Healthcare Productivity, Changing the Model of Care and the Role of GPs

This will be a long post and so apologies in advance. I wanted to be transparent and share the correspondence I had with the TODAY journalist who was obtaining perspectives for a ‘Big Read’ on healthcare productivity.

This was published yesterday in a long piece titled “The Big Read: Beyond a jobs boost, healthcare sector needs a new model of care, say experts”.

I was asked to share views on productivity and whether we had enough healthcare professionals, especially given the Ministry of Health’s statement that Singapore needed an additional 30,000 healthcare workers.

The gist of my response was as follows:

  • The manpower needs will depend on the model of care and especially how much we embrace technology and ‘top of license practice’
  • Continuing in the current model of care would be folly and doomed to failure, given the unprecedented population aging Singapore is facing
  • The public health objectives should be centered on increasing the healthy life expectancy and a strong community health focus would be critical. Hence the types of healthcare professionals Singapore would need would be those practicing in the community and that we should have more doctors such as geriatricians, rehabilitation physicians, general internists etc in the community
  • The role of family physicians in a new model of care would be critical as what they do will have profound implications on the number of and need for other specialists.

I’ve placed the email questions and responses below unedited to give the reader an unvarnished flavor of the discussions and included also follow-on questions about incentives.

All in, I thought the reporter did a pretty good job in highlighting some of the complex issues embedded into workforce planning and the inter-relations amongst policy decisions. She also subtly and gently hinted that the ‘business’ of healthcare does lead to market failures. [These are very difficult challenges the Singapore health system is facing and continued discussion and dialogue are key to evolving the ‘right’ solutions to meet Singapore’s unique needs.

[Journalist’s comments in black, mine (JL) in blue]

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As mentioned, we are working on a Big Read on healthcare manpower (for Saturday, Nov 26), and hope to get both experts’ and ground responses on how the manpower crunch/demand is held in various sectors. In the healthcare manpower plan announced last month, the MOH projected a growth of 30,000 healthcare workers—including both healthcare professionals and ancillary/support staff—between 2015 to 2020. An earlier projection had a lower figure of 20,000 healthcare professionals for the period of 2011 to 2020.

http://www.todayonline.com/singapore/30000-more-healthcare-workers-needed-2020-population-ages

 

