Angry Doctor

Friday, April 04, 2008

Rational Rationing? 2

angry doc is not too sure how to react to this latest piece of big news:

(emphasis mine)

New map for patient care
Healthcare to be organised along regional lines: Khaw
Tan Hui Leng

INTERMINABLY long waits to see a specialist. Unnecessary high-level care, leading to bigger medical bills for patients. These problems have dogged Singapore's healthcare system and hogged public debate in recent years.

But while palliative measures have been taken, the symptoms point to a more fundamental flaw in the system: The two-cluster structure, which now sees all hospitals and polyclinics come under either the National Healthcare Group or SingHealth.

Soon, that landscape will be completely redrawn.

Wielding the pen, Health Minister Khaw Boon Wan wants to have the island's north, east, west and central zones served by regional hospitals.

These hospitals would only refer patients to the national centres at the Outram or Kent Ridge campuses — where the Singapore General Hospital (SGH) and the National University Hospital (NUH) are located — if they have complications that require a higher level of care.

Meanwhile, the upcoming Khoo Teck Puat hospital (KTPH) in the north, Changi General Hospital in the East, the hospital planned for Jurong in the West and Tan Tock Seng Hospital (TTSH) in Central Singapore will manage patients' secondary care together with polyclinics, general practitioners and nursing homes in the same locale.

This "pyramidal structure", Mr Khaw explained, would facilitate seamless and integrated primary and secondary care — something the two-cluster system has not been able to achieve.

"If we do it well, the bulk of a patient's needs can be handled at that level – easily 80, 90 per cent of healthcare problems can be resolved at that level," said Mr Khaw, speaking to reporters at the commencement ceremony for the superstructure of KTPH. "That is the most competent level, at the lowest cost, and most accessible to homes."

To illustrate: A simple hernia operation is best done at a secondary care hospital, at a lower cost and with very much the same outcome as in a tertiary hospital, said SingHealth's group chief executive Tan Ser Kiat.

With such secondary-care hospitals playing "a gate-keeping role ", "this will bring about more optimal use of resource and lead to even better, more cost-effective and timely care," Professor Tan added.

With the possible exception of TTSH, each regional hospital would be run by its own board so that "effectively there will be several clusters".

Already, KTPH has an autonomous board. In February, a new board was also formed for the National University Health System – comprising NUH and the National University of Singapore's medical and dental schools. Changi is next in line for its own board.

Meanwhile, in this redrawn landscape, SingHealth will focus on running SGH and the Outram medical research campus, as well as KK Women's and Children's Hospital. The NHG will continue to run TTSH, the Institute of Mental Health and some polyclinics.

But with the Outram and Kent Ridge campuses shedding the load of secondary care patients to the regional hospitals, this means they need to nurture ambitions beyond Singapore.

"The reason is not because they want the money but because they need the patient load in order to practise," Mr Khaw said.

The impending changes were hailed by Lee Kuan Yew School of Public Policy's Phua Kai Hong as the way to go.
"It would encourage right-siting of patients as the Specialist Outpatient Clinics (SOCs) at hospitals now are overcrowded, and many of these patients can be decanted to GPs," said the associate professor of Health Policy & Management.

The current system does not encourage hospital doctors to refer such patients downward.

Conversely, in the new system, integrated care at the primary and secondary levels by geographical cluster means, polyclinics and GPs would have no vested interest in referring patients upwards. This translates into cheaper and more convenient medical care for patients.

Mr Khaw said he was in no rush to push the changes through, especially since setting up a board with suitable members takes time. "If we implement tomorrow, that will cause a lot of heartaches and trauma to everybody."

And while he feels the new system is theoretically sound, its implementation rests upon whether people executive it with a common vision to offer healthcare "of a high standard and yet affordable and easily accessible".

The article is short on details and big on unsubstantiated statements, specifically when the reporter blamed the flaws in the healthcare system on the two-cluster system without explaining how this created the problem, and then stated that the new system will be the solution.

While angry doc welcomes this new emphasis on right-siting, which is a form of rationing by need rather than by means, he is not, given the scant details of the proposed system presented in the article, optimistic that it will solve our problems.

Our current system already have a multi-tier system, or rather a two-tier system where primary care is provided by GPs and polyclinics, and secondary and tertiary care is provided by the hospitals. The proposed system seems to aim to further differentiate the hospitals into secondary-care and tertiary-care facilities - in effect moving from a 2-stepped pyramid to a 3-stepped one.

Will it work?

Well, first of all we must ensure that there is adequate staffing and resources on each tier of the pyramid. This issue is not addressed in the article, but hopefully the ministry has already looked into it.

The other point, and angry doc thinks that this is where the system may fail, is whether we have the political will to enforce the "gate-keeping" function of the primary and secondary-care facilities. Our GPs and polyclinics have traditionally been tasked with this "gate-keeping" role, yet it does not seem to prevent a situation of overcrowding at the hospitals; if we fail to right-site patients who belong on the first tier of the pyramid onto the first tier instead of the second, what is there to say that we will be able to keep these patients off the second or even the third tier under the new system?

