Opening of the Singapore Disease Management Conference 2008 & 1st International Conference on Healthcare Transformation

09 May 2008

By Khaw Boon Wan

“What Value, Medicine?”

1. Last month, there was an active debate on aesthetic treatment in Singapore.  It is a thriving business and there is a strong demand to look good and this demand will continue to grow.  As treatments become more invasive and surgeries to shape the body become more common, plastic surgeons are voicing concerns about patient safety.  From the initial concern about safety, the public debate quickly moved into the ethical issues of whether doctors should even provide procedures without strong scientific evidence of benefits like mesotherapy. 

What’s Happening to Medicine?

2. The debate prompted a former MP and a respected family physician, Dr Tan Cheng Bock to write a thoughtful piece in the newspaper.  It was titled: “What’s happening to medicine?”  As he sees it: “Aesthetics is … not medical practice.  It does not heal but only enhances appearances.  The practitioner of aesthetics is not treating sick patients but healthy individuals”.

3. Dr Tan lamented that with the growth of the industry, doctors would be tempted to “shift their emphasis from healing the sick to undertaking the more lucrative practice”.  He therefore worried about the future of our national healthcare programmes, “such as the current chronic disease management of diabetes and high blood pressure”. 

4. Dr Tan felt sorry for the rapid commercialization of healthcare but accepted that we could not turn the tide.  He sympathized with the need for some GPs to go into aesthetic procedures to satisfy some of their patients' needs and demands, and to cover the operating cost of their practice.  He therefore asked the regulators to clarify the aesthetic procedures that GPs could do.  We will.  More importantly, he hoped that MOH could do more to encourage and enable the GPs to stay involved in national health programmes, such as chronic disease management programmes.

Good GPs Support Good Health

5. I share many of Dr Tan’s sentiments and will do my best to ensure that competent doctors, trained at great cost to our society, do not end up neglecting real patients with genuine medical needs.  Like Dr Tan, I worry about the rapid ageing of our population and the consequential rise in demand for medical services.  In particular, this audience knows the disastrous impact on our healthcare resources if we do not have a good handle over the prevention and management of chronic diseases, like diabetes, hypertension, mental illness, just to name a few. 

6. In the fight against these diseases, GPs play an important role.  Good GPs are our unsung heroes.  They do not appear on TV or in newspapers, promoting beauty treatments to the rich and famous.  They work long hours, persuading Singaporeans to eat a balanced diet, exercise regularly, control their blood pressure and quit smoking.  They also comfort the terminally-ill, supervise home-nursing of the severely-disabled, do home visits so that elderly patients can avoid unnecessary trips to hospitals. 

7. Our healthcare system today is strong.  Our doctors are largely dedicated and ethical.  They retain their strong noble calling to serve the weak and the infirmed.  But will the future be the same?  I alone cannot provide the answer.  The answer must come from the society at large.  What value, Medicine?  How much are you paying your GP for a consultation session on managing your diabetes which may save your toe?  How much are you paying another for a session to whiten your skin?

8. If we, as a society, misalign our priorities, we cannot blame doctors for shifting their focus.  In the US, fewer doctors are going into primary healthcare.  More are going into glamorous, well-paying surgical specialties.  While we need both, some balance has to be struck.  Today, we have 7300 doctors in Singapore, with 2500 in primary healthcare.  Singaporeans are well served by the current distribution of doctors.  We must ensure that GPs continue to find it meaningful to be good GPs, serving the community at large.

Partners In Health

9. We encourage all Singaporeans to have their own family physicians, with a long-term relationship.  A long-term doctor-patient relationship is particularly important for the lifelong management of chronic diseases.  Doctor-hopping and serial episodic care will not produce good results.  Your disease will simply worsen with time, until a complication forces you to end up in a hospital emergency room.  Remedial care will then be much more costly, with little chance of a full recovery. 

10. To manage chronic diseases well, we need to rally our GPs and polyclinics to work together as one team, complementing each other’s strengths.  We are not competitors, fighting for the same market share.  We are partners in health, on the same side of the battlefield. 

11. Some GPs complain that their clientele has shrunk as their patients are lost to polyclinics with better facilities and subsidized medications.  To keep up with public expectations, we will continue to upgrade our polyclinics; and we will have to help the poor cope with long term medications.  But it is neither our intent nor our interest to enlarge our market share. 

