Healthcare: Tale of two nations
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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.Originally posted by NewAge: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. -
Originally posted by snow leopard:
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.What about prevention of chronic illnesses? You never quite did touch on that . You kept focusing on costs that you miss out preventative strategies. The risk of cancer, heart disease , diabetes can be decreased through prevention. Decrease the risk of chronic diseases and you decrease the healthcare cost of looking after those who have chronic diseases. Even those with certain chronic illnesses can control their disease by a healthy lifestyle which minimises complications and minimising the need for expensive healthcare costs treating the complications .
Yes I did refer you to a book which tells you how social policies and socioeconomics affect health policies and spending. If you choose not to at least skim through it because you think you know the solution to saving the world - then you will still find yourself stuck with me arguing with you about preventative health and cost control on the population side.
Yes yes I heard all the lamentations of singaporean lifestyle but hey if my relative could reduce his cholestrol by cutting down on unhealthy hawker food although he works from 8am to sometimes 10pm or 12 mn every weekday , and go exercising before he goes to work , why can't others? BTW he was forced to rethink his health because he didn't look after his heart and finally when he got his heart attack - he started taking care of himself . By that time , his medical fees are sky high when he needed to see a cardiologist.
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.
if a population has a less amount of sick people. Why do you even need to increase your pool of specialist doctors?
i suppose we need to use some and save some.
That is not really an answer. You have to have contingency planning for those who are in need - so what's the plan snow leopard?
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.
Back to square one of coughs and cold again. Coughs and colds are seasonal . I don't think gps will earn that much from seasonal illnesses. The reason why most people visit their HDB gps is because of convenience , rather than waiting in the polyclinics, and probably because they are so used to their doctors that they trust them alot more.
To the doctors owning their own clinic, they establish a trusting relationship with their patients. My mom has her own gp who she likes to see on top of the polyclinic doctors. When she needs medications - she goes to the polyclinic. When she needs monitoring , she goes to the gp. -
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
For example :
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.
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. -
Originally posted by fymk:
What about prevention of chronic illnesses? You never quite did touch on that . You kept focusing on costs that you miss out preventative strategies.
the way to deal with chronic illnesses, as i have indeed mentioned before (where were u heh?), is to have more doctors treating chronic illnesses rather than attending to coughs and colds. as for missing out on preventing 'strategies', tell me is it not common every now and then that we get campaigns like "climb the stairs", "ask for less sugar" ... it's already very prevalent here for decades, not something you just discovered reading a book. but how come after years and years of campaigning, we are still campaigning? because we don't have so much bloody time to exercise trying to make ends meet.
The risk of cancer, heart disease , diabetes can be decreased through prevention. Decrease the risk of chronic diseases and you decrease the healthcare cost of looking after those who have chronic diseases. Even those with certain chronic illnesses can control their disease by a healthy lifestyle which minimises complications and minimising the need for expensive healthcare costs treating the complications .
so is that rocket science or some latest discovery? it's been around for decades mind you.
Yes I did refer you to a book which tells you how social policies and socioeconomics affect health policies and spending. If you choose not to at least skim through it because you think you know the solution to saving the world - then you will still find yourself stuck with me arguing with you about preventative health and cost control on the population side.
oh, you can say all you want about preventive health, it's not new anyway and not effective so far ... unless we're all inmates in a camp or prison and you control the food we eat and the exercises we do.
Yes yes I heard all the lamentations of singaporean lifestyle but hey if my relative could reduce his cholestrol by cutting down on unhealthy hawker food although he works from 8am to sometimes 10pm or 12 mn every weekday , and go exercising before he goes to work , why can't others? BTW he was forced to rethink his health because he didn't look after his heart and finally when he got his heart attack - he started taking care of himself . By that time , his medical fees are sky high when he needed to see a cardiologist.
he has no choice, he has to do it to live. try telling that to the average singaporean who has no problems and probably has to work from 8 till midnight.
if a population has a less amount of sick people. Why do you even need to increase your pool of specialist doctors?
you can reduce the number of sick people, but unless you lock people up in camps and prisons and impose a regimen on them, campaigns and posters can only get you so far. furthermore, chronic illnesses has a lot to do with old age as well, you can't prevent ageing can you? it is far more effective to increase the pool of surgeons.
That is not really an answer. You have to have contingency planning for those who are in need - so what's the plan snow leopard?
we have compulsory medical savings and afforable insurances, which for the great majority of cases is sufficient for contingencies. problem is, one, two contingencies is sufficient to wipe out that savings. why? because medical bills are exhorbitant. so at the end of the day, finding the money to pay for contingencies is one thing. bringing down costs so that contingencies are affordable is another.
Back to square one of coughs and cold again. Coughs and colds are seasonal . I don't think gps will earn that much from seasonal illnesses. The reason why most people visit their HDB gps is because of convenience , rather than waiting in the polyclinics, and probably because they are so used to their doctors that they trust them alot more.
