Comparison of healthcare system between Singapore and the UK Career path for physicians upon graduation with MBBS degree Singapore:
UK:
Medical degree (5 or 6 years) The undergraduate course provides students with exposure to the different specialties within medicine. It involves basic medical sciences and practical clinical tasks, and seeks to develop attitudes and behaviours appropriate to the medical profession, as well as the skills of independent learning. Foundation Year 1 Newly qualified graduates from medical school receive provisional registration from the General Medical Council (GMC) and undertake foundation year 1 (F1) which is designed to build on the knowledge and skills gained during undergraduate training. On successful completion of F1, trainees receive full registration with the GMC and can continue to the second year of foundation training build on the knowledge and skills gained during undergraduate training. On successful completion of F1, trainees receive full registration with the GMC and can continue to the second year of foundation training. Foundation Year 2 Foundation year 2 (F2) training continues the general training in medicine and involves a range of different specialties, which could include general practice. By the end of foundation training, trainees must demonstrate that they are competent in areas such as managing acutely ill patients, team working and communication skills, to continue training in their chosen specialist area or in general practice.
Specialty and general practice training (between 3 and 8 years) On successful completion of foundation training, doctors continue training in either a specialist area of medicine, or surgery, or in general practice. The area of medicine chosen will determine the length of training required before becoming a senior doctor. In general practice the training is of three years’ duration, and in general surgery, for example, the training is eight years in duration. During this period of training, doctors learn and practice increasingly advanced areas of knowledge and skills in general practice or their chosen specialty in order for them to be able to undertake senior doctor roles once training is completed. Postgraduate training is overseen by the Postgraduate Medical Education and Training Board (PMETB). Continuing professional development On successful completion of postgraduate training, doctors gain entry to either the GMC specialist register or GP register and are able to apply for a senior post as a consultant or a GP principal, respectively. While these posts are viewed as career pinnacles, all doctors are expected to continually demonstrate their fitness to practise medicine, and so learning continues throughout a doctor’s career. Career grade posts: other opportunities for work These posts include those with titles such as trust doctor, clinical fellow, specialty doctor and consultant, amongst others. For all such posts, GMC registration and a current licence to practise is required. Within the UK these posts will usually include some opportunity for professional development, regular appraisal and the benefits of NHS employment including generous leave, competitive levels of pay and access to a final salary pension scheme. Doctors with Tier 1 (General) permission to enter the UK can compete with UK/EEA nationals for any career grade posts. Doctors without Tier 1 status will only be able to take up a post with sponsorship from an employer under Tier 2 (for example, where the resident labour market test has been met and no suitable UK/EEA doctor could be found). Career grade vacancies are usually advertised on NHS Jobs http://www.jobs.nhs.uk, a website dedicated to NHS vacancies, and/or in medical journals such as the British Medical Journal http://www.bmj.com Trust Grade Doctors Trust grade doctor is a term applied to a doctor who is working in the NHS in a non-training post. The term derives from the fact that the NHS Trust contracts the doctor directly rather than by the Deanery that supervises local medical education. There are many different types of non-training Trust grade posts. They can be clinical fellows, senior clinical fellows, clinical assistants or specialty doctors aiming to attract doctors with different skills and experience. Although they are neither training posts nor consultant posts, nevertheless they play an important and essential role in the NHS. It is not uncommon for posts of this type to be occupied by overseas doctors when they first enter the NHS. It can be seen as a first step before competing for a formal training post as it can provide essential NHS experience. Experienced doctors that may have already completed a training programme in another country can apply for appropriate Trust grade posts either to get further experience or before applying for NHS consultant posts if they are entitled to.