(Incidentally, isn't the concept of "gate-keeping" contrary to the minister's pursuit of a "perfect market"?)

angry doc believes that the failure to right-site stems from a lack of incentives to right-site patients, and the fear of disincentives from wrongly-siting a patient onto a lower tier than he will eventually prove to need. At the end of the day, the healthcare professionals making the decision on the ground must feel rewarded and protected in making the right decisions. Unless these specific issues are addressed and tackled, they will likely continue in the new system. From the last paragraph of the article, angry doc suspects that the minister is himself aware of this problem.

Finally, angry doc hopes that access to the third tier of care will not be rationed by means, since it is reported that cost will be one of the differences between the tiers.



  • "The reason is not because they want the money but because they need the patient load in order to practise," Mr Khaw said.

    When someone says it isn't about the money, it *is* about the money.

    By Anonymous lh, At April 04, 2008 10:38 pm  

  • i agree with lh. Don't see how this new pattern will make any difference. Sounds like rubbish.

    By Anonymous *_*, At April 04, 2008 11:02 pm  

  • Right pricing will ensure right siting. I expect secondary hospitals will charge less and have more limited capabilities than tertiary hospitals. A patient with a breast cancer that can just as well be treated in CGH as in SGH must be charged far more if she insists on seeing a surgeon in the tertiary hospital. She will have to pay the same high prices as the wealthy Indonesian tai tai. Our hospitals will differentiate by the capabilities as well as price of service.

    I expect the Minister will make it a financial disincentive for secondary hospitals to refer on patients to SGH and NUH. Doctors will therefore aim to keep their patients in secondary hospitals unless they really do not have the necessary expertise. But what if the patient insists on going to SGH/NUH? That's why tertiary hospitals must charge far more to encourage right siting.

    By Anonymous Anonymous, At April 05, 2008 8:37 pm  

  • A great blog! A comprehensive disclosure of what's wrong with our present system.

    Regarding primary care physicians: These doctors should be rewarded for their astuteness in diagnoses, appropriate referrals, and follow-up care. They are the "spine" of the whole system. They should not have to resort to gimmics to survive financially in practice.

    What's being done: Talk of reducing their reimbursement. Deplorable.


    By Blogger cclarksr, At April 06, 2008 12:20 am  

  • hi. really sorry... but i dont really understand the article. does that mean that all hospitals except SGH & NUH will "downgrade"?

    as in they will take on more simple cases?

    then what will happen to SGH & NUH?

    so sorry. pls dont scold me...

    By Anonymous Anonymous, At April 07, 2008 1:38 am  

  • [But with the Outram and Kent Ridge campuses shedding the load of secondary care patients to the regional hospitals, this means they need to nurture ambitions beyond Singapore.

    "The reason is not because they want the money but because they need the patient load in order to practise," Mr Khaw said.]

    Is this saying what I think it is?

    1. Shift patients to new hospitals to ease the load. (good)
    2. Current hospital now have less patients, need more patients. (har? lessening load was not the main aim of this revamp?)
    3. Get patient from overseas. (duh? why not get back the original patient load?)

    What kind of problem is this solution trying to fix anyway?

    And it sounds to me that they are trying to run the public hospital system like a Call Center.

    By Anonymous Amused, At April 08, 2008 2:15 pm  

  • this system might strenghen patients` misconceptions that CGH/TTSH "lousy hospital" "don't know my `complex` case" and NUH/SGH "good hospital" "sure can find out my `exact` illness"

    By Anonymous Anonymous, At April 10, 2008 9:17 pm  

  • The 60-million dollar question is capacity. When all it takes is a dengue outbreak to shut down TTSH, I fail to see how the Outram and Kent Ridge campuses can shed 'the load of secondary care patients to the regional hospitals'. For this plan to work, we need far more hospital beds in TTSH and CGH. KKH in the Singhealth cluster will have to be converted into a general hospital and take in patients other than paeds and OG cases.

    By Anonymous Anonymous, At April 13, 2008 1:28 pm  

  • dear amused,

    i am not defending the debated underlying motives of redirecting patients to the regional hospitals instead of SGH/NUH.

    Rather, i perceive it as 'redirecting' patients to their most accessible hospital rather than making it seem as though the central hospitals are shrugging or offloading their patients elsewhere. I see some sense in this regionalisation. its more accessible, geographcally at least. Assuming that each region's patient load is similar, the hospitals will not see overcrowding in some and idling in others. ( i am unsure of Spores pop distribution). a more even distribution of workload?

    i do see some sense in earning extra revenue where possible.

    i am rather confused about why primary healthcare physicians will not have the 'incentive' to refer upwards to hospitals with regionalisation?

    and do pple decide to go to SOC at hospitals directly rather than to poly/GPs? it is a matter of skills/operational times?

    i am new to the healthcare system

    By Anonymous Anonymous, At May 03, 2008 10:04 pm  

Post a Comment

Subscribe to Post Comments [Atom]

Links to this post:

Create a Link

<< Home