Heathcare changes: 3 clusters offer more 'firepower'

That's how one health expert describes the new system that will consolidate public healthcare into three large groups. The key this time is a focus on primary care, Insight finds.

For 71-year-old Lim Ah Sai, a double amputee who has five chronic illnesses, including glaucoma, healthcare gets very complex.

Three times a year, he goes to Toa Payoh Polyclinic to make sure his diabetes, high blood pressure and high cholesterol are in check.

He also has an appointment every two months at the National Skin Centre in Novena so doctors can keep tabs on his eczema.

Almost every day, he goes for day care at voluntary welfare organisation SPD - which cares for people with physical disabilities - or visits the senior activity centre run by Touch Community Services near his home in Geylang Bahru.

Mr Lim and his wife - who is working and cannot care for him - have no children.

"It's simple because they (all) arrange transportation for me," Mr Lim says. "But if they didn't, how would I get anywhere?"

Last week, the Health Ministry (MOH) announced a set of changes to the healthcare landscape that might make life simpler for people like Mr Lim who have multiple appointments around the island.

 
But at first glance, the changes make it look as if history is repeating itself.
 

The six healthcare clusters, formed in the late 2000s when two bigger groups were split up, are merging again. By next year, after the transition is complete, there will be three large groups overseeing public healthcare - SingHealth, the National Healthcare Group (NHG) and the National University Health System (NUHS).

As familiar as this landscape appears, experts are quick to point out that Singapore today is not the same country it was in the 1990s - and that makes all the difference.

MORE SEAMLESS

I think there is a recognition that collaboration is easier if there are fewer clusters, and between and within these three it will hopefully be easier to agree on workflows and processes, and ultimately standardise (them) at the national level.

DR LOKE WAI CHIONG, Deloitte South-east Asia's healthcare sector leader.

Reshaping the healthcare scene is meant to solve problems the Republic didn't have before, especially that of a growing senior population making frequent hospital trips for relatively minor ailments.

"At present, some patients have to make multiple trips to hospital specialist clinics for chronic disease management," says Dr Tan Wu Meng, an MP for Jurong GRC, who is on the Government Parliamentary Committee (GPC) for Health.

"But what if we could empower more family physicians to manage more such patients in the community closer to home - with specialist opinions in the same cluster just a phone call, an instant message, or an e-mail away?"

This is exactly what MOH hopes to achieve with its emphasis on primary care as part of the merger.

Primary care refers to polyclinics, general practitioners (GPs) and family medicine clinics - the first ports of call for most people when they fall ill.

LESS TO-ING AND FRO-ING

Having three large clusters rather than six smaller ones will make it easier to coordinate between hospitals and primary care doctors, says a ministry spokesman, and help to "anchor care in the community as a collective force".

 
 

"Primary care is the bedrock of a good healthcare system," the spokesman adds. "A patient with a chronic disease may require treatment at an acute hospital for a serious complication, but should ideally be able to be managed close to home by his regular family doctor over the longer term."

This means the changes could save people time and money - for if they find that they can rely on doctors near their homes, they have less reason to travel further and pay more for care in a hospital clinic. And it is not just savings in terms of transport expenses, but also in medical costs, as seeing a specialist is generally more expensive than going to a polyclinic doctor.

Comparing the healthcare system to a pyramid, Mr Roy Quek, chairman of private healthcare group Thomson Medical, says: "You want to catch people at the base of the pyramid first, rather than all the way at the top where the costs are much higher."

Mr Quek, who used to be deputy secretary of health policy at MOH, adds: "Primary care is always going to be our first line of defence - but it must be able to link back to the larger system."

WHAT BROUGHT ABOUT THE CHANGES

The changes will see the newly formed National University Polyclinics, managed by NUHS, take over the management of five of the 18 existing clinics - meaning all the new clusters will have their own set of polyclinics.

In 1999, the nation's public healthcare facilities - general hospitals, specialist centres and polyclinics - were divvied up more or less equally between SingHealth and NHG.

But under then Health Minister Khaw Boon Wan, they were hived off into six smaller clusters, each in charge of a specific geographical region, the idea being that these smaller clusters - each anchored by a general hospital - would have more room for innovation and become more independent.

However, last Wednesday, MOH announced the merger once again of these clusters, in anticipation of the growing complexity of healthcare needs. Each cluster will look after more than a million Singapore residents and partner with one of the three medical schools here.

Moving to a system where clusters cover broader areas makes it easier for institutions to work together and provide seamless care, says Dr Loke Wai Chiong, healthcare sector leader at Deloitte South-east Asia.

This means making it simple for patients - and their medical records - to move between institutions with the minimum amount of fuss. "If you think about seamless patient care, it happens only when you have the various care providers sitting down together to organise things," Dr Loke says.

"I think there is a recognition that collaboration is easier if there are fewer clusters, and between and within these three it will hopefully be easier to agree on workflows and processes, and ultimately standardise (them) at the national level."

MOH has said that the vast majority of healthcare staff will retain their current roles, with no changes to their monthly salaries. If people have to move, they will be offered jobs that match their skills and experience, and at the same pay.

However, the merger means many employees will get better opportunities for career progression and development, says Dr Lee Chien Earn, group chief executive of the Eastern Health Alliance, which will soon come under the management of SingHealth.

Each organisation that is now part of a larger whole will also have access to a wider range of facilities, services and networks.

HOW THE NEW SYSTEM WILL HELP

For example, says Health GPC member Dr Tan, polyclinics would be able to do more for patients with all the "firepower" of a large cluster behind them. "(This is) whether it's a remote consult with a specialist, being able to restock complex prescriptions without the patient going to hospital, or arranging tests and scans and being able to readily download the images and results."

Of course, it goes beyond just polyclinics and acute hospitals leveraging on one another's strengths. It also includes community hospitals and the national specialist centres. And it means that organisations formerly from different clusters will be able to tap one another's community networks - such as GPs in private practice, voluntary welfare organisations or nursing homes - to, and from which, so many referrals are typically made.

How all this potential will pan out in the next few years remains to be seen, although experts agree it should improve efficiency in the system, especially when it comes to planning and innovations.

"The gains may not be so immediate in terms of things like waiting times," Dr Loke says. "But the system now is less complex and there is more scale. Scale helps - it's hard to do things like telemedicine and telemonitoring without it."

And Mr Quek adds: "It should lead to greater efficiency when you consolidate manpower over a larger, integrated footprint."

A version of this article appeared in the print edition of The Sunday Times on January 22, 2017, with the headline '3 clusters offer more 'firepower''. Print Edition | Subscribe