Speech by A/Prof Benjamin Ong Director of Medical Services, Ministry of Health, at the SMA National Medical Students’ Convention, 26 August 2017

The future of Singapore healthcare and what it means to medical students today?

Distinguished guests,

Ladies and gentlemen

Good afternoon. It gives me great pleasure to join all of you at this inaugural National Medical Students Convention, as part of the Singapore Medical Week hosted by the Singapore Medical Association. I am heartened to see many of our medical students – our next generation of doctors in Singapore – join us at this event to discuss issues that would impact how they practise medicine in future.

Evolution of Our Healthcare System

1.    What would Singapore’s healthcare system be like in the future? I believe many of you here will not only be working in our healthcare system in future, but will also play a key role in shaping the way it is designed. However, before we look to the future, we need to first understand how we arrived at where we are today.

2.    Our healthcare system has come a long way. The first hospital built on the island was the Singapore General Hospital, in the early 1820s. In the early 1900s, the colonial government introduced basic healthcare facilities, such as the Maternal and Child Health Centres, and the School Health Service. With communicable diseases the main healthcare priority at that time, shortly after attaining self-rule in 1959, the Government embarked on a mass immunisation programme against tuberculosis and other infections. Besides building healthcare facilities, a series of health campaigns were rolled out, such as the Dental Health Campaign in the 1960s.

3.    With the set-up of a Committee for Postgraduate Medical Education in 1970, a push for medical specialisation began. In parallel, hospital infrastructure was upgraded, and more sophisticated equipment was introduced. In the 1990s, the Government built several national speciality centres, such as the Singapore National Eye Centre, the National Heart Centre, and the National Cancer Centre Singapore.

4.    While the Government also invested in the set-up and enhancement of polyclinics across the island, the development of the healthcare system in Singapore has been largely focused on acute hospitals and specialty centres delivering specialised, episodic care. Even though acute care will continue to be an important part of our healthcare system, the growing heath needs of our ageing population, with a corresponding increase in healthcare costs, makes the current hospital-centric model increasingly unsustainable.

Changing Healthcare Needs

5.    We are now faced with a new set of challenges. Even as our population growth slows, the number of Singaporeans aged 65 and above is increasing rapidly. This number is projected to double to 900,000 by 2030, meaning 1 in 4 Singaporeans will be in that age group, up from 1 in 7 today.

6.    As our population ages, there will be an increase in chronic disease burden and healthcare demand. About a quarter of Singaporeans aged 40 and above will have at least one chronic disease. For example, diabetes prevalence has been on the rise in Singapore. According to the National Health Survey 2010, the crude prevalence of diabetes in Singapore had increased from 8.6% in 1992 to 11.3% in 2010. One in three Singaporeans has a lifetime risk of getting diabetes and the number of those with diabetes is projected to reach one million by 2050, if current trends continue. Moreover, one in three diabetic cases in Singapore is undiagnosed, and of those with known diabetes, one in three cases has poor control. This increases the risk for developing serious complications such as heart disease, stroke, kidney failure, blindness and lower limb amputations. Thus, the chronic disease load will not only be larger, but also more complex to manage. Patients are likely to have multiple medical conditions that require a multi-disciplinary approach.  These ‘complex’ patients will form an increasing segment of our patient population even as medical standards advance and lifespan increases. The demands on our healthcare system will increase even as we face greater manpower and fiscal constraints in meeting those demands. This makes it even more challenging for us to meet the care needs of our patients.

Changing Healthcare Models

7.    We cannot continue to provide care the way we do today. We need to shift our healthcare delivery model from one that is centred around the hospital, to one that provides holistic and patient-centric care in a more sustainable manner, in the community. We have begun our efforts to do so. In 2012, we announced the Healthcare 2020 Master Plan, which outlined our plans to add capacity, improve affordability, and enhance care quality. More recently, we highlighted the three key paradigm shifts we need to make, in order to prepare our healthcare system for the long term, beyond 2020. These three shifts are encapsulated in the “Three Beyonds” – Beyond Hospital to Community, Beyond Quality to Value, and Beyond Healthcare to Health.