To the doctors owning their own clinic, they establish a trusting relationship with their patients. My mom has her own gp who she likes to see on top of the polyclinic doctors. When she needs medications - she goes to the polyclinic. When she needs monitoring , she goes to the gp.
whether it is cough or cold or some other mild illnesses, whatever that the doctor is treating in his own private is clinic does not justify his training and qualification. that same relationship can be built with the new phamacist type doctors. -
you're a nurse yourself and setting a question for yourself. if you can answer that, i rest my case.Originally posted by fymk: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. -
Statistics for anyone interested.
Upper Respiratory Tract Infections aka URTI ranks top to see a doctor - it accounts for 29% in all private and public clinics . It is a wide diagnosis which includes acute infections involving the nose, paranasal sinuses, pharynx, larynx, trachea, and bronchi. It can mean anything from colds, laryngitis , pharyngitis to tracheobronchitis ( and shit that hurts) Let's not look at private clinics but rather at the public clinics since most subsidies go to them.
In public clinics , 18% is attributed to URTI and Hypertension - they share the ranking of no. 1 problem. Diabetes ranks 12% .
Let's look at the wider spending now based on MOH report 2004/03
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Polyclinics cost 99 million to run ( with community health nurses, diabetic education nurses and doctors plus the diagnostic tests, medications etc)
Inpatient services 609 million to run ( your biggest winner)
A&E services 49 million
Specialist outpatient Clinics 173 million ( compared to polyclinics that is a heck lot)
- did you say more specialists?
Day surgery 74 million
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90% (of the 609 million) goes into subsidised wards- not perfect but good enough.
Now let's divert our attention to WHO on chronic diseases
http://www.who.int/dietphysicalactivity/publications/facts/chronic/en/
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And let's look back at the Top 10 charts of death and disease.
Oh look 10 top causes of Death
1. Cancer
2. Ischaemic Heart Disease
3. Pneumonia
4. Cerebrovascular Disease (including stroke)
5. Accidents, Poisoning & Violence
6. Other Heart Diseases
7. Chronic Obstructive Lung Disease
8. Diabetes Mellitus
9. Nephritis, Nephrotic Syndrome & Nephrosis
10. Septicaemia
And let's look at Top 10 medical conditions requiring hospitalisation
1. Accidents, Poisoning & Violence <- cannot do much about it
2. Cancer <- like lucky draw - but risk can be minimised
3. Ischaemic Heart Disease <- can be prevented
4. Pneumonia <- OH wait LOOK it just started from URTI which may even have started from a cough or a cold , risk is higher in long term smokers with crappy lungs.
5. Cerebrovascular Disease (including stroke) <- hypertension is a risk factor .
6. Other Heart Diseases <- depending
7. Chronic Obstructive Lung Disease <- stop smokers - mostly smoking related
8. Complications related to Pregnancy
9. Dengue <- mosquito breeding season - hard to eradicate.
10. Obstetric Complications affecting Fetus or Newborn -
I rest my case that you have no idea what you are proposing about then. You want nurse practitioners in to lower your costs.Originally posted by snow leopard:quote:
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Originally posted by fymk:
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.
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you're a nurse yourself and setting a question for yourself. if you can answer that, i rest my case.
But you have obviously no idea of impacts and feasibilities. -
Originally posted by snow leopard:
quote:
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Originally posted by fymk:
the way to deal with chronic illnesses, as i have indeed mentioned before (where were u heh?), is to have more doctors treating chronic illnesses rather than attending to coughs and colds. as for missing out on preventing 'strategies', tell me is it not common every now and then that we get campaigns like "climb the stairs", "ask for less sugar" ... it's already very prevalent here for decades, not something you just discovered reading a book. but how come after years and years of campaigning, we are still campaigning? because we don't have so much bloody time to exercise trying to make ends meet.excuses excuses
The risk of cancer, heart disease , diabetes can be decreased through prevention. Decrease the risk of chronic diseases and you decrease the healthcare cost of looking after those who have chronic diseases. Even those with certain chronic illnesses can control their disease by a healthy lifestyle which minimises complications and minimising the need for expensive healthcare costs treating the complications .
so is that rocket science or some latest discovery? it's been around for decades mind you.
Yes my point exactly on why you shouldn't make excuses on not trying to be healthy.
oh, you can say all you want about preventive health, it's not new anyway and not effective so far ... unless we're all inmates in a camp or prison and you control the food we eat and the exercises we do.
hang on , let me look for statistics on that. I.e. Australia has already decreased their incidence of lung cancer by tobacco control . I will try to look for stats on singapore and compare - difficult as it might be
he has no choice, he has to do it to live. try telling that to the average singaporean who has no problems and probably has to work from 8 till midnight.
more excuses
if a population has a less amount of sick people. Why do you even need to increase your pool of specialist doctors?
you can reduce the number of sick people, but unless you lock people up in camps and prisons and impose a regimen on them, campaigns and posters can only get you so far. furthermore, chronic illnesses has a lot to do with old age as well, you can't prevent ageing can you? it is far more effective to increase the pool of surgeons.
Heart diseases are hitting young ones as well . Diabetes as well . I am well aware of the age factor but healthy living in old people are also good for their wellbeing.
we have compulsory medical savings and afforable insurances, which for the great majority of cases is sufficient for contingencies. problem is, one, two contingencies is sufficient to wipe out that savings. why? because medical bills are exhorbitant. so at the end of the day, finding the money to pay for contingencies is one thing. bringing down costs so that contingencies are affordable is another.
