GPs and Primary Care: Today and Tomorrow

Today is the eve of tomorrow. Tomorrow 8 Oct 2011 will be an important day for GPs and primary care in Singapore. Hand to heart, I wish the best for the new Minister for Health tomorrow.


After tomorrow, we will know if the MOH will truly embark on renewal and rejuvenation of primary care in Singapore. Or, if it’s another round of GP engagement which like previous rounds, have promised much, but delivered little on the ground.


The event held tomorrow in MBS underlines the intent of MOH under the new Minister to bet heavily on primary care, and private GPs in general to address the healthcare needs of Singapore. He is right to say we cannot go on building more and more general hospitals. This hobbit reckons, each subsidised bed in a general hospital requires about $100,000 of subsidies to run a year. Each subsidized bed put into use is in effect an expensive commitment. The SOCs are also expensive to run as well. And it is plain for all to see that the public system is way overworked.


We need primary care to deliver the goods and deliver quickly it must. This must fall largely on the private GPs which constitute the lion’s share of primary care in Singapore. But to do so, we need to step out of certain psychological straitjackets and slay certain sacred cows. Let’s see what some of them are:


A Great Plan or Policy is One that Practically Eliminates the Possibility of Abuse of Subsidies and Medisave.


This great psychological straitjacket has really been one of the factors that has greatly hindered previous attempts to involve the private GP in tackling chronic diseases in a big way. Because of the lack of trust and the fear of abuse by policymakers, previous attempts involved many rules and reporting that were too burdensome and complicated for mass adoption by GPs on the ground.


If we want to do something that involves the masses, then some degree of abuse will be take place. By all means, reduce the abuse as much as practically possible, but recognize that the end is to get decent care delivered to many people by the GPs; the end is not to eliminate abuse. Indeed, the cost of eliminating abuse may far outweigh the benefits of mass adoption of a system. The police will tell you that there are compromises to be made even in tackling crime. The police has to tolerate and accept that there is an “ambient” level of petty crime that exists in a community while they practice a no-tolerance policy on major and violent crime. But the aim of eliminating all crime, whether petty or major, is impossible as the costs of implementing such an approach are prohibitively high.


So, hopefully, with whatever new policy that is going to be put in place or olds ones such as PCPS that will be broadened and enhanced, I hope the bean counters cut the GPs some slack so that the system is not stuck in bureaucratic gridlock because they want to eliminate abuse.


The Need for Accountability through Immediate Data Collection and Measurement of Improvement.


This is a corollary of the first sacred cow – which is elimination of all abuse. It is true that for every public dollar spent, there must be some accountability. And the default mode seems to be that accountability is best evidenced by showing some improvement. Hence the need to capture all kinds of data to facilitate the measurement of improvement, if any. And it seems the data must be collected repeatedly and in real-time.


Unfortunately, this is not one of the private GPs highest priorities. The GP’s highest priority is to treat his patients well so that he keeps his patients and gets new patients to support a viable practice.


There are certain simple age-old adages we should remember when we approach this data collection business:


  • Never collect data you don’t use. Many folks collect data just so they can sleep soundly at night. They may never look at the data later on.
  • There is a cost to collection of data, which is so far, never explicitly stated in the use of subsidies or when Medisave is used. The GPs know this but somehow every policy so far doesn’t recognize this. 5 minutes of data entry is equivalent to about $10 of lost professional fees to a GP.
  • Never force someone to adopt an IT system for your convenience or for control. Unless you are paying him an arm and a leg to do so. This is because it will cost the GP a lot of pain probably akin to an amputation for him to move out of his system to yours. In other words, it will not happen.
  • You can always collect data later. This is why the case-control study was invented.


People Have Short Memories.


A wise lady once told me – Never make people unhappy if you can’t make them happy.


The GPs are a very confused lot. On one hand, MOH and its agencies keep wanting to engage them. On the other hand, MOH also keeps making life tougher for them through ever tighter regulation. For example, the introduction of the Family Register is supposed to be a happy event, but somehow along the way, it has become controversial because of the issue of the use of the word “family”. Many clinics will have to change their names because of this unnecessarily puritanical approach to the idea of differentiating a family physician from other GPs. The new CFPS President has also said as much in the latest issue of the College Mirror. In the same breath, the GPs are told they are important people and GPs need to be engaged. Another case in point is the statutory requirement to stock 2 weeks of PPEs at GP’s own cost.


The GPs are receiving too many conflicting signals from the powers that are. And the natural response to these conflicting signals ranges from indifference to cynicism. You may think you can get their cooperation now by giving them a goodie or two when you had just inflicted pain on them a while ago because people have short memories. That’s wishful thinking. Especially when it comes to doctors. You don’t graduate from medical school by having lousy memory.


