20 Nov 2000
By Mr Lim Hng Kiang
The Challenges of Improving Healthcare in Singapore
In October last year, I announced the restructuring of the polyclinics and the remaining government hospitals. I also announced the re-organisation of the public healthcare system into two service delivery clusters. Both these steps were aimed at improving the quality of the healthcare services, while containing cost increases. Today's formal inauguration of one of the two clusters, National Healthcare Group or NHG, marks a significant milestone in our journey towards quality healthcare for all in Singapore.
Delivering good and yet affordable healthcare
By any yardstick of measurement, Singaporeans enjoy a very high standard of healthcare. Our healthcare system is rated highly in many aspects, such as care quality, cost-effectiveness and accessibility. In the World Health Organisation's first ever analysis of the health systems in different countries in the world some months ago, Singapore was ranked sixth.
How did we get here? If we look back at the development of healthcare in Singapore, we can identify several key turning points.
Key Turning Points
First, we tackled the basic parameters. We improved the living conditions, public health and nutrition, and we adopted sensible preventive measures. Proper sanitation, clean water, safe work places, all contributed hugely to prevention of illness and accidents. The mass vaccination exercises for our newborn babies and school children keep debilitating infectious diseases at bay. By working together to eliminate breeding places for mosquitoes, malaria and dengue, which used to be endemic in Singapore, were brought under control. Such vigilance continues even today.
Second, we emphasised personal responsibility. Now the major killers are non-infectious ones, such as cancer, heart diseases and cerebrovascular diseases. Collectively, they account for more than 60% of deaths in Singapore. Such diseases can be prevented and managed if we adopt sensible life styles. It is not so difficult-don't smoke, eat sensibly and in moderation, exercise regularly and manage stress. The National Healthy Lifestyle Campaign illustrates the priority given to this approach.
Third, we put in place the right financing framework for healthcare. We implemented the 3Ms - Medisave, MediShield and Medifund, founded on the principles of personal savings for healthcare, risk sharing for catastrophic illnesses and safety nets for the needy. Together with the principle of co-payment, even for the heavily subsidised wards, they reinforced the sense of personal responsibility in the usage of medical resources.
Fourth, we concentrated on our human resources. The high standard of healthcare in Singapore is largely attributed to our dedicated staff. You can build new hospitals, you can buy expensive medical equipment, you can order the latest drugs. But to deliver high quality healthcare at an affordable cost requires a highly trained and motivated management and professional team. We have build up such teams over the years. This is our most valuable asset.
Fifth, we have restructured our hospitals in order to improve efficiency. Restructuring, first tried out in the mid-80s, freed hospitals from the constraints of civil service rules. Together with an output-based hospital funding system, which paid only for work done, it allowed hospitals to improve their efficiency and serve their patients better. The recent introduction of casemix funding will strengthen the incentives further, and encourage hospitals to make better use of their resources.
Overall, our hospitals have improved markedly since they were restructured. The professionalism of staff in these hospitals, and the conducive healing environment all contribute to a better patient experience. With the success of previous restructuring exercises, the next logical step was to complete the exercise by restructuring Alexandra Hospital and Woodbridge Hospital, the last two remaining Government hospitals, and the Government Polyclinics. I am happy to see that the preliminaries having been completed, these institutions now enjoy the same autonomy as other restructured institutions. The work, however, has just begun, and in time, I am confident that these institutions will attain the same high standards of care which Singaporeans have come to expect.
Expanding polyclinic services
In the case of polyclinics, this restructuring exercise would also facilitate the Government's effort to further expand the provision of primary healthcare services, in line with the needs and expectations of the lower income groups. One important requirement is for the polyclinics to improve their employment terms so as to attract some GPs back to work in the public sector. I am happy to note that at least 12 GPs will be joining the NHG Polyclinics from January next year.
With the additional resources, the polyclinics will be able to improve its services to the public. They should actively expand its range and level of services. With the flexibility and autonomy they now enjoy, they should also reorganise the workflow and change the operating parameters, to provide even better services to Singaporeans.
In this regard, I am pleased to announce that the NHG Jurong Polyclinic will be launching a pilot night clinic in January 2001. The night clinic will provide lower income Singaporeans the convenience of medical attention at night, instead of having to wait until the following day. Hopefully, this will also ease the congestion in the polyclinic during the day time. Jurong is one of the busiest polyclinics in the western sector. If this pilot project is successful, we will consider setting up night clinics at other polyclinics with high demand. NHG will release details of the pilot project in due course.
Let me take this opportunity to assure the GPs that the Government has no intention whatsoever of crowding them out of the primary healthcare market. Our aim is to ensure that lower income Singaporeans will continue to have access to good and affordable primary healthcare. In expanding their services, the polyclinics will ensure that they keep to the 25% limit that has been set in the 1993 White Paper on Affordable Healthcare.
Integrating healthcare across the continuum
The latest turning point in our healthcare system is to integrate our hospitals and polyclinics into two clusters. The traditional approach of developing hospitals and primary care clinics as individual entities results in the fragmentation of patient-care. Once the family doctor has referred a patient to the specialist, he often hears very little about the progress of the care given to his patient. At the hospital end, after treatment by the specialist, he often has difficulty discharging the patient back to primary care physician for subsequent management. On occasions when patients are discharged back to the family physician, the family physician may not know the full details of the patient's medical condition.