Appeal for help. I am sure subsidised wards are available - just not that great. Seen some people stay in B1 class to show off that they are well to do when in fact they cannot afford the bill later.
whether it is cough or cold or some other mild illnesses, whatever that the doctor is treating in his own private is clinic does not justify his training and qualification. that same relationship can be built with the new phamacist type doctors.
Oxford mushroom did say you have to train pharmacists to be doctors which means back to square one.
Any private doctor who runs his own clinic as a business has the right to profit from anyway he wishes after all he is not getting subsidies which the public clinics are. In regards to justification, all doctors have to perform their bond or pay it back to the govt. Private doctors already served their bonds and they should be allowed to earn money on their own right like any lawyer or accountant. why do you still want them tied down to public service? Like a business, a clinic depends on its customers. You don't want to spoil the choices that people have between a polyclinic and a regular doctor they see ,right? Quit the private talk because it is irrelevant to cutting down costs.
TALK about public clinics - that is where public monies are going into - that is an expenditure by the government and that is healthcare costing for the general population
you can reduce the number of sick people, but unless you lock people up in camps and prisons and impose a regimen on them, campaigns and posters can only get you so far. furthermore, chronic illnesses has a lot to do with old age as well, you can't prevent ageing can you? it is far more effective to increase the pool of surgeons.
Increase pool of surgeons = increase cost to healthcare. What's the logic? More competition? Unless you can lock up your surgeons in Singapore , I think they will move off once the going gets tough. -
Originally posted by oxford mushroom:
drug addicts out there, you know where to go
this is a condescending statement suggesting pharmacists cannot make equal judgement with regards to dispensing controlled drugs as compared to doctors.
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.
but how much of what the doctor learns in the five years is used in a clinic setting? remember, medical school is medicinal bachelor and bachelor of surgery. how often does the doctor in the clinic does surgery? if it's half the course that we need to train a clinic doctor, then rightfully it should just take 2 1/2 years.
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?
how complicated can diagnosis in a clinic setting be? you mean it takes five years for a doctor to learn if someone's geniunely having a cough or not? every time i see the doctor, it's the same few, simple procedures, nothing complicated. you want to know if he's having a fever, a thermometer does the trick. it's not rocket science and with training, nurses and pharmacists (when that happens we no longer call them by those names) can do an equally good job.
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..
as i've said before, who can continuously take MC without getting himself into trouble with his own company?
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...
i suppose the selection of medical undergraduates ought to be more stringent, so that we get more doctors with the quality to go all the way.
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?
we cannot look at just the income but have to balance it with cost of living too. 100K pounds converted to SGD becomes SGD $300k. but a one pound ice cream converted to SGD is also SGD $3. furhermore, if you're talking about pay differences, it extends to all the other professions as well, as i've said to fymk before when he tried to compare us with aussie, apart from the president and the prime minister, probably every other job pays better in the UK.
so if your question is why should mobile doctors stay here when he can earn more in the UK, it is the same question as why a lawyer, financial analyst, engineer ... would stay here when they can earn more elsewhere ...
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.
the global market afflicts all professions, not just the medical profession. the first world countries have higher standards of living and can always afford to pay more, be it for an engineer or an accountant. to the extent that people here can find greener pastures elsewhere, it reflects the degree of variation in standards of living or exploitation here.
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?
well if they have no where else to go but here, they should not mind those extra tests. safeguards both parties.
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..
who's complaining about $8 in polyclinics? do i have to remind you like i keep reminding fymk? not $8 per say but the under utilisation of manpower resources used to treat coughs in polyclinics, unless he happens to be a new doctor and is in need of training and exposure.
i have no problems with rich, old women paying $800 for botox. but if they take good doctors away from surgery and other specialties then that is a problem ... i can only hope that $800 limits the number of botox customers to just a handful, which in turn can only support just a handful of beautician doctors. -
Originally posted by oxford mushroom:
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.
do existing specialists who treat chronic illnesses get $5K? if not there is no reason why doctors from polyclinics who choose to become specialists of chronic illnesses would get $5K, would they?
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...
yes a nurse is not a doctor and i'm not expecting a nurse to just put on a doctor's coat now and start diagnosing MC cases like a doctor. i would expect some kind of selection and conversion for the most competent nurses / pharmacists to a level that he has the ability to assume the role of a doctor in a clinic setting. do not under estimate nurses, some of them really know their stuff well ...
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.
my primary interest in this thread is to highlight the fact that we do have many qualified doctors who can be trained to become surgeons if only they're not encouraged to take the easy way out by setting up a private clinic. how a minister balances his budget is hardly my interest. nevertheless i shall make comment. from a minister's point of view, there is no way he will allow cost of essential items to fluctuate 300% from year to year. he would set a budget for this year's expected medical costs, using last year's surpluses. any shortfall would result in a deficit, as simply as that. if next year, there is a budget surplus, then that deficit can be replaced back. however, if we suffer deficits year after year, then there is a fundamental problem with our economy that we need to rectify.
is it meaningful to ask dad how much pocket money you'd be getting when dad is out of job?