Define the Role of the Polyclinics


At the risk of irritating my polyclinic colleagues, I will say this again – what is the role of the polyclinics? Are they supposed to provide cheap and good-enough care to the poor, or they are to be centres of excellence in primary care or both? If it’s both, then its about time the polyclinics adopt a classed system like the restructured hospital or to introduce means testing. The current FP clinics are still subsidized. If not, we have to recognize that polyclinics giving more and better and subsidized care will stifle the development of the GP sector. Good enough care is different from being excellent.


The Way Ahead for Training of Family Physicians: Residency?


Good training will ensure that the future of primary care is bright.


Family Medicine is highly contextualized and based on local factors. It is very different, say from “harder” disciplines such as Pathology or Radiology or even Anaethesiology. A Chest Xray is a Chest Xray, whether reported in Singapore or Sweden. But family medicine is different. The practice of family medicine is based on contextual factors peculiar to the local cultural, socio, economic and health system factors. A family medicine practice in Singapore is quite different that say in USA. For example, in USA, it is common practice for a GP to see his patient in the hospital after the patient had been admitted. In other places, it is common also for a GP to practice some obstetrics. This is rarely, if ever done now in Singapore.


The next thing to note is that the training of family physicians has evolved largely as a community effort over the years by many people working tirelessly in CFPS. The large public institutions came into the act later. Even now, for example, the number of GDFM enrollees outnumber the M.Med enrollees to the tune of about 4 to 1 each year. So while we need to focus on developing family medicine professors and institution leaders through the M.Med or residency route, the greater impact to society will lie from the products of the GDFM system.


For years, the GDFM route has coexisted well with the M.Med system. But with the forced adoption of the USA ACGME-I system, the equilibrium is disrupted.


  • Firstly, the residency system will produce even fewer family physicians than the M.Med system. It is essentially a high-resource, low volume system. It is a system of training that our polyclinic and GP system cannot afford, especially in the face of higher patient loads and more complex casemix in the polyclinics and hospitals.
  • Secondly, it does not take into account local factors – which is why it demands that family medicine residents must visit inpatients and that each resident must be provided with two rooms or that first year residents are limited to seeing two patients an hour (no typo here!). This is also why our training centres were only given a one-year accreditation by ACGME-I instead of full accreditation: we are not Americans and hence we cannot meet their requirements. The family medicine delivery and training systems of USA and Singapore are different.
  • Thirdly, a system should ensure clinical competence. The residency system does not have an exit clinical exam. Is it any wonder there is talk that the FRACGP will not recognize the products of the residency system even though it recognizes the M.Med(FM) we now offer?
  • Fourthly, the residency is institution based and there is a lot of duplication of resources in setting up of different training centres in NUH, Singhealth Polyclinics and NHGP. Ultimately, this sucking up of resources will affect the GDFM and undergraduate teaching programs. There are only so many teachers. There are signs that for example, many teachers can no longer participate as much in GDFM teaching as before because of residency responsibilities. But again, we need to prioritise – will GDFM have a greater impact on primary care delivery than residency or the way around?


We can go on and on about why the ACGME-I residency system is a poor fit for us. But to summarise- what Singapore family medicine training needs is a system that is efficient and capable of mass deployment, and relevant to local factors and needs. The USA ACGME-I system is inferior in all these three aspects to the current system we have so arduously developed over the years and in which now we are tragically dismantling. We should have evolved our current system to a Singapore-type of residency which is relevant to our needs. But instead, we have imported a foreign system which seems to undergoing a host versus graft reaction.


We train for the future and with the ACGME-I residency system, this Hobbit does not think the future of family medicine is bright.


Managed Care can be Left Unregulated


Managed Care is part and parcel of most GP practices now. For some strange reason or other, while possibly every aspect of healthcare has seen tightening of regulation in the last decade of so, three aspects of healthcare have escaped this fate: fee-charging, medical advertising and managed care. And these three aspects have probably contributed in no small way to the over-commericialisation of medicine that we have seen in the last few years.


Managed care is basically free-for-all now. Managed care companies range from $2 companies to multi-billion dollar insurance companies. Managed care affects GPs more than specialists. As we all know, through subtle practices or otherwise, managed care companies tend to cherry-pick and influence participating GPs to shift the more complex work to the public hospitals and polyclinics. And yet, managed care companies are not regulated as healthcare entities like healthcare professionals, facilities or medicines even though they can impact greatly on healthcare delivery. It’s almost like benign neglect and with things proceeding the way they are, very soon it will be malignant neglect. Either that or it almost seems managed care has been given some form of divine dispensation from regulation.


Currently, most GPs can live with this because with a fast growing population, there is enough low-brow work to keep GPs alive, even if the public system is unnecessarily burdened. But the fact remains that GPs can do more and if we really want to develop GPs capabilities to do more so as to relieve the overworked public system, Managed care has to be regulated.


So this is Primary Care today as the Hobbit sees it. Will there be a better tomorrow?

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