Radical Productivity ‘Today’ 1 March 2013

Singapore is staring down the barrel of a severe shortage of healthcare resources, including doctors, nurses, other healthcare professionals, hospitals, beds etc. There are 300,000 Singapore residents over the age of 65 years today; by 2030, this number wil balloon to 900,000, a three-fold increase. As Albert Einstein eloquently commented, doing the same thing over and over again and expecting different results is insanity. Building more hospitals, recruiting more doctors and nurses… All these are necessary in the short term, but we also need to fundamentally transform the way we strengthen health and deliver healthcare. “Necessity is the mother of invention”, and I am optimistic Singapore will find our own unique paths forward.

The commentary below was contributed to ‘Today’ to offer some thoughts and examples of what the possibilities are… 

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From Today 1 March 2013

Health sector needs to radically innovate, now

Singapore’s healthcare infrastructure is so lagging that it paradoxically may open up opportunities for radical innovation

Singapore is short of healthcare resources: We need 32,000 additional healthcare professionals by the year 2030 to care for our rapidly aging society, a 70% increase over today’s workforce; we currently have about 2 hospital beds (both acute and extended care) per 1,000 population which pales in comparison to the OECD average of 5 beds per 1,000 population.

What can we do then? We cannot lower our standards or compromise the health of our citizens, and must raise our productivity. We know we face, and will continue to face, severe manpower and infrastructure shortages. If we do not radically innovate and enable Singapore healthcare providers to do more with less people, fewer beds and so on, we will pay a price in human life. To avert this, the generous monies provided for the Ministry of Health in this year’s Budget, to the tune of S$5.7 billion (an 18-per-cent increase from last year), must be well spent. The often-quoted labor saving efforts such as mechanical patient lifters in nursing homes reducing the number of attendants needed or a pharmacy packing robot are really just incremental innovations. Can we do better than this?

MORE HEALTH, LESS HEALTHCARE

A pivotal insight is that healthcare providers offer ‘healthcare’ but what patients really want is ‘health’. How then can we have more ‘health’ even if this actually means less ‘healthcare’?

Productivity cast in this perspective then cannot be about squeezing more patients into an already over-booked clinic session or pharmacists being able to dispense medicines to 25 patients when they were previously able to only do 15. It has to be about achieving the same objective, ‘health’ and being agnostic about the means. Can we increase health even as we relieve the pressures on healthcare? Some examples from around the world to stimulate our imagination here in Singapore:

Chronic Disease Management– Does a stable and well-controlled hypertensive patient need to physically consult her doctor every 2-3 months? Would a virtual consult or even a computer-augmented self-management regime suffice in between annual visits to her physician? Years ago, I had the privilege to visit Kaiser Permanente, a world-renowned Californian integrated care provider. I asked my host: “How often does a well-controlled hypertensive patient need to physically consult?” His response: “Never, we can do everything remotely through the internet or over the phone”. He added that during the annual in-person general preventive health screening consultation, high blood pressure control could be discussed. Almost a quarter of the Singapore adult population has high blood pressure. Imagine how many physician visits could be obviated.

Minor Ailments– The average person is afflicted with ‘flu-like’ symptoms maybe 4-6 times a year with the vast majority being minor and self-limiting. How do we know which ones are “minor”? England has a remote care service called ‘NHS Direct’ where members of the public can consult over the telephone or online and as necessary, decide whether an in-person consultation is warranted. Do patients want ‘impersonal’ remote care? Well, yes, 4 million calls and 10 million online consults a year are made for all kinds of symptoms. The eco-system has to exist to support this, and by eco-system, I mean pharmacies where members of the public can purchase medicines for treatment of common ailments without a prescription and a societal model where workers can call in sick without the need for medical certification at least some of the time. Singapore has over 3.36 million persons in the workforce; multiple this by say 5 minor illnesses a year, and that’s almost 17 million consultations per year. Can patients self-manage select conditions with some help and minimize the strain on our healthcare system?

Specialist Referrals– Certain specialties such as dermatology are highly visual. Can a dermatologist provide advice remotely to a family physician instead of having the patient moving back and forth, creating additional visits? Sure. In the University of California Davis, dermatologists treat patients from 32 remote sites in California via ‘live interactive’ teledermatology. In Singapore, 5% of all GP visits are for skin-related ailments. How many progress to specialist referrals, and of these, how many could have been avoided by enlisting teledermatology?

A NATIONAL TELE-HEALTH STRATEGY?

Technology can transform clinical practice, but technology adoption does not occur in a vacuum. Premium cars will struggle if roads are rudimentary and signage is absent. In the same way, while technology (and especially tele-health) has tremendous potential to revolutionize the way we deliver healthcare and enable Singapore to mitigate our infrastructure shortfalls, government has a key role in ‘building the roads and organizing the street signs’. What is needed, and quickly, is a national tele-health strategy that establishes standards for appropriate remote practice, enables viable business models so that private enterprise can bring its creative energies into the fray, and empowers patients and healthcare professionals to do the right thing for themselves and for the country. The government has announced it will “build infrastructure well ahead of demand”. Infrastructure is not just beds or buildings; it also includes the policy and legal frameworks necessary to realize productivity and innovation. Let’s start doing things differently; we have to.

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One comment

  1. Some comments I have received that I think informative to share (Names have been withheld to protect the guilty!):

    A. I like the article. But it sounds too calm and non-hurried. The mood is slightly discordant with the disaster that’s about to befall us.

    B. I agree with you an urgent drastic change needs to happen! The SMC ethic code that strongly discourages telemedicine must surely be reconsidered. Shared care is great but responsibility of care needs to be very clearly defined. Stable hypertension and hyperlipidemia are certainly great examples that the patient may not need to see the doctor at all, probably just managed by computer system and a visit is arranged only when results are outside the target.

    C. There also has to be a cultural and mindset change on the ground. A few years ago, we tried out an outpatient tele-health febrile neutropenia service for a cancer center. That proved safe and cost-effective, but bombed because of physician resistance. It is these issues that pose significant (and sometimes unexpected) implementation barriers.

    D. May I add a few issues for discussion: 1. if you are a patient would you talk to your doctor face to face, or would you want your doctor to correspond with you on email? 2, if you are a doctor would you prefer to meet your patient at your clinic, or just to skype with or email with the patient?

    E. I really like the article. “Simple” solutions. Would need policy changes to make it happen though….

    F. Why do you consider robots incremental ? In Japan and USA they are trying to use them fairly seriously and radically. I use the term generally to include regular and very small devices.

    My thoughts:
    I agree the mindset is crucial and another thing to consider. And enlightened policy making is vital. Tele-health is a substitute and an imperfect one, but we live in an imperfect world!

    I’m reminded of 2 things:
    1. There is opportunity cost and the simple patient a specialist did not need to physically see is the complex patient who did not get a slot in the clinic and dropped out of the system. We have no visibility and these patients have no voice…
    2. In banking, everyone said the elderly would not use ATMs but as ATMs became more widespread and banks started closing branches, the elderly who would never have used ATMs learnt and adapted. When I was living in the US, we were charged by the bank everytime we physically attended at the branch whereas online and ATM services were free! In California, patients like tele-health as it saves a long drive. The basic point is that the best is a face-to-face consult but the best for one patient may result in nothing for the next patient and a sub-optimal system outcome. We all want the best for ourselves and so some degree of forcing function in the Singapore context is probably required.

    Robots are not incremental per se, but a simple labor substitution/ augmentation to me is not very remarkable as it does not seriously address whether there are opportunities to fundamentally transform the delivery model.

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