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     FrontPage Edition: Sun 30 March 2008

Promoting clinical research in public hospitals


Promoting Clinical Research In Public Hospitals
Speech By Khaw Boon Wan Venue: Merchant Court Hotel, Singapore 26 Mar 2008
Over the past 40 years, the standard of our healthcare services has gone up from third world to first.
We achieved this at a relatively low total cost to society. While other developed countries spend at least 7% of their GDP on healthcare, our spending at 4% puts us in the same band as the developing countries.
We Have Done Not Too Badly
How was this possible?
First, we waste less. As patients co-pay their fair share of the cost, there is less over-consumption. This link between payment and consumption is a fundamental pillar of our healthcare financing policy.
Second, there is less over-servicing and our doctors generally do not over-treat their patients. The recent public debate over questionable aesthetic treatments by some doctors suggests an exception but over-zealous consumers are part of the cause.
I was reading the Sunday Times over the weekend and the Sunday Times did a good job of surveying a range of opinions on patients who have used some of these treatments like mesotherapy and the opinions expressed not surprisingly covers a wide range.
While many agreed with the decision the MOH has taken, but as you can see, there are some who wanted us to do even more than we should - ban it and prevent people from putting out such treatments.
But on the other hand, there are others who think we should just leave things alone and leave the doctors to decide for themselves and the government should not interfere.
So there lies the difficulty of regulating this business called the beauty business. It is thankless job. But all I know is if tomorrow a bad accident happens and some patients end up with severe complications, all these people who expressed different opinions will gel together and condemn us for not regulating more tightly and say: “I told you so.” So that’s our karma.
I take a practical approach. Let us focus on where safety potentially can be compromised and regulate tightly those areas and leave the rest of the treatments to the professional bodies such as academies like the college of family physicians.
The professions ought to self regulate. As they do, I hope everyone sees the larger picture that one of the strengths of Singapore healthcare is our pool of ethical doctors. The vast majority practice ethical medicine and as a result there is trust and confidence of Singaporeans looking up so the medical profession remains respectable and people look at it with great respect.
I think it would be a pity if the profession for whatever reasons began to erode those ethical values and therefore the profession as a group must start thinking about how to regulate this very tricky area of beauty business. Do not allow a small minority who do this for personal financial reasons tarnish the reputation of the entire community.
Third, public hospitals are dominant players and we actively prescribe lower-cost alternatives, whether it is generic medicine or standard implants. We do so without compromising clinical quality.
But there is constant pressure to change the status quo. Patients demand higher subsidies to lower their co-payments. Doctors would prefer greater freedom to practice medicine without having to worry about the cost of treatment.
I once had a very good discussion with this professor from St Jude in the US. They are so well endowed with charity funds that he said for doctors working with St Jude, its like heaven. We never need to worry about how much things cost. Do as you wish, as you think best for your patients, he said. And often for the patients’ families, they fly in the families to visit the patients, with hotels and flights all paid for. So that is heaven.
But we are not in heaven. Certainly not in Singapore. Many consumers equate the latest drugs and high-tech equipment as better care.
In healthcare, the fundamental problem is that of demand exceeding supply. But demand is not always necessary. Hence public expectations have to be managed to reduce unnecessary demand. We have not done too badly in this regard.
Policies Need Regular Adjustments
First, we evolved our own healthcare financing model based on the 3Ms framework to support the co-payment philosophy while keeping healthcare affordable to all.
Second, we systematically rebuilt our hospitals and clinics and brought them up-to-date with the practice of modern medicine.
Third, we modernized hospital management, corporatised the hospitals and subjected them to greater commercial discipline.
Fourth, we re-organised the hospitals and polyclinics into vertical clusters to promote greater integration of care between the specialists and polyclinics and GPs. Patients will benefit if healthcare can be delivered more seamlessly. Vertical integration is the way to go, but it has taken time and will take us some more time to execute this well.
Going forward, we will continue to make adjustments and refinements in response to changes in the external environment. Tonight, I want to discuss a recent policy change and that is our decision to promote clinical research in public hospitals. I thought its worth discussing the implication of this recent change.
Promoting Clinical Research
Clinical research is not a new activity. We have always dabbled in it and all hospitals have included it as part of their core missions.
There have been some success stories. Prof SS Ratnam’s research on infertility in the old KKH was exemplary. In more recent years, Prof Ariff Bongso’s pioneering work on human embryonic stem cells helped pave the way for stem-cell research globally. There were many other examples.
But clinical research in public hospitals was largely confined to a small group of doctors whose achievements were due more to their passion rather than the active support of hospital administrators. There was an important consideration which underpinned such a tight-fisted policy in MOH.
Research was not a priority in MOH. Our priority has been to deliver affordable healthcare through a lean and cost-effective system. Cost control takes precedence over discretionary activities. There was only a nominal budget for clinical research and we had to beg from the Tote Board and other charities to support our researchers.
The concern was that clinical research would lead to more costly treatment options. This would increase healthcare costs and also fan up public expectations for esoteric treatment which our society might not be prepared to pay.
We used to look at the huge NIH research budget in the US which runs into billions of dollars a year and concluded that we could not afford such a luxury. Let the Americans do the research and we will send our doctors there to learn the new treatments and procedures after they have been established. It is a cheaper way to raise our medical standards.
I wanted to stress that these considerations were neither frivolous nor trivial. Indeed, many aspects of those considerations remain valid today.
But in 2006, MOH revised the policy and obtained the Cabinet’s approval to include clinical research as part of MOH’s mandate. MOH would henceforth promote clinical research in public hospitals and seek appropriate funding support for its researchers. Why did we change the policy?
This is not because we think we have arrived, that we are now a developed country and we are rich enough to support clinical research. We are not. Funding will remain tight and cost control will remain an MOH priority.
But we assessed that the time had come for Singapore to do more in the area of clinical research because such research, if suitably directed, could benefit healthcare.

Source: News 26 Mar 2008

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