ETHOS 26, Nov 2023
WHY IS THERE A FOCUS ON PRIMARY CARE IN SINGAPORE’S HEALTHCARE
Primary care is not new to the healthcare sector: certainly, it was around when I was born in the 1960s. In many ways, the notion of primary care back then was ideal: the general practitioner, or GP, was the one-stop doctor you saw for any medical condition you might have.
Since then, however, family medicine has become much more complex. It has expanded into many different subdisciplines. When I was a medical student, we were looking at perhaps ten subjects in this field. Today, we are looking at 32 subspecialities. While the field has advanced, GPs as a profession has not kept up with the times. In fact, in some ways it has regressed and we are now years behind other advanced nations.
One example of this is the way in which we put into practice the concept of third-party administration. In theory, it is meant to enforce efficiency and effectiveness to lower the cost of healthcare. A third party, such as an insurance company, puts pressure on doctors to try to lower costs. However, it also adds a layer of administration, which itself takes up costs. In response, some GPs might make up for these additional costs or loss of earnings by taking more patients. Or they may cut costs in other ways: they may give fewer days of medicine, prescribe a generic or cheaper drug instead of a more expensive one. Or they may even give fewer days of medical leave, even though it is not realistic to expect patients to recover in the given time. Ironically, these can lead over time to inefficient healthcare outcomes. Patients who fail to get well get referred to hospitals, which adds to the acute care burden, when in fact their conditions could have been resolved earlier at the primary care level. Third-party administration may also mean that some procedures and investigations which could have been done cheaply at the primary care level are delivered instead at the more expensive tertiary level. This raises costs, causes inconvenience to the patient and adds to the workload of our specialists.
A second factor is the way in which healthcare policy is structured. Healthcare subsidies are necessary, but how they are applied can make a difference and can shape where patients flow. For instance, why is it that for a patient to receive subsidised physiotherapy, their GP must refer them to an orthopaedic surgeon? The surgeon is not keen to see such patients, because his main role is to take on complex cases and perform surgery. This approach may have been relevant in the past, when physiotherapists were rare, and access had to be managed. Today we no longer have a shortage of them, but the way subsidies continue to be structured has yet to change to match the new context. This creates distortions in our system.
Many healthcare needs can in fact be met well and cost-effectively at the primary care level.
Another factor is the change in societal expectations. In the past, patients hardly ever saw specialists; the polyclinics handled conditions that today would be referred to a hospital or a specialist. The quality of medical care was just as good—but today, patients have different perceptions of what the healthcare system can deliver. Indeed, in the past GPs used to carry out routine procedures, such as childhood vaccinations, that today are often done by specialist paediatricians. Over time, GPs can feel that there is no longer demand for them to provide these services. GPs are generalists. If they lose some part of their clinical practice because of lack of demand, they can go into other areas to survive. The fear is that they might then lose touch with important skills or lack the confidence in these aspects of care, even though it is part of their medical training.
Many healthcare needs can in fact be met well and cost-effectively at the primary care level, whether by polyclinics or GPs.
There are also good reasons for preferring that patients be looked after by primary care rather than by acute care. In Belize, GPs are being encouraged to look after patients who are stable after cancer treatment. Because of modern medical developments, most cancer patients survive to have a decent quality of life. But they are still vulnerable: if they aren’t seen by their primary care doctors close by, they risk ending up in the hospital emergency ward each time they have a fever or even influenza that worsens.
In Australia, where my children practise as doctors, it can be difficult to refer patients to specialists in a city which could be hundreds of kilometres away. So primary care practitioners in smaller towns must manage on their own. They form groups of fellow GPs, each with special interests. These “GPwSI”1 groups are supported by specialists in main hospitals, through telemedicine as well as regular programmes where they are brought back every three to four months to familiarise themselves with the latest specialised medical developments and advances in management. So they are semi-specialists—or rather, they are specialists in family medicine, working together to support their rural or suburban communities. This is something we hope to see happen in Singapore in future.
We are persuading GPs that they should and are able to take care of most patients; we are setting up systems, and we will have systems to support and remunerate them for doing so.
HOW IS PRIMARY CARE IN SINGAPORE EVOLVING?
What we hope to achieve, through the Primary Care Networks and the latest developments in Healthier SG, is to transform primary care and shape it to match the demands and opportunities of the future. This is a long-term strategy that will take many years to achieve, but we are now moving a step closer.
Through the Primary Care Network and Healthier SG, we hope to transform primary care to match the demands and opportunities of the future.
