20 Mar 2001
Introduction
Two important indicators of service quality at the specialist outpatient clinics (SOC) of our public health care institutions are:
Waiting time for SOC appointment, defined as the time period from booking the first appointment at the SOC to the actual appointment date given.
Waiting time for SOC consultation, defined as time from the patient registering at the clinic to the first contact with the doctor.
The Ministry of Health recognises that long SOC waiting times is a significant problem and has been working closely with the public health care clusters to implement measures to address this issue.
Causes for Long Waiting Times
MOH and the clusters have identified 3 main causes for long SOC waiting times:
- - The nature of healthcare services which is inherently variable and sometimes unpredictable.
- Shortage of public sector specialists in some areas to meet rising demand.
- Cumulation of poor discipline in adhering to appointment system.
MOH is working with the clusters to address each of these causes and to adopt a multi-pronged approach to shorten waiting times. However, we recognise that this is a difficult challenge, to improve service quality while keeping healthcare cost affordable.
(A) Healthcare is inherently variable and sometimes unpredictable
Medical care is a very personalised service since each patient is different in terms of his or her medical condition and requirements. Even patients who are referred to the SOC for the same medical condition often have quite different needs. For example, one patient with diabetes may have a few mild complications while another may have many severe complications. In addition, some patients may raise additional complaints that require the attention of his doctor.
In the SOC, appointments are scheduled based on the estimated time required for each new and each follow-up consultation. However, it is not possible to predict exactly how much time each individual patient needs. When the doctor sees a patient with more complex problems, more time will be needed than the normal allocated time, and this increases the waiting time for subsequent patients.
Another unpredictable variable arises from the fact that specialists may have to attend to inpatients that deteriorate or have special needs. Some examples include:
An obstetrician who is running an SOC may be called away when one of his patients is in labour and is admitted to the labour ward.
Many specialists do rounds on their patients in the wards before they start their SOCs. If in the course of the ward round, more time is needed to attend to an inpatient who has deteriorated or is very ill, this will delay the starting of the SOC.
Many specialists may perform surgery or other procedures in the mornings and have clinics in the afternoon. If in the course of the surgical session, some of the patients take up more time because their problems are more complicated than anticipated, then this can result in the afternoon clinic being delayed.
A specialist who is in the midst of running an SOC can be called away if one of his patients in the ward has deteriorated.
MOH and the clusters recognise the need to look for solutions to better manage these unpredictable variables. The 2 clusters, in collaboration with MOH, will be engaging Operations Research (OR) consultants to study the problem of long SOC waiting times. The OR consultants will analyse the operations of the SOCs and recommend changes to optimise the hospital appointment and queuing systems to improve SOC waiting times. The study is expected to be completed by end of March next year.
The OR study will not solve all the problems. However, the results of the OR study should help the clusters to set up SOC appointment and queuing systems that would strike a better balance between keeping waiting times short while maintaining the efficiency of the SOC operations by not having too many unutilised SOC consultation slots.
Despite these efforts, we have to accept that there will be times when patients may still have to wait longer because of the inherent variability and unpredictability in the SOC operations. In addition, the Ministry is conscious that an overly inflexible insistence on strict waiting time norms has the potential to adversely affect the quality of patient care. For example, it would not be desirable for specialists to compromise on the time they need to give very ill inpatients, or for surgeons to rush through procedures which are more complicated than expected, in order to start their clinics on time.
(B) Shortage of specialists in some areas to cope with rising demand
Workload in the public sector SOCs has increased significantly in recent years. From 1996 to 2000, SOC attendance increased from 2.1 million to almost 2.8 million consultations per year, an overall rise of about 30%.
There is a shortage of specialists in some areas within the public health care sector. Overall, it is estimated that the public sector is short of about 100 specialists. This is caused, in part, by the high attrition rate of specialists from the public sector. Within the public sector, some of the areas with significant shortfalls of specialists include medical oncology, cardiology and neurology.
Attrition of Public Sector Specialists and Specialist trainees to Private Sector
Year Consultants
Associate Consultants
Specialist trainees
1994 51
1995 51
1996 39
1997 61
1998 40
1999 37
2000 100
A number of measures have been taken to increase public sector medical manpower
The intake of medical students by NUS has been progressively increased. It was increased to 180 per year in 1997, and will be 230 per year in 2001.