Singapore’s healthcare system: -
Under the responsibility of the Ministry of Health (MOH)
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Ranked 1st based on efficiency in the world (Bloomberg)
Outpatient Medical Services For outpatient medical services, heavily subsidised medical services are offered at 18 government polyclinics, including outpatient treatment, dental care, psychiatry, immunisation and health screening. In addition, over 2,000 private General Practitioners (GPs) are readily found in most housing estates. Public Hospitals in Singapore There are seven public hospitals in Singapore comprising five general hospitals, a women’s and children’s hospital and a psychiatric hospital. Non-Singapore Citizens and Permanent Residents may only stay in the A-class (1 or 2 beds per room) and B1-class (4 beds) wards. The Ministry of Health provides a list of complete charges including doctors’ fees for a comprehensive range of procedures at public hospitals here. Six national specialty centres provide specialist services for cancer, cardiac, eye, skin, neuroscience and dental care. There are also community hospitals for intermediate healthcare for the convalescent sick and aged who do not require the care of the general hospitals. Private Hospitals in Singapore The private hospitals in Singapore include Camden Medical Centre, East Shore Hospital, Gleneagles Hospital, Mount Alvernia Hospital, Mount Elizabeth Hospital, Raffles Hospital, and Thomson Medical Centre. Most private hospitals offer executive or VIP suites. Some also offer premium medical services, such as Gleneagles Hospital’s elite health screening and the International Patients Centre at Raffles Hospital. Camden Medical Centre, which is also centrally located, houses some 59 specialist clinics and the latest suite of supporting medical facilities and services. Medical Insurance Singapore Citizens and Permanent Residents are required to maintain a Medisave account as part of their Central Provident Fund (CPF), which is contributed from their wages and by their employers. Medisave is a national medical savings scheme which helps individuals put aside part of their income into their Medisave Accounts to meet their future personal or immediate family's hospitalisation, day surgery and certain outpatient expenses. It can also be drawn out to pay part of hospitalisation bills as well as outpatient treatments for four chronic diseases, namely diabetes, high blood pressure, lipid disorder and stroke .CPF members can also choose to be covered under MediShield, which is a basic, low-cost medical insurance scheme run by the CPF Board. Private health insurance can be basic, covering only inpatient hospital stays, or comprehensive services including inpatient and outpatient care, lab tests, x-rays and other medical services. There are many reputable insurance agencies in Singapore which offer attractive premium rates and coverage, to suit different lifestyles and needs. For more information, click here.
Healthcare in Singapore boasts excellent quality standards, both in the public and private sector. The system of public healthcare in Singapore consists of several government schemes for citizens and permanent residents. These schemes reimburse a substantial part of medical bills. Nonetheless, most participants still need to cover some costs from their own pocket – or via supplementary insurance. Government healthcare in Singapore is subsidized and organized by the CPF, the Central Provident Fund Board, and the Ministry of Health. The CPF is an integral part of Singapore’s social security in general. Its provisions for public healthcare in Singapore include the four insurance plans described below.
Medisave (1984) •
Every month, 8% - 10.5% (depending on age group) of salary is deposited into Medisave
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Money deposited can be used to pay for personal or immediate family’s hospitalization, day surgery and certain outpatient expenses bills
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Compulsory
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Contributions to the Medisave account has a limit of $34,500
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Medisave can be claimed only if the patient stays in the hospital for at least 8 hours (unless the patient is admitted for day surgery)
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MOH will allow the use of Medisave to help pay part of the outpatient cost, and reduce out of pocket payment for patients
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For each bill, patients will only need to pay the first $30 of the bill (as the deductible) as well as 15 per cent of the balance of the bill. Medisave can be used to pay for the remaining amount.
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This is regardless of whether the bill is for a one-off visit or a package.
MediShield (1990) •
Acts like a medical insurance: helps pay part of the large hospitalisation bills for treatment of serious illnesses or prolonged hospitalisations (even after Medisave coverage)
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Only claimable for approved medical services performed in Singapore
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Medishield will cover up to 80% of your large medical bill at the Class B2/C level
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Medishield covers hospitalization expenses, surgery/day surgery and certain approved outpatient treatments, such as kidney dialysis, chemotherapy and radiotherapy for cancer treatment
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Medishield is designed for Class B2/C wards, so for hospital stays in higher class wards/private hospitals Medishield claim will be calculated based on a percentage of your hospital bill
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Similarly, if you go for unsubsidised day surgery, your Medishield claim will be calculated based on a percentage of your bill
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Claims based on: citizenship, age group, class of wards/type of hospitals, length of medical procedure/hospitalization, type of medical procedure
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Why it is a good policy?
Gives benefits to both Singapore citizens and non-citizens (SPRs and foreigners)
ensure the harmony between the different groups in the society and even foreigners are given this benefit, thus ensuring that everyone in Singapore is given the same benefit, while giving Singaporeans more subsidy in their healthcare prices
encourages Singaporeans to continue staying in Singapore to receive such benefits and also to encourage foreign talents in Singapore to become Singaporeans so as to receive more benefits.