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..
the money is no more, not in medicine but in private clinics. other medical avenues are still lucrative, like surgery for example where it is most needed. if their training is medicine by profession, it would be hard for them to go into law or finance. mind you i am talking about doctors not pursuing specialties but opening up clinics instead. as for becoming a minister in the cabinet, there can only be that many cabinet ministers.
finally about going overseas, it is not just an issue with the medical profession but any other profession that is in demand all over the world. we're not, as i say again, making paupers out of doctors but nudging them to go higher and in turn earning more as well. -
Snow leopard
Let's cut the crap .
Let me refer you to all the working papers of specialist doctors and other health professional workforce issues in Australia . All the lovely issues of pushing them to a higher level .
Nurses, pharmacists, allied health professionals :http://www.health.nsw.gov.au/amwac/ahwac/index.html
Specialist doctors http://www.health.nsw.gov.au/amwac/reports.html
let's talk now about healthcare costs and how to reduce it .
WHO on reducing burden of disease
http://www.who.int/moveforhealth/advocacy/information_sheets/sedentary/en/index.html
New England journal of medicine - old but worth a look.
http://content.nejm.org/cgi/content/short/329/5/321
American ideas of reducing health costs since their healthcare system is always problematic
http://www.eip.sc.gov/costcutter/default.htm
http://72.14.203.104/search?q=cache:i4ZHfYvfZEIJ:web1.msue.msu.edu/home/outcomes/omfpapers/HealthCare11.pdf+reducing+healthcare+costs&hl=en&gl=au&ct=clnk&cd=5&ie=UTF-8
Healthcare Cost control
http://jama.ama-assn.org/cgi/content/abstract/288/15/1909
http://www.lww-medicalcare.com/pt/re/medcare/abstract.00005650-199901000-00003.htm;jsessionid=EJwxQ1E5V6Nn6lqo9PH5tlZK34Im4zGzgr33kwOOdqgBBCMMdjA2!-469394890!-949856145!9001!-1
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1117581
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8635258&dopt=Citation
http://bmj.bmjjournals.com/cgi/content/full/318/7177/182/
http://www.cmaj.ca/cgi/content/abstract/163/11/1435
http://www.ms-se.com/pt/re/msse/abstract.00005768-199911001-00026.htm;jsessionid=EJxBxNAP0QNYuSUJRmNdqCP1hHNxcmpr4T4YejQrPCRF3DiRcZ4O!-469394890!-949856145!9001!-1
http://content.healthaffairs.org/cgi/content/abstract/17/2/70 <- what I was trying to tell you. -
yes, we're not the same as the UK and as it is, if you propose what you proposed, the consequence that i painted, as disagweeable to you as it sounds, will result.Originally posted by oxford mushroom: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.
furthermore, people in the UK probably have more fulfilling jobs that they look forward going to everyday. taking the MC is an unwelcomed interruption to their happy working routine. on the other hand, many people here hold unfulfilling jobs and the dread and chore of going to a deadend job builds psychological stress that necessitates the MC for recovery. -
I think focusing on one side of the story is not going to solve anything.
I look at policy from a national level. You cannot implement things without just talking about the beauty of a one sided idea without knowing the possible impacts and consequences resulting from it.
I am not talking on a nursing level now - I given you the grassroot backlashes .
I am talking on a national policy level since I am dealing with it at work overseas tho. Let's get to the business of your idea
For all policies you have to go into the following properties :
Significance of the problem
Impact of the problem
Actions /Solutions
Alternative solutions
Cost efficiency
Cost effectiveness
Benefits socially and in health
Possible implications/backlashes of any implementation
Other contentious issues
Recommendations.
So call me intellectually challenged but I tend to look at things from a broader view than just saying "OH let's push doctors to a specialist level and let the nurse/pharmacist deal with minor ailments to reduce costs " . What are the potential backlashes? I have already given you the footwork by taking out the statistics in Singapore. You just need to start justifying your idea by using the properties of the policy proposal.Tell me where and who else have tried it and the economic results in terms of reduction of healthcare burdens. -
Originally posted by fymk:
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 asked me to make a survey before saying people want it. why don't you make a survey before saying people don't want it. who is adamant now? i adamant about nurse practitioners being viable or you being admant about nurse practitioners not being viable when it is actually functioning right under your noses?
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.
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; <- this is the knockback - RNs need at least 2-3 years to become a Clinical nurse specialist after their postgrad specialist qualification in a specialty area in Australia. Unless the RN have worked for 10+ years in the same area which means the RN will not have a wide scope of experience to draw back on. For midwifery , that might be a difference scenario but they can only deal with childbirthing not flus. For community health nurses , an RN needs at least 3 years in acute care especially emergency/cardiothoracic/critical care areas then they are able to work as community health nurse practitioner.
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.
you have listed many, many years of woking experiences, not years of studying in a school as pre-requisites have you?
so let me ask you, "work minimum 2 years", "5 years' post ... experience", "10+ years" ... are these not time well spent working as nurses and contributing to the nation's healthcare? it is not as though they have to spend an additional 2, 5 or 10 years in school to get their titles. they are working as per normal, treating patients and with experience gained from the 2, 5 or 10 years as nurses, they would have the chance to elevate themselves to manning a clinic. we are precisely choosing nurses that have commitment and innovation, those who have worked for years before we grant them the title of a clinic practitioner.