One of the things we want to do is to give GPs support for their clinics. Most GPs are solo practitioners. If we expect them to perform more healthcare services in future, they will need staff help. It is not efficient to see a patient and also carry out scans, tests, and other checks, all of which take time. It is better to employ a nurse to perform these tasks. They can spend an extended period talking to the patient, whereas a doctor may only be able to spare a few minutes before focusing on other areas such as prescriptions. We could also support family clinics to be multi-doctor practices, so that we can accommodate GPwSI practices and hence offer a better one-stop service. The space allocated to clinics in newer housing estates may also have to be much larger to accommodate entire primary care teams and the expanded role expected of family clinics.2
This is where the Primary Care Network (PCN) approach makes a difference. Each PCN is a virtual group of GP clinics, supported by a HQ. The HQ has a team of nurses and what we call primary care coordinators. These coordinators manage the software that helps keep track of patients who are lost to follow-up (say they had been prescribed three months of regular medication but have not come back for more after that period). The coordinators contact these patients and remind them to follow up. If these patients do not follow up regularly, their conditions could worsen and lead to complications that may land them in hospital or worse: which is bad for them and for the healthcare system.
My nurses have full access to my clinic management software and patient health records. They help to ensure that my patients do their follow up and ensure that the burden for remembering to check with patients does not only fall on the doctor’s shoulders. In some cases, such as for diet counselling, it may be even better for nurses to do so. They can be very good at administering injections or blood tests, or they may be better with talking to patients or persuading patients to observe certain health habits, than doctors are. Indeed, some of the older nurses are superior at these tasks because they are regarded as more patient and caring figures.
This is why our vision is not just to advance GPs and family medicine, but to upgrade the whole primary care system. We must involve not just doctors but also nurses. Nurses must be as well trained as doctors: the only difference is the licence to prescribe medicines. They can really multiply doctors’ capabilities, especially in primary care contexts.
There are also important allied health practitioners, such as optometrists, psychologists and so on. In Singapore, we look at psychology as looking after mental health. But in fact, they could also help encourage people to look after themselves: you don’t need to be mentally unwell to see a psychologist. This could be an important role as Singapore’s public health paradigm shifts towards preventive health and personal responsibility. Indeed, many targets of health promotion, such as obesity, exercise, healthy eating and mentally unwell to see a psychologist. This could be an important role as Singapore’s public health paradigm shifts towards preventive health and personal responsibility. Indeed, many targets of health promotion, such as obesity, exercise, healthy eating and so on, have to do with mental and psychological factors. We need the motivation to look after ourselves and to work out. Eating can be comforting, so if we feel stressed, we just want to eat comfort foods, which could be unhealthy ones in the long run. We know the obesity pandemic is greater than the COVID pandemic, and it can lead to all kinds of other conditions. But if we get our psychology and mindset right, we could stay healthy as a nation and not reach the disease stage nor require further healthcare. This could be a good way for a broader idea of primary care to shape the entire system and improve population health.
Our vision is not just to advance GPs and family medicine, but to upgrade the whole primary care system.
WHAT CHALLENGES DOES SINGAPORE FACE IN ADVANCING THE PRIMARY CARE SECTOR?
To move towards our vision, we need to address different stakeholders: including the practitioners themselves, policymakers, and the public, who are also the patients.
First, practitioners. Clinically, we are all well trained and know the right thing to do in medical terms. But we also need to make sure that the business model for GPs makes sense, or else their work is not sustainable. With Healthier SG, we want to change the primary care infrastructure to support GPs in doing the right thing. First, we create standardised clinical protocols that work like KPIs: for example, we specify that a diabetic patient should do a blood test every three months, which is the clinical best practice. When we did an audit of such practices, we realised that only about 50% of patients received such tests, when the aim is for 80% to 90% of them to do so. Next, we develop outcome indicators: for instance, whether patients’ sugar levels have really been brought under control. If so, the GP gets an additional bonus. If the patients are healthier, the GP gets rewarded. This helps make GPs accountable for the health of their patients.
At the same time, we also want to reward the patient for taking care of their own health. Patients can now get 3,000 health points (which is worth about $20 in value) for sitting with their GP to develop a health plan, looking for example at what they should be doing, such as exercising more or quitting smoking. We hope to empower the patient and at the same time encourage the patient to take ownership of their health.
We overturn the paradigm, so that instead of patients paying to see a doctor, they get paid to see a doctor once a year. And if they meet their health KPIs, they too get rewarded. In a departure from decades of policy on healthcare subsidies, we are also completely waiving the co-payment for certain procedures, such as influenza and pneumococcal vaccinations, for those who sign up with Healthier SG. This encourages patients both to enrol, and to get vaccinated: both of which contribute to overall population health.
Enrolling a person with a GP through Healthier SG gives both physician and patient a chance to build relationships and coordinate as well as to personalise care, which are principles of family medicine. It gives doctors a longitudinal and more comprehensive understanding of a patient’s needs and even that of their family. At the same time, Singapore’s version of the programme does not restrict patients to any clinics, unlike many other countries, where people are obliged to stay with the same clinic within their vicinity, which is often assigned by the government. Singapore allows patients to choose clinics freely, although subsidies are reduced if they jump clinics.