The number of specialist training positions has been increased particularly in certain disciplines e.g. cardiology, oncology and neurology. However, it takes 6 years to train a specialist so we need to find ways to deal with the shortage during this transition.
Active measures have been taken to retain public sector doctors and to attract doctors in private sector back to public institutions. With the operational autonomy given to the 2 healthcare clusters, public sector institutions are able to offer better terms and conditions of employment to retain doctors. The clusters will be looking into improving working conditions for doctors, such as providing more opportunities for research and training, and limiting the number of night duties per month. The Ministry had also recently announced a scheme for specialists called the Faculty Practice Plan (FPP). Under this plan, selected public sector specialists are allowed to practice in the private sector for part of their time. This would help to retain the specialists who would otherwise leave completely for the private sector. Conversely, the scheme seeks to attract private specialists to do a fixed number of clinical sessions in public hospitals to treat and manage subsidised patients.
The clusters have also been actively recruiting suitably-qualified foreign specialists from overseas. In 2000, a total of 48 foreign doctors (including 27 specialists and specialists-in-training) were hired by the clusters.
(C) Cumulation of poor discipline in adhering to appointment system
We need everyone to co-operate to operate an efficient appointment system. Doctors who do not start their clinics punctually, without good reason, will inevitably increase the waiting time for their patients. Patients who turn up late, who do not show up for their appointments, or show up without making appointments, will disrupt the operations of the SOCs and cause delay for other scheduled patients.
As many as 3 out of 10 patients fail to turn up for their appointments. The SOCs resort to overbooking of appointments to maximise the use of their doctors' time. When the patients all turn up, this results in delays in their appointments.
Another way that people try to get around the system is to present themselves at the Emergency Department, even though their case is not an emergency, hoping to get an earlier SOC appointment. This only serves to clutter up the emergency department with non-emergency cases. If they do succeed in getting an appointment, this would be through a "forced" booking which would contribute to longer consultation waiting times.
Pilot Projects in the Clusters
The hospitals are taking steps to ensure that doctors start their clinics punctually. Each cluster has also identified SOC clinics which will pilot innovative measures to ensure stricter adherence to the appointment system and to improve SOC waiting times. The pilot sites identified are SGH Colorectal Surgery and SGH Urology in Singapore Health Services (SingHealth), as well as National Skin Centre in National Healthcare Group (NHG). Both clusters will monitor and analyse the situation in the pilot sites. The pilot programmes will start on 1 Apr 2001 and be tried out for one year. If the measures prove successful at these pilot clinics, they may be extended to other SOCs in the clusters.
Provisions for Urgent and Emergency Cases
For patients who are assessed by their primary care physicians to require urgent specialist attention, the SOCs will ensure that they get the earliest possible appointments which may even be on the same day. However, if it is a medical emergency, the patient should be referred to an accident and emergency department directly. The work of the staff in all accident and emergency departments in the public sector are supported by specialists in the hospitals.
The current problem with urgent referrals is that these cases will usually be inserted within a fully scheduled SOC and those who had already been given appointments will be made to wait longer. To address this, urgent cases may be given appointments at the end of the queue on that day and such patients should expect to wait, unless there are other free slots available. SOCs will also keep some fixed slots open based on the average number of urgent appointments given to cater for such cases and not run a fully scheduled clinic.
Doctors-on-call who are responsible for providing consultation to emergency cases in A&E or seeing urgent referrals to SOCs on a particular day will have to take into consideration these commitments and arrange their schedules accordingly.
The two health care clusters have also announced last week that they have drawn up pilot schemes to allow family doctors to link their practices to the polyclinics, specialty centres and hospitals under each cluster. Private GPs will be allowed to admit some of their patients suffering from serious medical conditions directly to the wards.
Conclusion
MOH and the two clusters want to re-assure the public that we will actively improve the waiting time for SOC consultation. We cannot adopt a one-size-fits-all approach because each medical speciality is different. We recognise the inherent variability and sometimes unpredictability of healthcare services. Notwithstanding, we have established a target that at least 50% of our patients would be seen within 30 minutes of their appointment time, and that 95% of our patients would not have to wait beyond 75 minutes of their appointment times. To achieve, this, we need the co-operation of everyone involved.