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1.  Speech by Mr Koh Yong Guan, Permanent Secretary (Health), at the opening ceremony for 31st Annual Combined Surgical Meeting, Thurs 6 Nov 97, 5.30pm.

Trends in Medical Practice
2.  Medical practice has evolved considerably over time. During the first half of this century, medicine was devoted to combating infectious diseases and illnesses associated with poverty. Now, these have largely been overcome as a result of improved socio-economic conditions, better nutrition, education, and advances in basic medical care.

3.  The second half of this century has seen the rise of illnesses associated with affluence, changing life styles and increasing life expectancy such as heart disease, cancer, strokes, diabetes mellitus, trauma and AIDS. From a country’s per capita figure, you can quite accurately guess the main causes of death in the population. Although we have worked out the management strategies for some of these illnesses, many remain unresolved and require the collective efforts of society, government and the medical profession.

4.  Medical practice patterns have also changed significantly over the same period. One major trend that has been observed worldwide is increasing specialisation and subspecialisation, brought about by rapid advances in medical knowledge and technology. The pace of specialisation and subspecialisation is especially fast among surgical disciplines. We are also seeing a far quicker and more widespread diffusion of applications involving new and expensive high tech equipment and procedures into mainstream medical practice; often, at the expense of high-tech medicine, as Dr Wong Heck Sing has recently noted in his SMA Lecture. 

5.  We have achieved a high standard of medical care for our people in Singapore. We must accommodate the rapid changes in clinical practice in order to maintain our high standard of medical care and achieve our vision of becoming a regional centre of medical excellence. However, there is an ongoing public debate and socio-political concern about whether there is a trade-off between quality of care and cost of care. Will higher quality be automatically accompanied by increased cost?

6.  We in the Ministry of Health, Singapore believe that good quality health care and affordability are not irreconciliable objectives. On the contrary, we can achieve both objectives together, provided we put in place the right regulatory and professional framework. I would like to take this opportunity to share with you some of the more important emphasis and measures that my Ministry is studying or is in the process of implementing to ensure that good and affordable health care remains accessible to all Singaporeans.

7.  First and foremost, we believe that despite the rapid changes in the way medicine is being practised, the delivery of holistic care should remain the primary goal. To achieve this objective, specialists should ideally work closely with primary care physicians. One way is to establish shared care programmes, where the expertise, skills and strengths of both types of doctors are harnessed to optimise the benefits to patients. And patients should be discharged to their primary care doctors as soon as possible.

Specialist Training
8.  Next, let me touch on the training of specialists. In the past, the route to becoming a specialist was through a master-apprentice relationship during the training process. This practice is still vitally important. But in today’s context, each trainee must be exposed to a vast amount of information and clinical skills which no single teacher can realistically be expected to provide.

9.  We have already moved to a system of proper, systematic and structured training programmes to ensure every trainee is appropriately exposed to the depth and breadth of the speciality. These training programmes are reviewed periodically so as to remain relevant as clinical practices and health needs change over time.

10.  To maintain high standards, regular assessments are carried out to ensure that the training is adequately done. We are in the process of setting up an Associate Dean’s office in every public hospital where specialist training is conducted. Among other responsibilities, the Associate Dean will plan, co-ordinate and monitor the specialist training programmes as well as counsel and mentor the trainees. The Associate Dean will also provide invaluable feedback and assessment to the Joint Committee on Advanced Specialist Training (JCAST) which comprises the School of Postgraduate Medical Studies (SPMS), the Academy of Medicine (AM) and the Ministry of Health (MOH). We believe that the addition of the Associate Dean’s office to the training system will strengthen the co-ordination and enhance the standards of clinical teaching.

Specialist Registration
11. At the end point of training, we have put in place the requirement for proper exit certification, either in the form of a formal examination or other forms of assessment, before the trainee can be recognised as a specialist. Currently, the exit certification is performed by JCAST.

12.  By next year, the process of certifying specialists will change. The Parliament of Singapore recently passed a bill to amend the Medical Registration Act. A specialist register will be set up. Only properly qualified and trained specialists will be accredited and allowed to practice in the field of specialisation in which they are registered. The Specialist Accreditation Board, which will be established and chaired by the Director of Medical Services, will determine the requirements for specialist registration. The plan is to delegate some of the operational aspects of defining the content of training and the standards to be achieved to the School of Postgraduate Medical Studies and the Academy of Medicine. Both of them will also have to take on a more pro-active role and greater responsibility to supervise and assess the doctors under training.