8.    ‘Beyond Hospital to Community’ describes our emphasis on shifting the centre of gravity of our healthcare system away from hospital based, specialist provided acute care, to community based care, with the goal to help our population manage as much of their health needs in the community as possible. ‘Beyond Healthcare to Health’ describes our strategies to move upstream and focus on aspects of preventive health, to help our population stay as healthy as possible and to reduce the incidence of chronic diseases. ‘Beyond Quality to Value’ describes our journey towards developing a value based healthcare model, which allows us to critically ensure that the treatments we provide are cost-effective so that our healthcare system is sustainable in the long term.

9.    In line with the “Three Beyonds”, new models of care should be developed to support effective health promotion, chronic disease management in the community, and sustainable intermediate and long-term care (ILTC). Given that patients require different levels of care over their lifetime, a key ingredient of success is to make the patient care experience seamless by better integrating care across different settings. Earlier this year, we took the major step of reorganising our healthcare system in order to integrate care more effectively. With the reorganisation, each of the three integrated clusters will have a broader range of healthcare facilities, including its own group of polyclinics. This move to strengthen vertical integration within each cluster reflects our commitment to better care coordination and the central role that primary care will continue to play.

The Importance of Primary Care

10.    As the first and continuous line of care, primary care is the bedrock to support the shifting of healthcare beyond hospitals into the community. Recognising the need to transform the way we deliver care in order to meet more holistically the needs arising from the changing population demographics, the Ministry of Health has developed various new models for team-based chronic disease management within the community.

11.    Over the past few years, various healthcare clusters have partnered with private general practitioners (GPs) to set up Family Medicine Clinics with on-site support services, such as diabetic eye and foot screening. We also developed nurse-led Community Health Centres to support solo GPs with similar support services. Our polyclinics have also introduced care teams led by a family physician and supported by other healthcare professionals like nurses and allied health professionals, with chronic patients assigned to the same care teams to enable long-term doctor-patient relationships to develop. More recently, we started a pilot to organise like-minded GPs into Primary Care Networks, or PCNs. These virtual networks of GP clinics allow participating GPs to continue in their individual practices while sharing resources within their PCN, with government funding for services to strengthen chronic disease management, such as diabetic eye and foot screening, and nurse counselling.

12.    By transforming primary care through the development of these various models, our long-term goal is to achieve the vision of “One Singaporean, One Family Doctor”, which encapsulates the key role of family doctors as the trusted health partner of every Singaporean. As our primary care capabilities become increasingly strengthened, the polyclinics and GPs will not only anchor their existing patients in the community, but also play a greater role in shared care and right-siting patients from our public hospital Specialist Outpatient Clinics (SOCs). Even though such right-siting already happens today, the number and complexity of SOC cases shifted to primary care will only increase in the future.

Relevance to Medical Students Today

13.    I have shared a lot about the evolution of our healthcare needs and healthcare system. How is all this relevant to you as a medical student? A common thread running through our healthcare history is that of constant change. This means as future doctors, there is a need for all of you to be flexible and adapt to changing healthcare needs and the evolving care models.

14.    I had earlier highlighted the needs of our shifting population demographics and increasing burden of chronic diseases. The era of any doctor working in isolation has disappeared and effective care is now team-based. This team is inter-professional and the doctor is one member and may or may not lead depending on the situation. Many more doctors will need broad and general professional capabilities. This implies that a smaller percentage of each cohort will become specialists and narrow capability specialty practice will be less relevant. Most of you will practise in settings such as GP clinics, polyclinics, and community hospitals.

Developing Family Medicine

15.    A strong, well-trained primary care and ILTC sector is essential to cope with the increasing complexity of care in the community. The role of doctors practicing in these sectors is expected to expand, particularly in chronic disease management, for mental health issues, as well as for elderly patients with multiple co-morbidities. Although a fair number of doctors today practise without postgraduate qualifications, with the increasing complexity of care and their enhanced roles, the professional up-skilling of primary and community-based physicians through post-graduate Family Medicine training will no longer be optional.

16.    Training more Family Physicians is one of the Ministry’s key commitments because of the central role Family Physicians play in community-based care. Given the breadth of scope and continuity of care that defines Family Medicine, the Family Physician is best placed to manage a patient’s care needs from cradle to grave. Family Physicians have the best opportunity to develop strong and long-term doctor-patient relationships, enabling a holistic understanding of the patient and family’s medical, social and care needs. Such an understanding means that the Family Physician can adopt a personalised approach in identifying risk factors, formulating appropriate management plans and harnessing the family or care givers to effect behavioural change and meet care needs holistically. The Family Physician is also the patient’s navigator across the healthcare continuum through providing appropriate referrals and coordinating care.