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) .
as i posted earlier, you are completely mistaken about the number of years the nurse has to sacrifice, where she is not contributing as a nurse or earning an income. as for limitations, i've said again there will be conversion training of sorts. and lastly, about indemnity, i have agweed right from the beginning that indemnity will have to be tightened up. why do you keep bringing it up like a broken record?
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?
i'm sure with all those years of experience and subsequent conversion training, they would be up to mark.
And I am just stating facts here.
you have stated many facts but offered little interpretation and has persitently misinterpreted posts. worse still, i have to teach you how to intepret the facts you have stated. -
stop that bullshit. you asked me whether i know how a nurse should know what a nurse should know. a nurse like you should know better. ask yourself are you competent? do you know your work? do you have confidence seeing patients for everyday kind of mild illnesses? if you do not, would others?Originally posted by fymk:I rest my case that you have no idea what you are proposing about then. You want nurse practitioners in to lower your costs.
But you have obviously no idea of impacts and feasibilities. -
Originally posted by fymk:
I think focusing on one side of the story is not going to solve anything.
I look at policy from a national level. You cannot implement things without just talking about the beauty of a one sided idea without knowing the possible impacts and consequences resulting from it.
i think you're the one who is one sided and not receptive to what i or Mr Oxford has to offer.
you're not looking from a national level but from an idealist level where people are inmates whose diet and exercise are controlled by you.
I am not talking on a nursing level now - I given you the grassroot backlashes .
show me the statistics of grassroots backlashes like you asked me.
I am talking on a national policy level since I am dealing with it at work overseas tho.
no wonder you're so ingrained and irreceptive to ideas, you think just because you are the actual policy maker you know best.
Let's get to the business of your idea
For all policies you have to go into the following properties :
Significance of the problem
Impact of the problem
Actions /Solutions
Alternative solutions
Cost efficiency
Cost effectiveness
Benefits socially and in health
Possible implications/backlashes of any implementation
Other contentious issues
Recommendations.
when you pay me to do the job you do, i will give you all that crap as well. for know it is about the conceptual feasibility. the fact that there is a working model right under your nose means not only conceptually but physically, it is feasible.
So call me intellectually challenged but I tend to look at things from a broader view than just saying "OH let's push doctors to a specialist level and let the nurse/pharmacist deal with minor ailments to reduce costs " .
i don't mean to call you intellectually challenged. if only you would interpret posts intelligently and also quote facts intelligently.
What are the potential backlashes? I have already given you the footwork by taking out the statistics in Singapore. You just need to start justifying your idea by using the properties of the policy proposal.Tell me where and who else have tried it and the economic results in terms of reduction of healthcare burdens.
what backlashes? isn't aussie a very good example of success of the scheme? don't be silly asking for the obvious please. -
Originally posted by fymk:
will you cut your crap and stop quoting here and there and sometimes using those quotes in a not so intelligent way?
Snow leopard
Let's cut the crap .
if you will present your interpretation of those ideas here concisely. -
I am no policy maker - I just look at them and stick to the facts
Did I say I was? I said I work with them . Look who is quoting who unintelligibly.
I just asked you to provide substantiation which you failed miserably and once AGAIN lame insulting excuses on why you should not.
Just because you got discounted by the facts , you don't need to behave so defensively. Just because you cannot answer my questions , don't need to lash out at me. Hey you want your idea right? Go and pitch it to people - and when they ask the same questions like I do - you have to answer the same questions.
Compare Australia and Singapore is like comparing Durians to apples.
How many states does Singapore have? 1. itself only . Singapore is the capital of Singapore.........hello? Big difference from a continent country.
How many states and territories Australia have? 8
Australia has a working model because of a different kind of reason like size and shortage of doctors . There are also problems with it if you had cared to read.
I passed on papers for references. You have no substantive thing to say if you cannot even look at them. Basically you are just another arrogant person who just thinks he knows best because he thinks so. -
Originally posted by fymk:
I am no policy maker - I just look at them and stick to the facts
Did I say I was? I said I work with them . Look who is quoting who unintelligibly.
i see, so you're merely working with the policy makers and claiming to be looking at it at a 'national level'. you're deeming yourself higher than you think you are?
I just asked you to provide substantiation which you failed miserably and once AGAIN lame insulting excuses on why you should not.
substantiation for what? isn't aussie a very good point for substantiation? you are the one who persistently fails in delivering good arguments not to mention miserable and lameduck examples that are easily refuted.
Just because you got discounted by the facts , you don't need to behave so defensively. Just because you cannot answer my questions , don't need to lash out at me.
this is becoming childish.
Hey you want your idea right? Go and pitch it to people - and when they ask the same questions like I do - you have to answer the same questions.
this is where i pitch it. and with the pitching i got one positive feedback. that is good.
Compare Australia and Singapore is like comparing Durians to apples.
How many states does Singapore have? 1. itself only . Singapore is the capital of Singapore.........hello? Big difference from a continent country.