Policy is an opt-out one, thus government is actually providing citizens and non-citizens in times of economic crises, they will still have enough money to pay for hospital bills
Ensures that regardless of religion and race, everyone will receive the same amount of benefit, ensuring social stability
Only applies to certain government hospitals, which in turn will encourage citizens to visit government hospitals rather than private ones, thereby helping to contribute to Singapore’s economy
Medifund (1993) •
Endowment fund set up by the Government as a safety net to help poor and indigent Singaporeans pay for their medical care
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Acts as a last resort for patients who, despite heavy Government subsidies, Medisave and Medishield, are unable to pay for their medical expenses
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Patients receiving inpatient treatment in Class B2/C wards or subsidised outpatient treatment in the public hospitals may apply for help from Medifund
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Medifund is not an entitlement!, only for Singapore citizens facing hardship
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Patients have to fulfil certain income criteria before their applications can be approved. The amount of help from Medifund will depend on individual circumstances and the patient's financial background.
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Hospital Medifund Committee considers the application
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The applicant must exhaust all other funds (e.g. Medisave) first before the balance is being considered for Medifund
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No limitations to age, gender, race, religion
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Limited to Singapore citizens only
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Limited to certain hospitals, specialist centres and voluntary welfare organisations
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Limited to patients in Class B2 and C wards, subsidised outpatient treatments
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Available to all medical and healthcare services (including day surgery, hospitalisation etc.) EXCEPT respite care and delivery
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Why is it a good policy?
Eases financial burden of less well-to-do families (esp. in times of economic crises)
Not limited to race or religion: thus making it fair for all Singapore citizens who meet the other criterias to apply
Gives more support to elderly Singaporeans with no Medisave or who did not accumulate enough Medisave because the Scheme was implemented too late for them
Provides good welfare for all Singaporean citizens, regardless of gender, race, religion or age (ensures social stability), thus making it a sound and fair policy
Equal racial treatment and consideration for Singapore’s ageing population
Eldershield The 4th pillar of government-subsidized healthcare in Singapore is called ElderShield. As the name implies, this insurance schemes assists elderly patient with severe long-term disabilities. From the age of entry to the age of 65, those insured via ElderShield pay a yearly premium. For example, a 40-year-old Singaporean woman will pay an annual lump sum of SGD 218 for the next 25 years. The premiums for men are usually lower, due to their lower life expectancy. If ElderShield participants become severely disabled in old age – i.e. they need help with tasks such as washing, dressing, or feeding themselves – the program assists with nursing care. They get monthly cash payouts of SGD 400 for up to six years to cover some of the related costs. There are three governmentapproved insurance providers in Singapore that offer ElderShield plans. If you want bonus coverage with higher payouts or a longer period of time, you have to buy additional insurance from the same companies.
HOTA (Human Organ Transplant Act) The Human Organ Transplant Act (HOTA) allows for the kidneys, liver, heart and cornea to be recovered in the event of death from any cause for the purpose of transplantation. From 1 November 2009, HOTA will cover all Singapore Citizens and Permanent Residents of 21 years and above, who are not mentally disordered, unless they have opted out. The upper age limit of 60 years has been removed. Besides deceased organ donation, HOTA also provides for the regulation of living donor organ transplantation (i.e. the removal of organs from a living donor for transplantation into a patient). Anyone who opts out of HOTA receives lower priority for receiving an organ on the national waiting list should he require an organ transplant in the future. This will be specific to the organs which he opted out of. Cardiac Death The death as we are normally familiar with is technically called cardiac death. This happens when the heart stops beating irreversibly. At the point of cardiac death, all vital functions of the body stop. The vital