To do better, patient care has to be co-ordinated across the whole continuum. This is the main reason why we decided to go for clustering. Placing primary care clinics, hospitals and national centres under the management of the two clusters is just the first step in integration. Clinical protocols must be developed, and information systems set up to facilitate this. Administrative processes must be refined to provide the patient with seamless care.
In this regard, NHG's first 3 initiatives are clearly on the right track towards fulfilling the goals of clustering. Under the Direct Access Programme, patients from polyclinics can be admitted to public sector hospitals in the same cluster without having to be reassessed at the hospital. In similar vein, patients requiring urgent specialist attention could also be swiftly attended to by specialists in the hospitals. This is a demonstration of how institutional barriers to seamlessness can be overcome for the benefit of the patients. The pilot NHG Cancer Programme developed cancer treatment protocols for use throughout the cluster so that the best available practice will be adopted, to provide a consistently high level of diagnosis and treatment. It also allows various cancer specialists and the primary care physician to work together to provide more holistic management to the patient. In fact, it does not stop there because the Programme goes further to link the patient up to relevant cancer support groups, and provides genetic counselling to the immediate family of the patient where warranted. I am also impressed by the potential of the healthcare portal, NetCare, which will enable quick retrieval of medical records by the patient himself, and the various doctors handling his case. Hopefully, in this way, the patient will be less of a stranger to his doctor each time he comes into contact with any institution within the cluster. Then similar tests will not need to be repeated, and medication not suited to the particular patient could be avoided.
Meeting the challenges ahead
Let me now outline 3 challenges facing the two clusters in the coming years.
First, they should and can play a greater role in the area of primary and secondary prevention. The 1998 National Health Survey indicated that 9% of adult Singapore residents are diabetic. Out of these, almost two-thirds did not even know that they had diabetes. If left undiagnosed and untreated, many will develop complications such as heart disease, stroke, kidney failure, blindness and limb infections. Apart from the human suffering this would cause, it would also result in costly downstream medical interventions. The same could be said for other chronic diseases like high blood pressure, and high blood cholesterol if they are not well managed.
What this indicates is that more must be done to identify those with higher risks through screening, so that they would know early that they have such chronic conditions. When they are found to have these chronic diseases, proper treatment can be prescribed, and appropriate dietary and lifestyle counselling given to prevent the onset of complications. The large number of private GPs and well-trained polyclinic doctors are ideally suited to provide such care. If done properly, it will have a significant impact in reducing our disease burden in future years.
In this regard, Singaporeans themselves have a critical role to play. In the ongoing Community Health Screening Programme, teams of nurses and doctors have gone round to the housing estates on Sundays to make it convenient for residents to have their health status checked. While the response has been relatively good, it has remained below expectations. About a third of those who signed up for the screening did not show up. This was despite the fact that the screening was heavily subsidised, and participants need only pay $2 - $3 each. Another example was screening for breast cancer. Although the number of women going for such screening is increasing, the overall take-up rate remains low.
We owe it to ourselves, and nobody else, to keep fit and stay healthy. Unless we each take responsibility to get ourselves screened, no amount of health education or health promotion would work. One of the reasons cited for the low participation rate in health screening was that elderly Singaporeans were fearful of finding out their health status. This is understandable, but misguided. Complications arising from such diseases can be kept under control with proper treatment, but only if the conditions are detected early. Spouses and children must help their loved ones understand this, and give them the confidence to get themselves screened.
Second, the clusters must continue to focus on serving subsidised patients well. About half of all acute hospital beds in Singapore belong to the heavily subsidised wards of B2+, B2 and C. Middle and lower income Singaporeans know that should they have the misfortune of being struck by an illness, they will be able to avail themselves to basic, but good healthcare in our restructured hospitals. This aim has not changed with the restructuring of the last Government hospitals. The clusters must continue to be vigilant in cost control in the midst of rapidly advancing medical science, and to introduce new diagnostic tests, drugs and treatments only when their value has been proven.
Our healthcare system would not be what it is today if not for the high standards of our healthcare professionals. And this brings me to my third point which is that clusters must continue to provide the institutional support to our doctors and healthcare professionals to ensure that not only are their skills constantly upgraded, these skills are passed on to the next generation. Unlike the private sector, many doctors remain in the public sector because of opportunities for training, teaching and research. The advancement of medical knowledge is so rapid that without institutional support in terms of time off, or funding for these activities, doctors will find it difficult to keep abreast of such medical progress.
Conclusion: Adding years of healthy life
In conclusion, we have made great strides in health outcomes since our independence. In particular, we have succeeded in preventing the spread of infectious diseases. Because the main killers today have shifted to lifestyle diseases such as cancer, stroke and heart diseases, we have to adopt a different strategy. Organisationally, we have grouped the public hospitals and Polyclinics into two clusters. With clustering, they would be in a better position to move towards providing much more integrated care to patients. Seamlessness should be a goal for both clusters, so that the whole patient experience could be more pleasant, and more conducive to patient recovery.
With these words, may I wish the National Healthcare Group every success in achieving their vision of "Adding years of healthy life to the people of Singapore.