How many states and territories Australia have? 8
you're the one who likes to bring aussie in the picture, remember?
Australia has a working model because of a different kind of reason like size and shortage of doctors . There are also problems with it if you had cared to read.
the fundamental problem is the same - shortage. and the solution that they applied can be applied here too. size of their country merely accentuates the shortage.
Basically you are just another arrogant person who just thinks he knows best because he thinks so.
it is the same feeling i get about you. -
Originally posted by fymk:
excuses excuses
excuses to some extents yes but in a very real way, many people are too bogged down with life to afford the time to exercise.
Yes my point exactly on why you shouldn't make excuses on not trying to be healthy.
i'm not making excuses, just stating the fact that many people have to put in long hours just to earn a livelihood and many people have mutiple commitments, especially mid career professionals
hang on , let me look for statistics on that. I.e. Australia has already decreased their incidence of lung cancer by tobacco control . I will try to look for stats on singapore and compare - difficult as it might be
we do have regular anti smoking campaigns you know? Taufik is our anti-smoking ambassador.
Heart diseases are hitting young ones as well . Diabetes as well . I am well aware of the age factor but healthy living in old people are also good for their wellbeing.
but how many heart diseases are hitting young ones versus how many are hitting the older ones? healthy living is well and good but it is a simple fact that all the major problems start cropping up when we grow old.
Oxford mushroom did say you have to train pharmacists to be doctors which means back to square one.
refer to my reply to him then. it is not back to square one.
Any private doctor who runs his own clinic as a business has the right to profit from anyway he wishes after all he is not getting subsidies which the public clinics are. In regards to justification, all doctors have to perform their bond or pay it back to the govt. Private doctors already served their bonds and they should be allowed to earn money on their own right like any lawyer or accountant. why do you still want them tied down to public service? Like a business, a clinic depends on its customers. You don't want to spoil the choices that people have between a polyclinic and a regular doctor they see ,right? Quit the private talk because it is irrelevant to cutting down costs.
we are not denying their right to start and own a business, just allowing other adequately competent people to start and own their businesses and allowing society at large to enjoy the same services at better prices.
just because you can't see it, doesn't mean it is irrelevant.
TALK about public clinics - that is where public monies are going into - that is an expenditure by the government and that is healthcare costing for the general population
but i thought you're looking at the problem from a 'national level'? why exclude the private sector from the picture? the crux of the issue is that good doctors are being poached by private hospitals so there is an acute shortage in public hospitals. they are interlinked, you cannot see the whole picture, just by looking at one side.
Increase pool of surgeons = increase cost to healthcare. What's the logic?
you got the logic wrong. increase pool of surgeons, means price of surgery goes down. when price goes down more than increase in supply, healthcare costs goes down.
More competition? Unless you can lock up your surgeons in Singapore , I think they will move off once the going gets tough.
it would be a delicate balance, the change over will be gradual, there will be plenty of other avenues for doctors to achieve even higher levels and profitability. as for intenational competition for talent, it is a problem that afflicts all occupations, not just the medical profession. -
this is a condescending statement suggesting pharmacists cannot make equal judgement with regards to dispensing controlled drugs as compared to doctors
They have different training and different roles. Pharmacists can and do dispense controlled drugs but they do not have the right to prescribe them. That remains the job of the doctorhow much of what the doctor learns in the five years is used in a clinic setting? remember, medical school is medicinal bachelor and bachelor of surgery. how often does the doctor in the clinic does surgery? if it's half the course that we need to train a clinic doctor, then rightfully it should just take 2 1/2 years.
2.5 years will not be even enough to train a nurse, much less a doctor. Why don't you look around for a medical school somewhere in the world with such a course?
how complicated can diagnosis in a clinic setting be? you mean it takes five years for a doctor to learn if someone's geniunely having a cough or not?
It takes at least 5 years (probably more) of training and experience to be confident enough to DENY an MC to a malingerer....even then doctors have been known to get it wrong. You think a nurse with 2.5 years' training can do that?as i've said before, who can continuously take MC without getting himself into trouble with his own company?
Ask the many who will be taking MC soon to watch the world cupi suppose the selection of medical undergraduates ought to be more stringent, so that we get more doctors with the quality to go all the way
With a global pass rate of 40%, assuming that doctors from UK and Australia aren't all fools, how many of these top-quality doctors you will find in Singapore? And if you do find these rare gems, why should they take a lower pay than what they can get overseas?
You are right about demand and supply. If you demand the best, the supply is more limited and you have to pay more for them.so if your question is why should mobile doctors stay here when he can earn more in the UK, it is the same question as why a lawyer, financial analyst, engineer ... would stay here when they can earn more elsewhere ...
Exactly...how many lawyers, financial analysts, engineers from Singapore have qualifications that will enable them to compete favorably with those overseas? If they can, they will go and we will have to pay more if we want them here. Doctors have qualifications that can allow them to go...Many Indian doctors had to sit entry examinations to get to work in the UK and those who fail will have no choice but to accept lower pay in Singapore. To get my UK General Medical Council registration, I just walk up to the counter, show them my certificates and pay a $75 adminstrative charge. Unfortunately, not many of our accountants are chartered accountants and not many of our engineers are chartered engineers...