organs quickly become unusable for transplantation after cardiac death. However tissues such as bone, skin, heart valves and corneas can be donated within 24 hours of death. Brain Death In some cases, when there is a brain injury (for e.g. due to accident or stroke), the brain may stop functioning before the heart. Brain death means there is no flow of blood or oxygen to the brain and therefore, the brain cannot function in its capacity and never will again. Other organs, such as the heart, lungs, kidneys, pancreas or liver, may function for a brief period of time after brain death if person is supported on a ventilator. Unless damaged by disease or injury, these organs may benefit other individuals in need of organ transplants. Donation of vital organs such as kidneys, heart and liver is usually possible only after brain death. Brain death is accepted as the legal definition of death in Singapore and in other advanced countries. It is determined based on a standard, well-defined set of clinical criteria. This definition is similar to those used in countries such as Australia, Canada, Denmark, the United Kingdom and the United States of America. AMD (Advance Medical Directive) An Advance Medical Directive (AMD) is a legal document that you sign in advance to inform the doctor treating you (in the event you become terminally ill and unconscious) that you do not want any extraordinary life-sustaining treatment to be used to prolong your life. Making an AMD is a voluntary decision. It is entirely up to you whether you wish to make one. In fact, it is a criminal offence for any person to force you to make one against your will. "Terminal illness" is defined in the Act as an incurable condition caused by injury or disease from which there is no reasonable prospect of a temporary or permanent recovery. For such a condition, death is imminent even if extraordinary life-sustaining measures were used. These measures would only serve to postpone the moment of death for the patient. "Extraordinary life-sustaining treatment" is any medical treatment which serves only to prolong the process of dying for terminally ill patients but does not cure the illness. An example is the respirator that is connected to a patient to assist him/her to breathe. It serves only to artificially prolong the life of a terminally ill patient. Anyone who is 21 years old and above, and is not mentally disordered can make an AMD. All you need to do is to complete an AMD form, sign in the presence of two witnesses, and return it to the Registrar of AMDs.
How Singapore’s Healthcare system compares with other countries?
How robust is the Singapore healthcare system? Here is an excerpt from the headlines in the United Kingdom of late: “LONDON (Reuters) – The deaths of hundreds of hospital patients, left without food or water in filthy conditions, exposed an urgent need to change the culture of Britain’s National Health Service (NHS). Between 400 and 1,200 patients are estimated to have died needlessly at Stafford Hospital in central England between January 2005 and March 2009. “There were patients so desperate for water that they were drinking from dirty flower vases,” Prime Minister David Cameron told parliament in a statement on the report. Describing events at Stafford Hospital as “a despicable catalogue of clinical and managerial failures” Across the world, healthcare is always a hot button issue that can polarise people and divide nations. While it’s important that people have access to affordable public healthcare as countries need healthy citizens to drive the economy, it’s also a question of how much of taxpayers’ dollars should be spent to keep the system running. Healthcare can be costly to the individual and potentially blow his or her life savings, and it’s unfair for anyone to be denied medical attention because he or she couldn’t afford it. Major procedures like heart surgery can cost several hundred thousand dollars in Singapore for example, and that’s not something that the average Singaporean can afford to pay. Insurance is a smart option, but insurance providers have conditions that often exclude those who have a previous medical record or senior citizens as these individuals would be more likely to fall ill and file insurance claims. What then, is the solution to this problem, especially in countries like Singapore where we have a greying population? Should healthcare be free or heavily subsidised? How will taxpayers then be affected? Let’s have a look at two contrasting models: the UK’s healthcare system which is fully paid for by taxpayers versus Singapore’s system which is based on a hybrid model where medical costs are co-funded by residents and the government. The UK’s National Health Service The UK system is an example of tax-financed healthcare where services are provided free of charge and funded by the state. In 2010-2011, the UK government spent a whopping 137.4 billion pounds on the National Health Service, which is equivalent to 8.9 percent of national income. The key advantage of such a system is that no citizen is left behind and this solves the problem of the less well-off being denied healthcare because they couldn’t afford it. However, with every upside there is a downside. Demand for healthcare in the UK often exceeds supply and many have to wait in line just so that they can receive attention or treatment. It’s not uncommon for patients to wait weeks or months before they get to see a doctor. Now, if more resources are used to meet the high demand, then healthcare spending will go up inevitably. Not to mention the strain on healthcare workers to support the population, which would then lead to lower service standards. It’s apparent that this system, while it helps lower-income citizens meet their healthcare needs, is fraught with problems.
