Reinventing Singapore’s GPs

Singapore’s healthcare needs are characterised by a fast-ageing population and a sharply rising burden of chronic diseases. By 2030, Singapore will join 34 countries among the world’s super-ageing countries, where one in five people will be above the age of 65. A majority of the elderly population will suffer from chronic diseases ranging from hypertension to dementia.

It is estimated that Singapore needs to increase its manpower pool of doctors, nurses and other healthcare workers by 70 per cent just to keep pace with the rise in demand for healthcare leading up to 2030.

The Republic will also need more critical care hospitals, community hospitals, day centres and nursing homes, which translate to increased public health spending on infrastructure.

An ageing population also means more retirees and a smaller workforce to support the population.

There are serious concerns that the economy will be adversely affected when the population goes into the super-ageing phase. Clearly, the current healthcare model of relying on hospitals for most healthcare needs is unsustainable.

How, then, can a more cost-effective model of care be developed to keep the population healthy and active?

RELOOKING COMMUNITY HEALTHCARE

First, there is a need for a radical change of mindset by patients and doctors alike to embrace community healthcare.

Research has shown that health systems that invest in better facilities in the community and deploy more well-trained healthcare workers achieve better health outcomes for their citizens, at far lower cost, than those that invest in building more state-of-the-art hospitals.

For community healthcare to succeed, more general practitioners (GPs) must train to take on the roles of family physicians (FPs). Family medicine requires structured training that is similar in intensity and duration to doctors undergoing specialist training in other fields.

The training helps these doctors to manage more-complex cases in the community without having to refer them to hospitals, unless necessary. In many situations, by preventing patients from going to hospitals unnecessarily, they reduce the costs to both the patients and the system.

More importantly, they prevent patients from the harm of unnecessary hospitalisation, such as hospital-acquired infections. In the United States, research shows that 19 per cent of patients discharged from hospitals experience a bad outcome such as poor health or complication requiring hospitalisation within three weeks of leaving the hospital. For patients with complicated healthcare problems, 20 per cent are readmitted to hospitals within 30 days of discharge. Another study shows that up to 49 per cent of patients make errors in continuing with their medication and tests.

Our GPs must be encouraged and supported with better resources to take on greater responsibility in the evolving healthcare system. But it will take more than only additional training for GPs to function as family physicians. The entire healthcare system needs to be remodelled into a more cost-effective one that is rooted in the community and focused on keeping our ageing population in the best of health and in the comfort of their own home.

Family physicians will have to work with a more diverse group of specialists and support services, including medical social work, occupational therapy and physiotherapy, to provide team-based care. As a result, the traditional role of our GPs must evolve into that of a specialist family doctor to help patients and their caregivers better navigate the healthcare system and ensure the smooth transition between different healthcare settings and specialist departments. For GPs, this means keeping pace with the changing patient needs and evolving treatment paradigm.

Finally, policies need to be put in place to facilitate the emergence of this new model of care. The Ministry of Health’s (MOH) ambitious master plan to revamp Singapore’s primary care so that the management of chronic diseases lies primarily within the community is a good start.

The crux of the master plan is to build a more inclusive healthcare system that places the patient at the core, supported by primary care and social services.

As part of the master plan, the MOH has launched a series of innovative care models such as Family Medicine Clinics and Community Health Centres for more effective chronic disease management. The MOH is also providing funding between S$4,800 to S$7,200 to encourage doctors to take up post-graduate training in family medicine.

Together with funding schemes such as Medisave, Community Health Assist Scheme and Pioneer Generation schemes, family doctors will now need to play an even larger role in our communities.

COLLABORATIVE NETWORKS

Today, many GPs are working in solo or small group practice. More, surely, can be done to form collaborative networks of GP practices in communities. This will bring economies of scale as well as provide better access and coverage for patients living within the community. For example, clinics can coordinate their operating hours and provide mutual coverage when they go on leave. This will encourage doctors to move from the competition paradigm to the collaboration paradigm and inspire more young doctors to become community-based family physicians.

Polyclinics should work with GP clinics around them as partners that provide primary care to the population living in a defined community. The network should go all the way and extend upwards into the acute hospitals. Our healthcare system needs to function as a system and not as silos divided by complex differences in funding and organisational structures.

Another existing need is to link up social care with GP clinics. Currently, it is very challenging for GPs to arrange for social care for their patients. There is practically no access to medical social workers, case managers and other allied health workers. Many elderly patients are disabled by their illnesses to different degrees, while others are troubled by difficult social circumstances. To live well in the community, they need social care and support services. Such services need to be coordinated with the GPs of the future, who will provide comprehensive holistic medical care to such patients.

Singapore has made giant strides in the past 50 years. Our health system has consistently stayed ahead of the curve, avoiding wasteful and low-quality care that had troubled many developed countries that followed conventional thinking.

This new paradigm of bringing care back to the community to support active ageing in our heartlands holds the promise that will enable us to weather the challenges that come with a rapidly ageing population.

ABOUT THE AUTHOR:

Associate Professor Lee Kheng Hock is President of College of Family Physicians Singapore.