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.