  1. How large a factor is the ageing population in driving up the demand for healthcare workers? Apart from an ageing population, what other factors may fuel demand? [Population aging per se does not substantially increase demand for healthcare professionals. Rather it is the onset of chronic conditions such as diabetes and hypertension that tends to accompany aging and their sequelae that cause the demand. Hence the concept of ‘healthy life expectancy’ is an important one. If Singaporeans live longer as we do now and also enjoy good health as we age such that the number of years of poor health remains the same of even declines, then our healthcare demands should not dramatically increase. This explains the government’s efforts in preventive health. Other factors that may fuel demand would include new medicines or procedures for conditions that previously had few or no therapeutic options, or simply changing norms as to what constitutes disease or requires health professionals’ input, e.g. cosmetic and aesthetic medicine. The issue of insurance is a very topical one with the release of the Health Insurance Task Force report which suggested that MediShield Integrated Plan policy holders with riders had higher medical bills compared to policy holders without riders. Whilst insurance is crucial for protection against the financial consequences of serious illnesses, overly generous insurance plans may lead to over-treatment which would need more health professionals to provide.]
  2. Which departments or specialties (e.g. primary/acute/community care, which specialties or forms of care) do you think the demand for healthcare workers will be most sorely needed? In a similar vein, what types of healthcare workers will be in greatest demand? [Globally, healthcare is shifting out of the hospital into the community and the chronic diseases are accounting for the majority of healthcare utilization. Hence any specialties that are community-based should be in greater demand as well as specialties that deal with patients with chronic conditions and especially multiple chronic conditions. I would expect there to be high demand for geriatricians, rehabilitation physicians, general/ internal medicine physicians as well as doctors who deal with diseases much more common amongst the elderly, e.g. cancer (oncologists), arthritis (orthopedic surgeons) etc.]
  3. Specifically, do you think there is a shortage of doctors or specialists? Or a disproportion between generalists vs. specialists? Do you think moves to hire more foreign workers and subsidise Singaporeans to study medicine abroad have alleviated this? [Singapore enjoys respectable doctor to population ratios which are steadily improving with the expansion of medical school cohorts and recruitment from overseas. The question of shortages and in which specialties would fundamentally depend on the model of care Singapore embraces (my emphasis). As long as we continue to be hospital-centric and heavily biased towards specialist care, then we will face shortages due to the increased numbers of patients consequent to aging and onset of chronic diseases. However, if Singapore radically transforms the model of care, e.g. with family physicians managing all but the most complicated cases of diabetes, heart failure, arthritis etc, then we would need pretty major adjustments to planning parameters and the projections for various types of specialists. Likewise, if nurses and allied health professionals take on more and more of the work that junior doctors today undertake, then we would need more nurses and allied health professionals and may not need more doctors. The efforts to hire more foreign health professionals or encourage Singaporeans studying medicine abroad to return to Singapore are salves rather than fundamental solutions. The number of Singaporeans over the age of 65 years was just under 300,000 in 2005 and is expected to almost triple by the year 2030. Does this mean we need to triple the number of hospitals and clinics? Triple the number of doctors and nurses? Of course not. There is urgency to redefine the model of care to be smarter in where we provide care, who we provide care with and leveraging technology as a force multiplier.]
  4. How far can technology improve healthcare productivity? There has been a slew of pilot initiatives lately, in terms of allied healthcare, etc,. How can we push for innovation that will enhance productivity across the board? [Technology can be hugely impactful in improving technology but only if we are imaginative and ‘disruptive’. We can think of technology as supporting incremental improvements, e.g. a machine helping a doctor measure a patient’s blood pressure in the clinic, or we can completely transform the care model by having patients self-manage using technology and customized algorithms and doctors being alerted only when there are significant changes. The 3-monthly doctor consultations are then replaced by an annual one during which all preventive health measures such as vaccinations and screenings are carried out at the same time. If efforts seem piecemeal, that might be because we are focusing on the technology rather than the problem we are trying to solve. Let’s not think about a clever gadget but instead ask how can we manage 1 million diabetics with the same number of doctors, nurses and other health professionals as we have today?]
  5. Apart from technology and raising the number of healthcare professionals, what can be done to tackle the rising demand for healthcare services here? Preventive health, for instance—do Singaporeans take their health seriously enough? [Medical services can be under-used, over-used or abused. We should be emphasizing preventive health which is under-used, discouraging consultations for minor ailments which are self-limiting and doing away with administrative processes that are not medically necessary. Do employees really need medical certification to have recognized time off work? There have been pilots providing for a few days of medical leave without the need for certification (http://www.straitstimes.com/singapore/employees-take-4-days-of-sick-leave-a-year-poll). Is it time to expand these and  reduce the demands on an already stressed health system? Policy plays a role too. Foreign domestic workers today are required to have 6 monthly examinations (http://www.mom.gov.sg/passes-and-permits/work-permit-for-foreign-domestic-worker/eligibility-and-requirements/six-monthly-medical-examination). If we are desperately short of doctors and nurses, would we reconsider this administrative requirement?]
  6. A little off-track, but how about mental health staffing? The issue of professionals handling wellness in institutions has been in the spotlight recently: http://theoctant.org/edition/v-8/news/turbulent-fall-yale-nus-struggles-mental-health-resources/ [No response as I have not thought deeply about this thus far]
  7. Any further comments on this topic? [I’ve written about this a few years’ back (http://www.todayonline.com/commentary/health-sector-needs-radically-innovate-now). Think the issues have not been fully addressed and I hope we will recognize how critical it is for ‘radical productivity’ today before it is too late]

Follow-on Discussions

Thanks for the point on changing our model of care. There’s been perennial calls to shift care towards family physicians/primary care for years, a decade perhaps? What is causing the inertia? Where are the stumbling blocks?

[Short answer is incentives. Altruism will only go so far. For a whole system transformation, Singapore needs to be comprehensive and direct money, prestige and organisational power to the parts of the healthcare value chain we want to strengthen.]

I was then asked to elaborate:

[Money. Just follow the money and it will become clear why family physicians are so reluctant to focus their practice on chronic diseases. It would probably be useful to get a briefing on managed care and the rates doctors are paid as well as the limits placed on medicines etc.

This is almost a decade old but still relevant: http://annals.edu.sg/PDF/37VolNo2Feb2008/V37N2p109.pdf]

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To sum up, while I respect and welcome other views, my position is that GPs and family physicians in Singapore are reluctant to focus their practice on chronic diseases. ‘Focus’ to me means concentrating on mainly patients with chronic conditions such as diabetes, heart failure, chronic obstructive pulmonary disease, kidney failure etc. and this is entirely rational given the current funding model. This is not to say GPs don’t see patients with chronic diseases, many of them do but the data from the Primary Care Survey 2010 (Chart 3 on page 10) suggest that proportionately, polyclinics manage a larger load of chronic patients.

Do I hope that family physicians will take up a much larger role in the health system? Yes. Do I believe primary care is the foundation of any high performing health system? Yes. Is Singapore there? Sadly, no, but we can be. And given the population challenges, we have to be.

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