Correcting Imbalance

12. But polyclinics’ market share for chronic diseases is disproportionate.  More than 40% of primary care visits for chronic diseases occur in polyclinics.  This is way above our market share of the primary healthcare sector.  We are addressing this imbalance.

(a) Returning Patients to GPs

13. First, our hospital specialists actively refer the patients back to their family GPs, after their conditions have been stabilized.  The hospital specialists are there to give a specialist opinion, not to take over the lifelong treatment of the patients.  That is why NHG has many programmes to partner GPs to care for the patients referred back from the specialists, for heart disease, asthma, and mental illness.

(b) Medisave for chronic diseases

14. Second, we have allowed Medisave to be used for outpatient treatment of the 6 key chronic diseases.  More than half of all GP clinics participate in this programme.  We are encouraged by the early results.  About 70% of diabetic patients enrolled in this programme had acceptable or better control of their diabetes.  Nearly half of the diabetic patients with lipid disorders had good control of LDL-Cholesterol. 

(c) Better Disease Management Programmes

15. Third, hospitals and polyclinics actively pilot disease management programmes and share them with GPs.  We will continue to support GPs in this manner, so that they will be able to consistently provide quality care to their patients.  For instance, NHG’s pilot Heart Failure Programme aims to improve the quality of care of heart failure patients through a multidisciplinary team approach, with strong patient education and close monitoring by case managers.  Within two years, the programme has reduced repeat hospitalizations by 6%.  Hospitalisation stays were also cut by 30% from 11 to 8 days.  For diabetes, the SGH has successfully piloted the DOT (Delivering on Target) Programme with a group of GPs.  We have therefore decided to roll it out nation-wide.  All our public hospitals have decided to come together to fight diabetes in a comprehensive way, in partnership with the GPs.  There will be more such collaborations as we bring hospital specialists together to establish national programmes to accredit, train and work with GPs to care for patients discharged from hospitals.

Greater Support for GPs

16. We will do more to support GPs in managing their patients’ chronic diseases.  Let me highlight two new initiatives.

(a) Systematic Health Screening

17. First, we will get Singaporeans to be systematically screened by their GPs for the common chronic diseases.  From next month, Singaporeans aged 40 and above will receive a letter from the Health Promotion Board informing them of the importance of appropriate screening and the GP clinics near them at which they can get screened.  For the poorer 30% of the population, HPB will render some subsidy to help cover the cost of the screening. 

18. The screening programme will cover diabetes, hypertension, lipid disorders and cervical cancer, at the appropriate, recommended intervals.  More importantly, we will put in place measures to ensure that there is follow-up to the screening, if the result is abnormal. 

(b) Extend PCPS

19. Second, we will extend the Primary Care Partnership Scheme (PCPS) to cover the main chronic diseases.  At present, means-tested patients can enjoy subsidized care at participating GPs for their acute medical conditions, like coughs and colds.  From next year, PCPS will also cover the 3 main chronic diseases of diabetes, hypertension and lipid disorder.  PCPS card-holders with these chronic conditions will then be able to enjoy subsidized care by participating GPs, for consultation, medicine and lab tests.  In turn, MOH will through the polyclinics pay the GPs a subvention, on a per-attendance basis.  This will enable such patients to see their regular GPs for both acute and chronic conditions.  We will leverage on the IT platform which currently supports the Medisave for chronic diseases to help the participating GPs to report and monitor the health outcome of their patients. This will allow GPs to compare how they are faring, and in the end, patients will benefit.

Greater Cooperation

20. I am sure there is more scope for greater cooperation with GPs and we are open to suggestions.  Whatever that is practical to help you be a better GP to your patients, we will be happy to consider it. 

Conclusion

21. Singaporeans enjoy a high level of health, comparable to the best in the world.  We have much to thank our doctors for.  But the reality is that Singaporeans themselves hold the key to their own health.  We, the healthcare providers, are just there to support the patients and to catch them when they fall.

22. A wise doctor said that health is a combination of two factors: genes and lifestyle.  We cannot choose our parents but we can choose the way we live our lives.  Good health requires great discipline.  Eat less, exercise more and get slimmer.  And you will live healthier and longer.  There is no short cut to such a good outcome. 

23. On this note, let me congratulate the National Healthcare Group for organising these two conferences.  I wish you all a very productive time of learning.