Continuing Medical Education for Specialists
13. Ultimately, what is desired is a high standard of holistic medical care. To meet this objective, specialists must not only be knowledgeable about their own speciality or sub-speciality but also keep up with general medical progress and advances. However, medical science and technology are advancing so rapidly that what trainees are being taught today may well become obsolete very quickly. Therefore, the initial training that a specialist receives is unlikely to sustain him for the rest of his working life. He must continuously update and upgrade his knowledge and skills. This will not only protect the interests of patients who require specialist care but also safeguard the intellectual capital base of the medical profession.

14.  One way to keep up-to-date is to participate in continuing medical education (CME) programmes. In Singapore, we hold numerous CME activities. Many specialists already participate in them on a voluntary basis. The Singapore Medical Council (SMC) is currently working to improve the existing CME system. The SMC intends to enhance the structure of CME programmes and expand CME activities. The SMC is also reviewing the monitoring of doctors’ participation in CME activities.

Credentialling
15. AII hospitals in Singapore are required to have some form of credentialling processes to regulate the kinds of treatment procedures specialists can perform. This is necessary as clinical outcomes depend, to a significant extent, on whether the specialists who perform the procedures have been adequately trained. The need to credential specialists for specific clinical procedures has become increasingly important as new procedures are rapidly being introduced into clinical practice nowadays.

16. To ensure better professional standards, it is a requirement under the Private Hospitals and Medical Clinics Act for all hospitals to put in place a credentialling mechanism for specific clinical procedures. At present, this varies from hospital to hospital. We will standardise and strengthen the mechanism of credentialling for specific procedures for all hospitals.

Evidence-based Medicine
17. As the 20th century draws to a close, specialists realise that it is no longer sufficient to practise medicine based solely on what was taught at medical schools, supplemented by cursory gleans from learned colleagues, journals and conferences. One exciting change on the horizon is the use of evidence-based medicine to transform clinical practice. Evidence-based medicine is the conscientious use of individual clinical expertise, together with the best available external evidence, to make informed decisions about the most appropriate medical care for patients. 

18. The movement, which started in the 1970s, is slowly gaining momentum and recognition internationally. Today, the medical profession in many developed countries, including the United Kingdom, Australia ancl the United States, have accepted evidence-based medicine as the most scientifically proven way to practise medicine to deliver the best outcomes, given limited financial resources and manpower. We in Singapore are studying how to use evidence-based medicine to help us to provide the most appropriate care to patients and to find a way to ensure continued affordable and accessible health care.

Clinical Practice Guidelines
19.  The most immediate and practical application of evidence-based medicine is to develop good clinical practice guidelines and to transform them eventually to clinical pathways. These guidelines will help clinicians to deliver the most appropriate management of specific disease conditions. 

20. My Ministry intends to appoint working groups to draw up and update clinical practice guidelines to guide clinician practice in Singapore. When these guidelines are ready, they will be disseminated to all meclical practitioners. The guidelines will be reviewed and updated regularly. The National Medical Research Council will fund the ongoing activities of these working groups.

21. As a start, we will focus on the more important and common medical conditions. The national specialist centres, such as the KK Women’s & Children’s Hospital, the Singapore National Eye Centre, the Singapore Heart Centre and the Neuroscience Institute will be asked to take the lead in their speciality areas. In the other speciality areas, the specialist departments, the professional bodies and the Academy of Medicine will provide the professional leadership in the preparation of clinical practice guidelines. My Ministry will provide support to the working groups on the necessary steps to be taken to develop the guidelines. We will also help source for relevant guidelines developed in other countries. Eventually, the hospitals and professional bodies will be tasked with monitoring the compliance of doctors with these guidelines.

Conclusion
22. What I have covered are some of the more important initiatives that the Ministry of Health has embarked on to ensure that Singapore has well-trained and experienced specialists who will deliver high quality, yet affordable health care to their patients. But in the final analysis, specialists must decide on what works and what is the best thing to do in the interest of their patients, given the finite national resources available.

23.  With this, I wish all of you a fruitful and enjoyable meeting.