Four health ministers, four reorganisations. Senior Health Correspondent Salma Khalik explains why the restructurings have been a necessary process for Singapore.
Since I started covering the Health beat for The Straits Times 17 years ago, I have seen four health ministers leading the ministry - and each, some time during his tenure, reorganised the public healthcare system.
In the 1990s, each hospital was run separately. In 2000, when Mr Lim Hng Kiang was at the helm, polyclinics, hospitals and national centres were grouped into two clusters. Then in the late 2000s, the healthcare system was put into six regional groupings under Mr Khaw Boon Wan.
The latest move to group healthcare institutions into three clusters comes about five years after Mr Gan Kim Yong took over as health minister in 2011.
Explaining the move to have three clusters this time, the Health Ministry says each will have polyclinics, community hospitals, a general hospital and even a medical school. Specialist centres will be an exception - they will be shared by the whole nation as Singapore is not big enough to have, for example, three skin centres.
Three large clusters will also give healthcare professionals more opportunities to progress and move into areas they prefer.
Were these multiple reorganisations over the decades necessary? Did they improve the public healthcare system, or were they just about ministers trying to stamp their mark on healthcare, and in so doing cause a lot of unnecessary fuss?
I would argue that the changes in the past three decades have contributed to improving the healthcare system - resulting in Singapore today being acknowledged internationally as having one of the best healthcare systems in the world. Not every move was perfect, to be sure, but they have improved the system.
Singaporeans' long life expectancy and low infant mortality also attest to that.
THE FIRST RESTRUCTURING
This happened in the late 1980s, when public hospitals were "restructured", which led to them having their own boards, and being able to decide - within limits - how they rewarded staff. Then Acting Health Minister Yeo Cheow Tong said this should lead to greater efficiency and better service.
Previously, all hospitals - except for the National University Hospital, which was owned and run by Temasek Holdings - were run by the Government.
Restructuring gave each hospital the leeway to manage its own affairs within certain parameters, such as providing subsidised care. Each had its own board of directors, could set its own fees and could recruit the doctors it needed. They continued to receive government funding for subsidised patients.
Each hospital could set its own priorities. They became more efficient, since money saved could be used to further their own goals, such as to boost training, get better equipment or do more research.
Singapore benefited as treatments and procedures improved, with hospitals taking ownership and competing to provide better service - where previously, the bottom line was not such a concern.
Through annual reports, each could also see how well the others were doing in comparison - and try to do better.
When Mr Lim took over the Health portfolio in 1999, he decided to group all public healthcare assets into two huge clusters - SingHealth in the east and the National Healthcare Group (NHG) in the west. Each cluster consisted of acute hospitals, some specialist centres and half the polyclinics.
Mr Lim did that to reduce the "compartmentalisation" of various institutes. Before, the clusters, polyclinics, hospitals and specialist centres were run separately, and competed for patients. Integrating various facilities forced them to work together. It was also good for patients with complex ailments, who could get care from doctors at clinics or hospitals in the same cluster.
Where previously, polyclinics and hospital specialist centres might compete, say, for a diabetic patient since they received a government subsidy for the patients under their care, the subsidy now went to the cluster - regardless of whether the patient was treated by a specialist or a polyclinic doctor.
It made sense then, for the patient to be treated at the level most appropriate. So a diabetic patient might be seen by a specialist when his condition was unstable. But when he was better, he would be cared for at a polyclinic.
On the flip side, the clusters fostered a competitive pressure, with each vying for talent.
AND THEN SIX
When Mr Khaw took over, he broke up the clusters into regional groupings within Singapore, each headed by a hospital.
This was because he wanted to regroup both the public and private sectors in healthcare. The duo-cluster system had affected only public hospitals and polyclinics.
Mr Khaw wanted to involve the private sector. In Singapore, general practitioners account for 80 per cent of primary care. Community hospitals and the majority of nursing homes meanwhile were run by voluntary welfare organisations.
Mr Khaw wanted health practitioners and planners to go beyond the public sector, to work more closely with the private and charity sectors in their geographical location.
Four regional groups were set up. The number was expanded to six when the Khoo Teck Puat and Ng Teng Fong hospitals opened. A seventh was slated for when the hospital at Sengkang opens next year.
Each of the six regional groupings was headed by a general hospital. Two had polyclinics but the rest didn't. The plan was for each group to team up with private and charity players in their region.
Changi General Hospital, for example, formed the Eastern Health Alliance, which included Saint Andrew's Community Hospital, Peacehaven nursing home and daycare facilities, GPs in the east and polyclinics.
Because it was responsible for that area, it moved beyond its hospital walls to provide health screening in the community, to keep residents healthy and out of hospital. Part of this was driven by the acute shortage of beds.
There was similar cooperation in the other regional groups between acute and community hospitals, nursing homes, rehabilitation and eldercare facilities, and GP clinics.
There were also greater link-ups with charitable organisations to help poorer patients, especially on their return home.
AND NOW, THREE CLUSTERS
What will this round of change bring?
While the regional clusters have seen a closer working relationship between the public, private and charity sectors, the growing number of clusters is beginning to fragment healthcare here.
What started as four regional groups has grown to six and, with hospitals in Sengkang and Woodlands being built, the number would increase to eight in six years' time.
This could become unwieldy.
Singapore's future healthcare needs will also be different. The population here is ageing rapidly. Today, there are 450,000 people aged 65 years and older; the number will double to 900,000 by 2030. Generally, older people require more healthcare services. Many will suffer from one or more chronic ailments, which will make their care more complex.
Mr Gan has said often that primary care has to be the cornerstone of a good healthcare system.
GPs and polyclinic doctors see patients at the start of their chronic ailments. If they are able to delay or prevent the progression of these diseases, people will stay healthier longer, and the need for hospital care will be reduced. Half the patients with chronic diseases are looked after by polyclinic doctors.
So how will having just three clusters help?
With the restructuring, each of the three clusters will have between seven and nine polyclinics (including five yet to open).
Each cluster will have a medical school, to improve professional training and research.
Specialists can move within a cluster - perhaps spending part of the week at a different hospital within the cluster, making it easier for patients to access them without switching to a specific hospital.
THE FUTURE DIAGNOSIS
There are no glaring problems that have fuelled the latest changes. Rather, things are still working well, but the restructuring is part of planning for future needs, and doing so before push comes to shove. Indeed, there is no urgency now, so the restructuring can be done slowly over a year.
But the reality is, in the future, Singapore will need to do more with less. Demands from a rapidly ageing population will outstrip the supply of medical professionals. Singapore is already recruiting many foreigners for medical roles.
This latest restructuring hopes to optimise available resources better. One way is to move care upstream, to prevent problems or to maintain patients so their medical issues do not deteriorate so rapidly. In other words, to try to keep them as healthy as possible for as long as possible. Hence the shift in focus to primary and preventive care, and the need to work with voluntary welfare organisations and others.
It remains to be seen, of course, just how the new cluster system - which will take a year to implement - can improve healthcare delivery.
Previous reorganisations made for a better system. Restructuring gave hospitals more autonomy. Clusters helped tertiary and community hospitals work with one another and with polyclinics. The setting up of regional groupings facilitated working across public, private and charity sectors.
As the healthcare landscape changes, so too must the way Singapore meets emerging needs.
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