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"it is hoped that through such dialogue sessions, there
will be better understanding of the issues and
challenges on the delivery of healthcare in Singapore."
- Dr Chee Phui Hung

"Alumni Dialogue Session With Minister"
Speech by Dr Chee Phui Hung on Friday, 8 February 1999 at Alumni Medical Centre at a lunch in honour of The Minister of Health, Mr Yeo Cheow Tong.

The Minister of Health, Ladies & Gentlemen,

This is one of the sessions in Alumni’s programme of get-togethers with Ministers, Permanent Secretaries and other personalities involved in the entire spectrum of health care. It is hoped that through such dialogue sessions, there will be better understanding of the issues and challenges on the delivery of healthcare in Singapore. Such sessions also provide for opportunities on how, as a concerted effort, we can deal with these issues in an optimal way.

The escalating cost of modern medicine arising from the demand for the latest treatment and an aging population has serious implications even in rich and developed countries like the United States. Even the holiest of holy cows, the British National Health Service is now under severe strain and is being reformed. It is heartening that our Ministry of Health is taking steps to anticipate problems that will arise. The Minister’s recent statements on Casemix and the National Medical Audit Programme are to be taken in this context.

I was asked three days ago by the Alumni’s President, Professor Arthur S M Lim to bring up some issues to the attention of the Minister, and for discussion and input by this distinguished gathering especially by the array of University dons led by the Vice Chancellor and his deputies. I shall briefly mentioned four healthcare issues. 

1. Casemix

Until 3 days ago, Casemix was just a confusing term to me. Since then I have read the Minister’s Statement on this subject and just last night in the Singapore Medical Journal an article by J Cheah and Chee Yam Cheng entitled "Casemix for better or for worse." On the whole, the concept of Diagnosis Related Group or DRG is innovative. It is fiat accompli by the Ministry and should be supported by the medical fraternity. However, I have some reservations.

Professor Don Hindle, an architect of the Australian casemix system also observed recently in a paper entitled "Casemix funding in Australia – Time for a rethink?" (MJA Vol 168 June 1 1998) that "no matter how enthusiastically it is applied, casemix, as implemented is not sufficient because it is unsuited to the task of management at a higher level than a single institution. Furthermore it does not deal with the problem of health gain; it says something about costs, but little about value."

The Minister has stated that they have decided to adopt the AN-DRG ie. The Australian National DRG. Is it in toto? Why not adapt instead of adopt? I would prefer a DRG with Singapore characteristics. I understand that a pilot scheme has started in Singapore General Hospital and in Changi General Hospital. Several teams have been and are being sent to Australia to study the Australian system. I hope that before a DRG is fully implemented, factors peculiar to Singapore will be studied and included. Also, the Ministry must allay the suspicion that schemes such as the DRG and the Medical Audit are intended for the control of the private sector. 

2. Non-doctor administrators

This matter has been touched upon by the President of our Medical Alumni Association in an article entitled "Medical Dilemma _ Vision into the 21st Century" in the 75th Diamond Souvenir Magazine. Professor Arthur Lim wrote, "Unfortunately, administrators tend to ‘treat’ patients as figures and statistics... My concern for medical progress and the quality cure of patients lies in the increasing participation of highly intelligent, well-meaning competent administrators with limited understanding of medicine."

The solution must be to send doctors with potential to be administrators to do degree courses in hospital and healthcare administration. I did bring this matter up with Mr Goh Chok Tong, when he was the Health Minister some years ago. I also hear that doctors are being asked to do degrees in Public Health. They are to be future administrators. Frankly how does a degree in Public Health qualify a doctor to be an administrator?

We are lucky that we have in our minister, someone who is a second-time Minister in the Health Ministry - not a freshie. Also our senior Minister of State, Dr Aline Wong, has been with the Ministry for a long time. I hope that their exposure to doctors will have rubbed off on them so that they are more sympathetic to the plight of the patients than to the bottomline of profit and loss. 

3. The MOH and the University

We are glad to note that the rift between the two has been healed. It was ridiculous that at one time the National University Hospital was under the Minister of Education. Now it is directly under the Minister of Health. I think that all hospitals should be under the Ministry of Health. Also there should be closer rapport between the Faculty of Medicine and the MOH for important policy decisions such as the intake of yearly cohorts and undergraduate clinical postings in public hospitals and perhaps in future even in private hospitals.

The appointment of Associate Deans is a progressive move. Why has it taken so long? I could give another suggestion. Why not assign university professors to restructured hospitals and hospital heads to the NUH for six months or a year so that they can have first hand knowledge of the respective styles and culture? 

4. Health care organisations as publicly listed companies

The Government has allowed health care organisations to be listed as public companies on the Stock Exchange. Investors in public companies are primarily if not solely interested in returns on their investments. There was a recent case when some doctors here gave profit guarantees to investors. Luckily they later withdrew the guarantee. One hears of Australian doctors protesting when an American health care corporation wanted to move into Australia. Singapore is the South East Asian hub for many things. We can expect such healthcare organisations to come into Singapore and use it as a base to go into the region. If not for the financial downturn, probably some would have already done so. I hope the Ministry will study the implications and problems involved.

These are my concerns on the four healthcare issues which I hope will be discussed by the well-qualified audience here.