10 August 12 The Straits Times
FORTIS Colorectal Hospital is Singapore's smallest and newest hospital, with only 31 beds. It is also the butt of jokes as the first such specialist hospital dedicated to bowel conditions in South-east Asia. But its CEO, Dr Jeremy Lim, 39, has serious, outsized, almost monumental hopes for it.
He is counting on it changing the face of private practice here.
The public health specialist, who left SingHealth last year to set up Fortis Healthcare group's 76th and smallest hospital here, wants it to be a class act which provides top-notch clinical services, research and teaching too.
He has inked a public-private research initiative to establish a $4.5 million colorectal tissue repository with A*Star's Institute for Bioengineering and Nanotechnology to enable research into colon cancer genetics, and set up a first in South-east Asia "Centre of Excellence" with American medical device firm Medtronic to treat patients with bowel incontinence.
Through his hospital, he hopes to address the "false dichotomy" between public and private health care and the unhelpful caricatures of both that prevail.
For one thing, he wants Fortis to be both a good teaching and research hospital, not just treat patients.
"We want to be at the leading edge not just today but also in 10 years' time," he says, adding that the most scathing and often justified criticism levied against private-sector doctors is that they stagnate clinically. Unlike in the public hospitals, there's no base salary or training funds for professional development. "So in emphasising teaching and research, we will either live up - or down - to expectations," says the former executive director of the Lien Centre for Palliative Care.
It irks him when people talk as though "the private sector is concerned only with profit and has scant regard for patient safety" and the public sector is viewed "as noble, striving against the beast of commercialism to provide health care for the poor".
He retorts: "There are many doctors in the private sector who gladly waive fees for the needy, just as there are public-sector doctors who almost exclusively treat private patients, leaving subsidised patients to inexperienced juniors."
Light needs dark
A GENERAL surgeon by training, Dr Lim spent more than 10 years in the public sector as a Ministry of Health senior consultant overseeing clinical services planning and SingHealth director of Research and Education. He notes that many doctors, like him, have left public health care for the private sector, but retain their instincts and innate values in wanting to do good for patients.
"But once we exit into the private sector, suddenly, oh no, these guys cannot be trusted; they will fleece the patient.
"Really, what has changed in this space of 24 hours? One day you are one of the loyal, dedicated people who remain in the public sector. And the next, you've crossed to the dark side. Such caricatures don't engender constructive dialogue," says the National University of Singapore medical school alumnus who has a master's in public health from Johns Hopkins University and is president of the Fulbright Association (Singapore).
It's partly a system failure too, he avers. "If we are 'enemies', it is because of system design," he says. He's referring to the fact that private hospitals are not allowed to recruit doctors from overseas directly because of restrictions imposed by the Singapore Medical Council. This leaves them with no choice but to compete with the public sector.
He disagrees with those who take the view that private-sector hospitals won't be able to provide adequate supervision for foreign doctors of uncertain quality.
Private-sector workloads and patient volumes are lower than in the public sector, which give senior clinicians more time to supervise and strengthen patient safety. Private doctors also build careers on their reputations, "so we are unlikely to bring in someone from overseas who will compromise our reputation both as an organisation and as individuals".
"I would argue that the private sector will be far more concerned about the calibre and the quality of the doctors that we bring into Singapore."
The Government's answer to the brain drain from public to private sector is to raise public salaries, a cost ultimately borne by taxpayers. There's also a "Visiting Consultant" scheme that allows private-sector doctors to see patients, teach medical students, and do research in public hospitals, which he says "works better in theory than practice". A better solution, he says, is to see the health-care system as one ecosystem. This way, resources of both private and public hospitals can be pooled to meet rising health- care needs in an ageing society.
Government polyclinics and government hospitals are overstretched as patients who want subsidies need to go to these institutions. Some private GPs and specialists, meanwhile, complain of falling patient numbers.
Why not make the subsidy portable - give a patient a fixed subsidy amount for a certain type of treatment and then let him choose whether he wants to be treated in a government or private hospital.
Dr Lim notes that Australia has a "voucher system", where people are given a government grant to use at a public hospital, or can top up to get treated privately. In Australia and Britain, doctors straddle both the public and private sectors, caring for public patients, doing research and teaching in the public system, and supplementing income in the private sector. Some public and private hospitals even exist in the same building.
He applauds recent changes along this path in primary care. Health Minister Gan Kim Yong recently expanded the Community Health Assist Scheme to allow those with a per capita monthly household income of $1,500 and below to get subsidised treatment at private GPs and dental clinics. Currently, he says, there is a severe load imbalance. The public sector is doing more than it should and the private sector is doing less than it is able to.
"From an engineering point of view, we have two machines. One is performing at 120 per cent capacity. The other is performing at 60 per cent," says the father of three who is married to a paediatric anaesthetist at KK Women's and Children's Hospital.
Milk and honey
HE LETS on that a number of private-sector specialist practices, including Fortis, have offered to treat subsidised patients in their own clinics at the same rates the patient pays in a restructured hospital plus the usual government subsidy. So far, the answer has been "no" but he is pressing on.
Asked why private specialists prefer to see subsidised clients in their own clinics, he explains: "Overheads - for clinic rental and nurses' wages - are already sunk in. The nature of private practice is that few patients are on appointments scheduled weeks ahead. If specialists are not in their clinics half the time but attending to patients in government hospitals, their colleagues start to refer patients to others."
From a service point of view, he adds it makes sense because public hospitals are bursting at the seams. "There are not enough consult rooms and operating theatres. And it doesn't make economic sense to build more in the public hospitals and leave the ones in the private sector empty because the doctors are being visiting consultants in public hospitals."
It is not entirely altruistic, of course. Many private specialists, who used to see up to 40 patients a day when they were in the public sector, now see maybe 10 or fewer a day. "For those who want to be at the forefront of sub-speciality practice, in terms of science and technology, volumes matter." Not to mention, tending to subsidised patients - after the fairly generous government subsidy is factored in - will help private doctors pay their bills too.
He maintains it is good for patients and the health-care ecosystem here to open up the private sector - as a new frontier in terms of medical capabilities - to treat subsidised patients. "At the same time, we can help to decant patients from the public sector. Why do patients need to wait six to 12 weeks if they can get an appointment within a week?"
But isn't the long wait a means of stemming the flood of demand for health care, that will likely surge when patients can speedily get treatment by private specialists at subsidised rates? And who will pay?
The former national chess player, who has spent years studying health-care systems worldwide and teaches, writes and researches copiously on the issue, agrees rationing by queues and waiting is a reality in every health system. But it needs careful calibration so that patients' health-care needs are not compromised, he adds.
He suggests other control measures include assessment of clinical need and also pre-qualifying only certain private health-care groups which have good clinical outcomes and price transparency.
On the question of who will pay, he says the citizen - through taxation - is already paying.
"The Government here functions as a commissioner of services on behalf of citizens, and as commissioner, can and should set fair rates and quality standards to ensure that citizens obtain the best possible health care in a timely and affordable manner. There should be no arbitrary distinction between 'public' and 'private' - what should matter to the Government as commissioner is which organisations can provide the sought-after health-care services in the most quality- and cost-efficient manner."
Singapore, he says, needs to remove "ideological blinkers of who is good, bad, efficient and inefficient". "We're all good in different ways. But we could be so much better together. The public and private sectors should be like milk and honey. Individually, each has some benefits, but taken together, their healing properties are enhanced."
Susan Long will be taking a break. The Long Interview resumes on Sept 28.