Three-cluster health system: It's about integration, not competition

"Old wine in new bottles" was the cynical reaction to the news that the six public healthcare clusters would be merged into three - Singapore Health Services (SingHealth), National Healthcare Group (NHG) and National University Health System (NUHS).

This is understandable. After all, SingHealth and NHG were established in 2000, bringing together almost 20 public healthcare institutions under two clusters before they splintered into six.

Now they are reclustering into three? On the surface, it does look like an expensive 17-year journey to get to the same place. But it's not.

This time, it is different.

Let's first review the reasons for the clustering back in 2000. Then Health Minister Lim Hng Kiang explained the benefits of vertical integration, saying clustering would "provide more integrated and better quality healthcare services through closer cooperation and resource sharing".

Subsequently, Mr Khaw Boon Wan, who was Health Minister from 2004 to 2011, also noted the policy intent for "the two clusters to compete more actively to provide better care at lower cost to their patients".

In the intervening 17 years, three paradigmatic shifts in medicine and society have become obvious.

As Singapore's population becomes increasingly aged, it is necessary to update the care models, highlighting population health, preventive care and a truly integrated health system. The three clusters have enough residents to justify a full complement of specialists across the major disciplines and a network of primary care facilities. ST FILE PHOTO

Firstly, the "silver tsunami" is well and truly upon us. In 2000, only 7.3 per cent of Singapore residents were aged 65 and above.

Today, this number is 12.4 per cent. By 2030, a mere 13 years away, one in five Singaporeans will be elderly.

Secondly, chronic diseases are rampant - if left unimpeded, we face a potential future where Singapore's diabetic population will grow from today's 440,000 to a million.

Finally, government spending on healthcare has burgeoned. The Ministry of Health's (MOH) budget grew from $1.2 billion in 2000 to a whopping $11 billion last year.

"More of the same" will doom Singaporeans to a gloomy, disease-filled future and Singapore to a funding crisis. We need to transform our care models, emphasising population health, preventive care and a truly integrated health system.

This reorganisation is an integral part of this transformation.

What's different this time is that clustering is less about competition and more about integration. What's different this time is also that integration is across healthcare and community services, focusing on health and healthcare.

Imagine a future where a Singaporean who breaks his hip is taken by ambulance to the nearest general hospital, undergoes hip replacement surgery the next day, and after another day of convalescence, is transferred to an adjacent community hospital for rehabilitation.

Instead of staying for a month there, he goes home after a week and enjoys the convenience of a day rehabilitation centre just across the road. His kopitiam friends pop in during his rehabilitation to cheer him up.

Two months later, he's walking independently, unlike his aunt, who never walked again after she broke her hip, was on the waiting list to enter a community hospital and died in a nursing home less than a year after the accident.

In this same future, a Singaporean diabetic wakes up every morning, heads downstairs for an hour of exercise with her neighbours and, after that, learns healthier ways of preparing her favourite foods.

Every day, she checks her blood sugar using a cluster-provided device which wirelessly transmits the data to her healthcare team. An alert is sent if anything is amiss.

Her mother developed kidney failure five years after being diagnosed with diabetes. It has been 15 years since her own diagnosis during a routine community screening, and her kidneys are functioning just fine.

We all have to die but we don't have to live in poor health for years before death. This is what our health system has to support every Singaporean to achieve, and achieve at reasonable costs, and organising into integrated clusters is the way to achieve this.

This week's announcement about the reorganisation is hence necessary. But it is also insufficient.

The reorganisation addresses only the public healthcare components of the ecosystem and does not formally involve the private or the equally important voluntary welfare organisation (VWO) sectors.

Secondly, patients are still free to "cross clusters", for example, seeking care in Yishun Polyclinic (NHG) and having elective surgery in Singapore General Hospital (SingHealth) even if he lives in Jurong (NUHS geography).

Unless patients stick to the same cluster for virtually all their healthcare needs, the complexity of coordinating across clusters will defeat the purpose of reorganising.

 Also, making structural changes without aligning incentives will not change behaviours.

Why would specialists work with GPs differently after the reorganisation? Or GPs bother with tele-health? Financial and policy levers will in time be needed to encourage providers, whether public, VWO or private, to work together seamlessly with each other and with patients, and for Singaporeans to remain within the geography of their clusters.

Finally, the question: Why three and not two clusters?

Well, we can only speculate, but one major difference since 2000 has been the development of another two medical schools.

Practically, it would be difficult to reconcile two medical schools with vastly different pedagogical methods and objectives within the same cluster.

Besides, with roughly 1.5 million to two million people each, the three clusters have sufficient numbers to justify a full complement of specialists across the major disciplines and a network of primary care facilities.

In announcing the reorganisation,MOH took pains to reassure patients that they "will not need to make any changes, and can continue with their existing healthcare arrangements and appointments".

This sets the bar too low. Patients should expect more than just "existing healthcare arrangements".

Singaporeans should hold MOH and the health system accountable for building on the scaffolding that this reorganisation provides and quickly realising a future where our health system truly is, as NHG's tagline promises, "adding years of healthy life".

  • The writer is partner and head of health and life sciences for the Asia-Pacific at management consulting firm Oliver Wyman.
A version of this article appeared in the print edition of The Straits Times on January 21, 2017, with the headline 'Three-cluster health system: It's about integration, not competition'. Print Edition | Subscribe