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THOUGHTS ON ORGANISING PRIMARY CARE

The Health Minister, Mr Lim Hng Kiang’s speech on health policy directions in Parliament is reproduced as the lead article in this issue of SMA News. In his meetings with various professional groups, he has spoken on the clustering of health services in Singapore into two groupings, East and West. In each grouping, there will be a government primary care cluster and hospital cluster of service units. Such clustering will enable the seamless progression from primary care to hospital care and vice versa to happen but the details need to be worked out.

What role will the polyclinic play? The raison de’tre of polyclinics is to care for the poor. The polyclinic has also in the course of time, particularly with the setting up of the Family Medicine Master’s programme, taken on a role in training family doctors. Also, every year the polyclinics provide a real life view to the 150 - 200 medical undergraduates in their one-week attachment in their third year of training. This one-stop service centre contrasts with the more customised care provided by the single-handed general practitioners.

What role will the GPs play? There are three major areas in which primary care can make an impact on the population’s health status, morbidity and mortality, and the nation’s health bill. They are namely, the care of chronic medical problems, preventive care and care of the elderly. Because GPs provide 80% of the primary care for the population, their role is quite substantial.

The integration of the levels of care vertically will provide opportunities to innovate and test out systems that network the GPs and the hospitals in providing seamless care. It is in chronic care that the potential for shared care between neighbourhood GPs and the regional hospital specialists to have an impact on health status is the greatest. Arrangements for GPs to obtain drugs for their patients at hospital rates for chronic conditions will go a long way to help to reduce costs for the patients. There is a need to look into logistic and administrative aspects to make these arrangements happen.

The question of whether the polyclinics should be dismantled or not has been raised by some doctors. On balance, most doctors generally feel that the polyclinics have important roles that could not be performed as well as by the private GP sector. There are specific roles that polyclinics could play in primary healthcare delivery in Singapore, namely (1) to serve the poor, (2) to be a benchmark for primary care delivery, (3) to provide real-life experience for postgraduate family medicine trainees in adult care, elderly care, and mother and child care under one roof, (4) to provide real life experience for the undergraduate students who have their one-week attachment, and (5) preventive care and health education.

With integration in place, the polyclinics together with the GP clinics can be clinics for step-down care. Here hospital specialist outpatient clinics need to work out the discharge criteria of their patients and also shared care arrangements with both the polyclinics and the GP clinics. Secondly, the polyclinics can serve as support centres for GP care. The polyclinics together have sufficient MMed (FM) graduates to be able to offer such second opinions for referring GPs. And the polyclinics can help to integrate the hospital, the polyclinic and the GPs for CME activities. This is something the polyclinics have done before and could be explored further with the development of clusters.

Preventive health care, health promotion and care of chronic medical conditions remain the cornerstones of primary care besides curative care. Enough resources in terms of people and material resources should be provided for the polyclinics to run and develop its services. High technology specialist care is glamorous but have a low yield of effectiveness. There is therefore a need to maintain a balance in spending the health dollar.

The idea of linking GPs to hospitals in the clusters for shared care and cheaper drugs for the patient should be pursued actively. There is a need to work out the mechanisms. There is also a need for the GPs in both the group practices and individual practices to work together to provide care for the patients. Competition is not enough to ensure sustainable and high quality primary care. Co-operation and networking will become more important as Singapore strives towards an integrated health care delivery system.

GPs in individual practices, small practice groups and big practice groups need to put their act together as professionals. There is a need to charge a consultation fee that will help to sustain good quality care without having to be heavily cross-subsidised by profit margins from pharmaceuticals. For patients who are needy, there is obviously the place for charging less as a service to mankind. It is conceivable that clustering will explore the possibilities of big group practices working with hospitals. Perhaps the individual GPs and small practice groups should consider forming clusters of co-operatives to exploit the administrative advantages which big group practices have. Some natural leaders in the GP community need to think further about these ideas.

Many primary care doctors perceive the role of the College of Family Physicians to be more important than before. It should provide the academic leadership for primary care. Firstly, there is the idea of the College setting up a vocational register for primary care doctors to encourage them to upgrade. Secondly, the College could encourage the practice of self-audit; it can run courses on such activities, like what the College of General Practitioners, in the United Kingdom, is doing. Thirdly, it could play a role in the development of clinical guidelines for common and important clinical conditions based on evidence based medicine applied to the outpatient setting. Fourthly, the College should play a key role in working with the profession to define a menu of continuing medical education “must know”, “good to know” and “nice to know” topics for the primary care doctors. More attention can be paid to hone the knowledge and skills for the “must know” topics.

A/PROF GOH LEE GAN