17.    Family Physicians in primary care settings are also at the frontline of defence for public health threats. For example, during the Zika outbreak last year, Family Physicians were the ones who identified the clues which led to the first reported case of community spread. It was their vigilance which enabled timely discovery of the outbreak.

18.    Both undergraduate and postgraduate training in Family Medicine have been enhanced in tandem with the growing recognition of the discipline. Today, Family Medicine is part of the curriculum in all three of our local medical schools. We also have a robust postgraduate Masters of Medicine in Family Medicine residency training programme offered by our three Sponsoring Institutions. Since 2014, Fellows of the College of Family Physicians Singapore (CFPS) have been inducted to the Chapter of Family Medicine Physicians under the Academy of Medicine Singapore, in recognition of their academic excellence and equivalent standing. We will continue to enhance Family Medicine as a key part of medical training, as it provides important foundational breadth for all doctors.

Family Medicine as a Career

19.    I strongly encourage our medical students to consider pursuing Family Medicine as a career. The field of Family Medicine is an exciting and rewarding one, which will provide you with the opportunity to be personally involved in shaping its development as a key enabler to transform healthcare in Singapore.

20.    Besides traditional outpatient primary care settings such as polyclinics and GP clinics, there are various settings where Family Physicians can practise and lead care. A key example is the community hospitals, such as Outram Community Hospital, which is expected to open in 2020. These community hospitals serve as step-down facilities for rehabilitation and sub-acute care for patients after the acute admission. Family Physicians are at the forefront helming care teams in these institutions. Also, many patients in hospices are cared for by Family Physicians. The bio-psychosocial model in Family Medicine is highly relevant to hospice work, which can be a fulfilling career for some. Some of our Family Physicians focus on transitional care, working with colleagues in restructured hospitals to bridge the continuum of care from tertiary hospitals to patients’ homes.

21.    For those of you aspiring to be Family Physicians, the Family Medicine residency training programmes run by SingHealth, NHG and NUHS provide comprehensive and robust training at the Masters level, equip you for your broad scope of practice in future. The residency programmes are designed for trainees to undergo a wide range of rotations in hospitals as well as ambulatory care settings in the community over the course of three years. The Ministry also works closely with the College of Family Physicians Singapore (CFPS) to provide other structured Family Medicine training programmes, such as the Graduate Diploma in Family Medicine (GDFM) and College MMed(FM) Programme, to equip trainees with knowledge in Family Medicine practice as a base. CFPS also offers a post-Masters Fellowship Programme which provides a framework for mentorship for advanced clinical practice, education and research in the practice of Family Medicine.

Impact on Specialist Training

22.    For those training to be specialists, there will also be a shift in emphasis towards developing the more generalist disciplines, as well as those with greater roles in the community, such as internal medicine, geriatric medicine, and rehabilitation medicine. These specialists with broader skills are important contributors to healthcare provision in the community, especially for elderly patients. We will expand the number of specialists we train in these areas to provide for shifting care needs. At the same time, it is important for all specialists not to overlook their broader competencies, and to treat their patients holistically instead of focusing solely on the diseases or body part relevant to their discipline. We will assimilate into their training core broad competencies that all specialists should continue to practise. This will better equip them to manage patients in areas outside of their narrow interest, allowing them to provide consistent and planned longitudinal care.

Conclusion

23.    What advice can I leave you with? First and foremost, we all signed on to be doctors because we have a heart and desire to serve. This has been the reason that our profession has been held in high regard. At its core, service means meeting needs – the needs of individual patients and the public. Our career aspirations, our competency development and maintenance should therefore seek to address these needs. We should not be in it for prestige, financial rewards or fame. We should not seek to be a super-specialist when there is limited demand for such capabilities or choose a specialty primarily because it gives us a good work-life balance.

24.    The Singapore healthcare system has come a long way because we have been blessed with pioneers and leaders in the past who worked to serve. This led to the development of a strong foundation in public health and a particularly strong acute hospital care system. Our future care must address the needs of intermediate/ long term care and community care. This will need our best talent and minds to aspire to be part of the needed evolution of our healthcare system. Aspire to be equipped for this emerging role and do not be distracted from this. Thank you.