address.
i saw the paycheck myself (won't tell u whose) and it is $20k. a few years ago i met a dentist during ICT, a young chap who already earns $15k. even an old bird pilot told me he earns $20k. figures are not at all surprising when you consider specialists who earn millions each year.
First of all, you are advocating a communist system whereby highly trained professionals like doctors are paid not more than the 'great majority of the population'.
not true. i quote myself "they'd probably need at least $10,000 a month to be happy." so i'm actually advocating that they be paid the premium that society accords them ... but not overly so.
Why bother to slog so much, spend 6+4+2+5=17 years (2.5 years more for the boys in NS) of your life to qualify as a doctor (if you pass the first time)?
for any local graduate with honours, they would be spending 6+4+2+4=16 (2.5 too for boys). so what's with that one extra year?
Do not forget also that medical students now pay 18k per year for 5 years in NUS (again, provided they pass every year). During the additional year as a houseman they are paid just below 2k and if at the end of it all, you will not be paid much more than the average Singaporean and with a 100k debt from NUS, why would anyone bother with medicine?
but if you look at the future stream of income, it more than makes up for the initial investment.
It is too late to turn back the clock in any case. If we were to place a cap on doctors' salaries at the 50th percentile as you suggest, we will lose a large proportion of our doctors. Our qualifications are recognized in the UK and other Commonwealth nations where there is a shortage to meet the needs of their aging population.
i quote myself again "they'd probably need at least $10,000 a month to be happy." so on the contrary i'm not limiting their pay to 50% percentile. i'm putting them right on top although i am advocating that between top and the rest, the gap shouldn't be like $17k ($20k - $3k).
There is another fallacy: that medicine obeys the economic principle of demand and supply. It does not....in fact, quite often, we see a supply induced demand in medical practice. We used to take out gallbladders by making a long incision in the abdomen but I do remember the days when we started doing laparoscopic surgery, making a few holes instead of a long cut. The patient could also go home earlier but it also costs more. The moment one patient in the ward had it, all the other patients waiting for the operation also wanted it. The more surgeons who can do this operation, the more such expensive procedures are undertaken.
this is similar (though not entirely the same) as when the iPod was first launched. before the iPod, nobody wants to buy an MP3 player but when the iPod arrived, everybody started buying it. so what happened really is that an innovation created a whole new market.
When you want to buy a dress, you shop around for the best price and you decide what you need and pay what you consider to be a reasonable price. With medicine, it's different. Your doctors tell you what needs to be done and does it, you pay him whatever he charges. We know that the rate of caesarian deliveries and all surgical procedures is higher among private patients, if doctors get a cut of the operating fees. As medical students, we could almost predict who will need assisted delivery by just looking at the ward class of some patients.
i think if we better educate the public, publish prices and set up a forum for people to comment about services and skills of doctors, and infuse the arena with sufficient numbers, there will be quality of choice at affordable prices.