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Recently, the usage and waiting times of A & E, polyclinics and other outpatient services as well as the workload of public sector doctors have been discussed and highlighted on various occasions by the media, doctors and even the government lately. Are doctors overworked? Are waiting times too long? Are patients going to A & E unnecessarily? Perhaps, perhaps not.

Let us look first at the polyclinic. The polyclinic is perhaps the simplest health care institution to examine. Some may lament that there are too many patients relative to doctors. As a result, doctors do not spend sufficient time with each patient and waiting times are too long. A quick possible remedial action would be to double the number of polyclinic staff, from doctors to health attendants. But one big problem remains; there is practically no means test for patients to qualify for the hefty polyclinic subsidies. Practically anyone can walk into a Polyclinic to see a doctor, from tycoons, professionals, bus drivers to the aged, destitute and young. The only means test is what I call the GST2 (to differentiate from the original GST), ie. the Gluteus Stamina Test. As long as one has the stamina to sit in a polyclinic from 1 to 3 hours, one gets to see a doctor for $7, maybe even $3.50. So while a quick infusion of staff may cut the waiting time dramatically in the short run, slowly but surely, the workload of each doctor will still creep up to 70 or so a day in the medium or long-term. That is because the current long-term equilibrium is determined by the waiting time tolerance of patients (GST2), which is I guess, up to at most 3 hours, but generally about 1 to 2 hours. Simple economic theory states that short-term equilibrium will move towards the long-term equilibrium. Therefore, even if we double the number of polyclinic MOs, it will not be long before all these young and frail doctors will be seeing 70 a day again and they will start complaining and comtemplate resigning again.

Perhaps we need to question assumptions once in a while, as the Prime Minister pointed out recently. Should the Gluteus Stamina Test be the only means test for eligibility to receive polyclinic subsidies or should there be others? Surely, the old, young and destitute deserve every bit of help they can get, but how about economically productive individuals? Surely, even blue-collared workers like factory production line workers and bus drivers are paid enough nowadays to afford private GP fees charged for the treatment of ailments that should be treated at the primary health care level. Or have we nurtured a welfare mentality that demands subsidised health care when we think nothing of spending $7 to see a movie (excluding snacks which is about the cost of medicine in polyclinic) or $7 to $8 for a haircut at a barber (note: not hairdresser but barber)? I don’t know, but honestly, I am old enough to remember spending 50 cents on a movie ticket at an open-air cinema in Holland Village and I wince at seven bucks. And it would be reasonable to surmise that an average working adult visits the barber or hairdresser at least as frequently (if not more) as he visits the polyclinic or his family doctor.

Let us move on to A & E. The recent announcement by the government of its intention to review A & E fees is timely. It could be an admission that patient education alone will not achieve the aim of offloading unnecessary workload from A & E departments. Price and charges will have to play some part in achieving this regulation of workIoad. This is because inefficiencies will always be exploited in a market economy. No matter how altruistic some may be, there will be others who will take a good deal when there is one.

The conclusion that can be made is that we should not call those who unnecessarily use A & E, polyclinic and even Specialist Outpatient Clinic services, “irresponsible” and “kiasu”. They are merely exploiting market inefficiencies, as clever people are supposed to in a market economy. 

Some of our health care services may indeed require a more comprehensive workload regulator than the Gluteus Stamina Test. Waiting time may be more than an indicator of service quality. It may itself determine service quality in the absence of other regulators such as charges. For example, a polyclinic doctor who is perfectly competent to do a simple toilet and suture for a small laceration will refer such a case to A & E because he is given 6 minutes on the average to see a case (Not many doctors can assess, clean and sew up a laceration in 6 minutes, especially when polyclinics are often big buildings with treatment and consultation rooms located some distance apart.) Service quality of both the polyclinic and A & E suffers. Polyclinic is doing less than it is capable of in terms of physical facilities and skills (but not time). The A & E waiting times aIso go up. If practically every working adult can afford SOC, A & E, private GP and polyclinic charges, then the differential ability to wait among patients determines who goes to these health care institutions on which occasions. This is especially so when other obvious determining factors, such as the severity of symptoms and financial affordability are equal.

Affordability can be measured in dollars and cents as well as in minutes and hours.