..the global market afflicts all professions, not just the medical profession. the first world countries have higher standards of living and can always afford to pay more, be it for an engineer or an accountant.well if they have no where else to go but here, they should not mind those extra tests.
True, but our tests must be easier than the ones in UK that they have failed right?not $8 per say but the under utilisation of manpower resources used to treat coughs in polyclinics
And fymk is saying that the bulk of government healthcare expenses go to inpatient care. If you want to cut healthcare costs significantly, you have to get cheaper drugs, cheaper doctors and nurses for the public hospitals.
I have also said minor coughs and colds don't require a doctor's attention, it's the MC that people want. If we abolish the MC system today, I bet there will be fewer attendance in the polyclinics tomorrow.i can only hope that $800 limits the number of botox customers to just a handful, which in turn can only support just a handful of beautician doctors.
Well, if I were a GP finding that I have to lower my charge per consultation from $25 to $15 because of competition, then I will start offering botox at $650 instead of $800. Why treat diabetes in that case? -
do existing specialists who treat chronic illnesses get $5K? if not there is no reason why doctors from polyclinics who choose to become specialists of chronic illnesses would get $5K, would they?
Of course not. Don't you get it? If they are specialists with equivalent skills and qualifications, they would demand a similarly high salary. So how will you lower healthcare costs in the polyclinics?i would expect some kind of selection and conversion for the most competent nurses / pharmacists to a level that he has the ability to assume the role of a doctor in a clinic setting.
And I say that to do that they have to go through medical school.however, if we suffer deficits year after year, then there is a fundamental problem with our economy that we need to rectify.
That is not good enough for the patient who needs medical treatment in a recession. Relying on surpluses to fund the healthcare system is worse than relying on gambling winnings to put food on the table.
It is a very irresponsible dad who relies on Gentings for his son's pocket money.mind you i am talking about doctors not pursuing specialties but opening up clinics instead
Not sure what you mean...presume you mean doctors who work as private specialists rather than working in public hospitals. That's my point, doctors will work in the private sector and overseas where they will earn more than in public hospitals if we lower their pay in government hospitals. If you don't lower their pay in order to keep them, you cannot lower healthcare cost.
As I said, I think the government is already addressing this issue of training. The Minister has said that we are recruiting bright foreign students to supplement our limited talent pool to produce a new breed of clinician-scientists (doctors who are also PhD scientists). They will deliver the high tech medicine that will attract foreignh and paying patients to Singapore. As for poor patients who want cheap, basic medical care in our public hospitals, we are recruiting cheap, foreign doctors who are not as qualified. -
Originally posted by oxford mushroom:
They have different training and different roles. Pharmacists can and do dispense controlled drugs but they do not have the right to prescribe them. That remains the job of the doctor
that's why i am suggesting that the pharmacist's training and role ought to be expanded so that he can take on the doctor's job in a clinic setting.
2.5 years will not be even enough to train a nurse, much less a doctor. Why don't you look around for a medical school somewhere in the world with such a course?
firstly, only competent and experienced nurses would be considered for the position. the fact that they have a wealth of experience means they probably know more than a freshie doctor who just completed 5 years medical school. next, the selected nurse would probably have to go through some kind of conversion course. the fact that she only needs to know the medicinal bachelor portion of the MBBS course means she doesn't have to go through the entire 5 years but selected modules to earn her wings. that's where 2.5 years comes in, it represents the medical bachelor portion of the MBBS course. with the nurse's experience, it can even be cut down to a year perhaps.
It takes at least 5 years (probably more) of training and experience to be confident enough to DENY an MC to a malingerer....even then doctors have been known to get it wrong. You think a nurse with 2.5 years' training can do that?
but we are choosing experienced and competent nurses for such positions, experienced enough to deny the MC. you are mistaken. i meant, an experienced nurse with additional training on the medicinal portion of the MBBS course, which cannot be 5 years for otherwise you would have no time for the other surgical portion.
Ask the many who will be taking MC soon to watch the world cup
but that's only once in four years right? even the CEO might be taking MC to watch world cup. i remember when South Korea was in the semi finals, many companys officially set up TV boxes to watch world cup in the office.
With a global pass rate of 40%, assuming that doctors from UK and Australia aren't all fools, how many of these top-quality doctors you will find in Singapore? And if you do find these rare gems, why should they take a lower pay than what they can get overseas?
we need not restict ourselves to the UK, there are many more prestigious medical schools in the US.
You are right about demand and supply. If you demand the best, the supply is more limited and you have to pay more for them.
the alternative would be to increase supply, so that you don't have to pay more for them.
Exactly...how many lawyers, financial analysts, engineers from Singapore have qualifications that will enable them to compete favorably with those overseas? If they can, they will go and we will have to pay more if we want them here. Doctors have qualifications that can allow them to go...Many Indian doctors had to sit entry examinations to get to work in the UK and those who fail will have no choice but to accept lower pay in Singapore. To get my UK General Medical Council registration, I just walk up to the counter, show them my certificates and pay a $75 adminstrative charge. Unfortunately, not many of our accountants are chartered accountants and not many of our engineers are chartered engineers...
you mean you can get your "UK General Medical Council registration" just by showing your NUS MBBS degree?