A positive side effect of the Healthier SG programme to enrol patients with GPs is that it gives the clinics a regular customer base. This is not a captive market, since patients are free to change doctors, but if the relationship between them is a good one, they are likely to stay on. Over time, this gives family clinics a clear sense of value: not only the clinic’s premises and equipment, but the patient enrolment numbers, which are tied to the remuneration given to primary care under Healthier SG. Being able to envision the total value of the clinic as a sustainable business means there can be continuity over time: Doctors who retire may be able to take on and groom younger physicians, who can take over the clinic in time, with confidence that the business will be viable. In turn, the local patients can get to know a new doctor at the clinic they have become used to and continue the good relationship they have. This transition of care, when done well under Healthier SG, will benefit the public by adding stability to the care of the population.
HOW IS THE PRIMARY CARE SYSTEM EXTENDING BEYOND MEDICAL NEEDS
TO SUPPORT OTHER ASPECTS OF WELLBEING?
An important development in our vision for primary care is the renewed emphasis on social prescribing: that is to say, any kind of care provision that has to do with a person’s survival and wellbeing. This is related to our understanding that health has many social determinants. To be healthy, we need food; we need money; we need to have a job; our mental wellbeing depends on having a sense of identity, dignity, self-esteem, confidence and so on. Healthcare needs go beyond the medical field per se. This concept is not new, especially to public health physicians, and in the old days, GPs were often consulted on non-medical issues by their patients. Nevertheless, it is probably unfamiliar to most clinicians in Singapore today. Doctors have come to see these non-medical aspects of care as not part of their job.
Today, we have a Referral Management System (RMS), based in our Primary Care Network HQs, that can help connect patients with important services such as social services, palliative care, homecare, and even community funding. While in the past it was difficult to find information on these services, the RMS now consolidates these into a single portal. It is currently underused because many GPs are not aware of it. But we want to expand this. Voluntary Welfare Organisations are being funded and trained to be the extended arms and legs of our GPs, helping to monitor blood pressure and sugar levels of the elderly, for instance. In this way, the broader community, not just medical personnel, can contribute to primary care for Singaporeans.
We want to remind our physicians that they are responsible for their patients not just in clinical terms, but for the whole being of the person.
There is synergy between the development of the healthcare system and other sectors, with the new focus on not just disease prevention and treatment but overall wellness. In fact, in some countries, such as Malaysia, the Ministry of Health also has responsibility for Social Services. The work we do to take care of Singaporeans in different ways could involve all aspects of service provision, across the whole public sector and community ecosystem.
As services become more and more specialised, they tend to fragment, and then the tendency is for any part of the system to be bypassed or overlooked. Instead, conceptually, the GP should be the first point of contact for help in Singapore. We want to remind our physicians that they are responsible for their patients not just in clinical terms, but for the whole being of the person.
They will be supported in this role and should know what resources are available for them to do so.
GPs need to relearn this conceptually, but also to put it into practice actively. As with any process, if you don’t practise it, you will not be sharp at it, and will not remember all the resources that are available. GPs should make it a habit to always bear these other aspects of care in mind when helping patients.
WHAT DO YOU SEE AS THE ROLE OF FAMILY DOCTORS IN AN IDEAL FUTURE?
The healthcare system cannot just be about primary care or tertiary care. Every aspect of the ecosystem has a role. Each must talk to one another so that the patient can get what they need, without the care they receive becoming disjointed or disconnected. We want our GPs to become patient advocates, helping the patient to understand and navigate the system and to communicate with say, other doctors or specialists and allied health professionals. Communication will be key to this new role of our primary care practitioners.
We must see our patients not as customers or even clients, but as a friend and person we want to help. Like many civil servants, most doctors come into this vocation wanting to do good. If we focus on the whole person, we will do these things for them as a matter of natural progression and logical course.
My vision for the future of primary healthcare in Singapore is based on the point of view of the ordinary Singaporean. If I face any problems, whether it is a health issue, or a social, money or job issue, I want to go to one point of contact for help, who is a trusted friend, and that is my GP. I want to be able to talk to them freely, without being judged, and be pointed to the right place, without having to navigate the whole system on my own. The GP will be able to put me in touch with a primary care coordinator, who will know how to arrange all the services I need across the whole complex spider web of services and resources. And once that is done, I will not need to be anxious, and can continue to live my life well. I will be taken care of, not just for health matters, but for all aspects of being.
Healthier SG is the first of many steps towards this future.
- General Practitioners with Special Interests (GPwSI) is a term commonly used across Commonwealth countries. They may also sometimes be referred to as GPs with Extended Roles.
- Currently, the HDB shop space for clinics is between 40 to 50 square metres, whereas it may need to be 2 to 2.5 times larger. Another approach may be to only allow Primary Care Networks HQs to bid for these larger units, as PCNs are the main movers for developing the primary care system of the future.