Singapore’s healthcare system Singapore’s healthcare system is based on a hybrid model where citizens receive subsidies for healthcare as opposed to being fully funded by the state. In 2012, the Singapore government spent only about 1.6% of GDP on healthcare – a figure that is much lower than other developed countries but resulting in health outcomes that are comparable if not better than other developed nations. In the year 2000, Singapore was placed 6th in the world in the World Health Organization’s ranking of the World’s Health Systems. Singapore was only one of two Asian countries in the list, with the other being Japan at 10th position. So what makes the Singapore system so successful? Singapore’s public healthcare is split into two broad areas, namely primary care and hospital care. Primary care, which covers small ailments and is often less convoluted as they can be treated with common medicines, is predominantly managed by the private healthcare industry and paid for by citizens themselves or by their employers under company-based insurance schemes. 80 percent of the primary care sector is left in the hands of private medical practitioners. Hospital care, on the other hand, is largely managed and subsidised by the government. There are regulations and policies in place to ensure that there are enough public hospitals, doctors, nurses and healthcare workers to meet the demands of a growing population. There are also community hospitals where patients are placed if they do not require specialised treatment and services that are only available at the major hospitals. Singapore residents are also given ward class options where they receive the highest subsidy (80 percent of hospital charges) for the lowest ward class. The purpose is to enable lower-income individuals to enjoy the benefits of a top-notch healthcare system without the frills (eg. in Cclass wards, fans are used instead of air-conditioning to save costs) while the well-heeled can opt for the higher-class wards with less or no subsidy from the government. Regardless of the ward class, patients receive the same quality of treatment and medication. To defray healthcare costs, which are already subsidised by the government, Singapore has a 3Ms financing framework consisting of three schemes: Medifund, Medisave, and MediShield. These enable Singaporeans and PRs to fund part of their individual medical costs. Most Singapore residents are covered under Medisave and MediShield, while those who are still unable to foot their hospital bills can rely on Medifund, which is an endowment fund set up by the government to help the poor. Looking ahead It’s without a doubt that the Singapore healthcare system has been working for the nation for decades, and by comparison with the UK system is more efficient in many areas. But with a growing yet ageing population, we cannot afford to be complacent. With an anticipated one million more people to add to the current population of 5.3 million within the next 15 or 20 years, much more needs to be done to expand and refresh the infrastructure so that the quality of healthcare isn’t compromised and that Singaporeans, regardless of income level, can get the medical attention they need in a timely and efficient fashion.
Comparing healthcare systems between countries: BRITAIN'S National Health Service (NHS) was recently judged the “world’s best health-care system” by the Washington-based Commonwealth Fund in its latest ranking of 11 rich countries’ health provision. The Commonwealth Fund tends to give the NHS a pretty clean bill of health in its assessments (it also scores Switzerland, Sweden and Australia highly). Other rankings reach different conclusions. How do you compare something as complex as a national health-care system with its peers? The Commonwealth Fund makes quality, access, value for money (cost-efficient care0 and equity the leading criteria for judging which countries perform well. Its emphasis on access and per-capita spending mean that America, struggling to extend its insurance coverage, while committing a large amount to overall health-care spending, regularly comes bottom of the Commonwealth Fund table. But that judgment overlooks what American health care delivers well: it scores highly on preventative health measures, patient-centred care and innovation, for instance. It has led the way in reducing avoidable harm to patients, with Seattle’s Virginia Mason hospital delivering “near zero harm”, something many systems, including England’s, are seeking to emulate. What the NHS is good at is providing cost-efficient care. It spends $3,405 per person per annum, less than half America's outlay of $8,508. Alas, that does not mean the NHS is financially secure: a £2 billion ($3.4 billion) shortfall looms from 2015 and NHS England is struggling to implement £20 billion in savings. And some outcomes for serious conditions do not commend the English model, which does worse on serious cancer treatment than Canada, Australia and Sweden, according to data from the King’s Fund, a health-care think-tank based in London. American women have higher survival rates for breast cancer. Mortality rates following strokes also let down the English system. Not everyone agrees with the Commonwealth Fund about what should be measured, and how the results should be weighted. A survey on health-care efficiency by Bloomberg recently chose Hong Kong, Singapore and Japan as the best performers, based on their efficiency. Adding greater weight to patient choice, for example, might reshuffle the rankings. The Commonwealth Fund most values equity and access, and so rewards the systems where it finds these. But change the weighting given to each category and you can quickly change the outcome. When it comes to judging the world’s health systems, preferences and values guide conclusions, as well as raw data.