True, but our tests must be easier than the ones in UK that they have failed right?
i'm talking about tests to become clinic doctors to provide basic healthcare, not tests to become specialists. granted MBBS courses aren't too different everywhere, there is no reason they should not pass. it is a safeguard just to make sure they are up to mark.
And fymk is saying that the bulk of government healthcare expenses go to inpatient care. If you want to cut healthcare costs significantly, you have to get cheaper drugs, cheaper doctors and nurses for the public hospitals.
cheaper drugs can come from combined purchases from many hospitals though there is a limit to how far you can go. cheaper doctors can only come about when you have more doctors for inpatient care, which means we have to somehow move doctors from private clinics to inpatient, which consequently requires some mechanism for their work to be taken over by competent and experienced nurse / phamacist practitioners.
i've explained this many times already.
I have also said minor coughs and colds don't require a doctor's attention, it's the MC that people want. If we abolish the MC system today, I bet there will be fewer attendance in the polyclinics tomorrow.
but i've also said that certain controlled cough mixtures cannot be obtained over the counter from the pharmacist. so it is not just the MC really. we shouldn't be going through this again.
Well, if I were a GP finding that I have to lower my charge per consultation from $25 to $15 because of competition, then I will start offering botox at $650 instead of $800. Why treat diabetes in that case?
but if there are only say 200 old ladies here rich enough to pay for botox every other week, even if i want to go into botox, i would have to consider how many beautician doctors are already out there and whether or not there is enough business for me right? -
Originally posted by oxford mushroom:
Of course not. Don't you get it? If they are specialists with equivalent skills and qualifications, they would demand a similarly high salary. So how will you lower healthcare costs in the polyclinics?
then clinic doctors who become specialists would not get $5K, they would get close to what these specialists are getting initially. we have a shortage of specialists. that can only mean two things. specialists are currently overworked trying to meet the demand and patients have to wait longer for critical operations that may save lives. when we increase the supply of specialists, even if their salaries do not go down at first, it means either specialists can spread out work more evenly so that they are less overworked and less inclined to cross over to the private sector, or it means that more patients can be handled than before.
so even though let's say instead of having one specialist earning a million, we might have two specialists earning $2 million. does it mean that the price we are paying for healthcare has doubled? no, it is still $1 million for one specialist, but we get twice the amount of patients getting operated on.
in the long term, when the shortage is eased and there are enough specialists around, the price of specialists will go down.
And I say that to do that they have to go through medical school.
not the enitre school, coz you hardly perform surgeries in the clinic and MBBS is half medicinal bachelor and half bachelor of surgery.
That is not good enough for the patient who needs medical treatment in a recession. Relying on surpluses to fund the healthcare system is worse than relying on gambling winnings to put food on the table.
you didn't read me right. there would be budget for healthcare based on what we need. but the money that goes to foot this healthcare budget would come firstly from last year's income and if that is not sufficient then we would have to take from surpluses won't we? worse come to worse we borrow. never is there a question of the patient not getting medical care even in a recession.
i don't quite understand you. let's say you are the health minister and this year's healthcare budget is $40 billion. are you saying we won't pay for this from last year's surplus? we won't even pay for it from all the surpluses we have accumulated all these years? where then would you get the money to pay for healthcare?
It is a very irresponsible dad who relies on Gentings for his son's pocket money.
but you have wronged the dad. he is not relying on Genting for the family's needs. he draws firstly from his paycheck last month and if that is insufficient, from his life savings for the son's pocket money.
Not sure what you mean...presume you mean doctors who work as private specialists rather than working in public hospitals.
that's not what i meant. i meant doctors becoming specialists be it in private hospitals or public hospitals rather than setting up a clinic to treat everyday outpatient cases.
As for poor patients who want cheap, basic medical care in our public hospitals, we are recruiting cheap, foreign doctors who are not as qualified.
i feel our good, old experienced nurses are a better choice. we don't have to deny either source of doctors. we just test them thoroughly and whoever makes the grade or impresses surely deserves the chance? -
The statistics are all on MOH's website . I just quoted where the bulk of money goes to.
Anyways, nurses who want to be doctors can be doctors - same for the pharmacist. Doesn't matter if you are clinical nurse specialist.
In Australia.
If the nurse has the bachelors, Grade point average must be at least 3.5 for everything with double weightage given to the third year.
Then the nurse takes the GAMSAT which is worse than the MCAT - score about 60% percentile to ensure an interview into a recognised university. If they pass the interview which is not too easy- it will be 4 years minimum for the medical degree.
But then again snow leopard makes it sound so easy.
First of all you have to get NUS or NTU to agree on a 2.5 shortcut medical degree. Then you have to get people to pick and choose out of the syllables to give the nurse /pharmacists a qualified recognition.
- 1. Everything is evidenced based now - you have to ensure half the degree is made out of how to scrutinise evidence based research.
-2. You need to retrain them on pathophysiology , anatomy which takes at least 3 years from theory to application .
So snow leopard - you have ideas - so how would you implement it?