Four things to consider in review of key healthcare services law

The Ministry of Health last week announced a review of the Private Hospitals and Medical Clinics Act (PHMCA). The Act, which governs practices in medical facilities including hospitals, nursing homes and laboratories, was last amended in 1999 and a comprehensive review is long overdue.

The world of healthcare has changed dramatically in the intervening years. Surgeries such as hernia repairs, which were once the exclusive domain of hospitals, are now routinely performed in medical centres that may be part of shopping malls. Tele-radiology linkages between Singapore and India have been established, and the list goes on. Sports medicine and palliative care did not exist as recognised specialities in 1999.

Unsurprisingly, there is no category for hospices in the current PHMCA and this is urgently needed, given the expanded need for quality, cost-efficient end-of-life care.

Furthermore, the lines between healthcare and hospitality have become somewhat blurred. Farrer Park Hospital has been described as a “hospitel”, a co-located hotel and hospital, the idea being patients can shorten their hospital stays by moving from the hospital to the hotel and still enjoy the monitoring and close proximity to their doctors. Technology, which increasingly permeates every aspect of our lives, enables remotely delivered care — think doctors sitting at Orchard Road adjusting a diabetic patient’s insulin dosage or changing pacemaker settings far away from the patient resting in his or her home in Pasir Ris.

The review is therefore focusing on the service provided, rather than the site of care, as Minister of State for Health Dr Lam Pin Min rightly emphasises. Governing the site of care is overly simplistic; the same physical site may provide different types of healthcare services and so merit different levels of regulatory oversight. For example, a community hospital may provide rehabilitative services, but also sub-acute care closer to that of a general hospital and even hospice services.

The proposed review is thus timely, and we propose four considerations as the Health Ministry conducts the review. Firstly, given the immense complexity of modern healthcare, it would be an exercise in futility to even try to cover every possible permutation and stipulate rigid rules. Instead, well-designed principles codified into law with their underlying rationale well explained and understood might work better.

We recall a foreign medical educator a number of years ago bemoaning his country’s rules requiring medical schools to include smallpox in the curriculum. Smallpox was eradicated in 1980 but changes in regulations had not kept pace. Perhaps, if regulations had to be stipulated, they should have directed schools to focus on diseases of greatest public-health importance, instead of specifying which diseases.

Secondly, the ministry should adopt a risk-based approach and consider the appropriate level of safeguards vis-a-vis the risks. Health policymakers have been adroit at this previously in dealing with aesthetic medicine, determining that some invasive surgical procedures, such as nose implants, could be performed in a clinical setting, while others, such as liposuction, with more than a litre of fat removed, imposed too much risk and had to be carried out in a formal operating theatre.

At the same time, policymakers need to balance safety with a very pragmatic appreciation of the cost implications. In the ideal world, there would be senior specialists from multiple disciplines at all hours of the day in every hospital, but this comes at a very heavy staffing cost, and regulators need to strike the balance so that healthcare costs are sustainable for society.

One way of extending the reach of intensive care specialists has been the introduction of tele-ICUs. Intensive care specialists are scarce and largely reside in major cities. But patients in smaller cities still fall critically ill, and tele-ICUs have been very effective in overcoming the constraints of geography. Doctors in capital cities watch patient monitors, and high-resolution cameras allow close-up visualisations of patients.

When adjustments to medicine dosages are indicated, the specialists instruct junior doctors on-site on the needful. Sounds irrelevant in tiny Singapore? No, even in our city-state, tele-stroke services see neurologists (brain specialists) in our specialist hospitals review CT scans of Emergency Department patients and examine them remotely before ordering “clot busting” medicines. Of course, a neurologist on-site and being there in person can conduct a better evaluation, but as the medical saying goes, “time is brain” and even minutes cannot be wasted in stroke cases. Our regulations must enable and encourage clever ways to manage rising healthcare costs.

Thirdly, we should strike the right balance between safety and being conducive to innovation. Innovators routinely complain about rules, and as we safeguard patient safety, we need to ensure genuine innovation is not inadvertently stifled by clumsy regulations. Singapore is facing an unprecedented, serious challenge in addressing population ageing. We need to find innovative solutions to allow us as a country to continue to offer all our citizens high-quality, affordable healthcare. And this means doing this very differently.

Prime Minister Lee Hsien Loong, in launching the Smart Nation initiative two years ago, painted a future scenario of one’s home as a health facility where patients and caregivers do not have to travel to the hospital, “but from the hospital we can connect up and you can talk and find out what is happening, and give advice and monitor and treat the patient”. It would be a shame if regulations impede these offerings.

Finally, reviews should be holistic and regularly scheduled. Last month, the Singapore Medical Council issued updated ethics guidelines — the first review since the guidelines were introduced in 2002. Now, the PHMCA is being reviewed. Regulations governing hospitals and clinics, and codes and guidelines for doctors and nurses, are inextricably connected, and any review of one set of regulations should be considered holistically. There will be downstream implications on other Acts and codes governing doctors, nurses and other healthcare professionals. Inconsistent and incongruent rules are at best confusing and at worst fatal.

Also, medical technology and societal norms will continue to evolve, and we should not review the PHMCA on an ad hoc basis. Instead, build into the Act an automatic review every five years or some appropriate interval.

Singaporeans have a health system we can be justifiably proud of. It delivers high quality, embraces patient safety and manages at relatively low costs. But medical care has transformed, societal needs have evolved and our venerable PHMCA is no longer fit for purpose. Let us work together, as doctors, health facility operators, policymakers and patients, to bring it into modern times.

ABOUT THE AUTHORS:

Dr Jeremy Lim is head of the Health and Life Sciences Practice in Asia at Oliver Wyman, the global consultancy. Dr Jonathan Tan is director at the Asia Pacific Risk Centre.