Polyclinics have made progress

30 Jun 2006, Today

Question

Name of the Person: Tan Hui Leng

Polyclinics have made progess

25 years on, the long queues remain 

When I was young, my medical condition was managed by a polyclinic doctor in the east, because my parents were civil servants. I remember my mother telling me to "get a number" very early in the morning, then come home for breakfast before going back to rejoin the queue closer to opening time. 

I remember the crowds, some patients sitting on old wooden benches, but most standing on mosaic-tiled floors. Hours later, my name would be called out by the nurse. After the consultation with the doctor, I would have to wait just as long for my medications to be dispensed at the pharmacy. 

Fast-forward to 15 years later. When I was a third-year medical student, I was ill one day and wanted to find out if there were any improvements in the polyclinic system. I headed to a polyclinic in the central region at about 8am. I was disappointed and swore I would never visit another polyclinic when I am ill. I was seated in the midst of people coughing and sneezing, but this time on better benches with electronic numbers flashed on large screens. By the time I left the polyclinic, it was close to noon. 

Fast-forward again, 10 years later. Recently, I asked one of my former classmates now working as a polyclinic family physician if there was any improvement in their situation. She told me even though they have tried to improve the efficiency in the system, results seemed to be marginal at best. 

Another doctor who just went into private practice told me that in the polyclinic she dealt mainly with chronic disease cases. She had hardly any time or chance to deal with other aspects of acute family medicine, such as suturing of cuts and lacerations from trauma. No wonder our emergency departments are overwhelmed as well! 

My father-in-law is a diabetic patient, and was seen by the polyclinic for many years until recently. When I asked him why he stopped seeking treatment there, he answered that most of the time, the doctors were not Singaporeans and could not communicate in Hokkien. A recent Primary Care Survey in 2005 revealed that 21 per cent of patients patronising polyclinics stay in one to three-room flats and presumably require health subsidies. This proportion is slightly higher than the 21 per cent (staying in the same flat types) who visited private family doctors. 

Some residents in my neighbourhood stay in houses larger than my humble five-room HDB flat, and they tell me they go to the polyclinic for their disease management. I asked why they were willing to wait in the long queues, and their common answer was: "I am a retiree, so I have time." With the recent case of an elderly woman's death, I wonder if there will be any improvement in the situation. 

It is now more than 20 years from my first experience as a patient in the polyclinic. If nothing drastic is done now, I doubt there will be any change even 10 years or more from today. 

This is contributed by a reader, a medical doctor.

Dr Dana Elliott Srither 

Why those long polyclinic lines pose a health threat 

THINK queuing up for a copy of this newspaper is a drag? Try joining a similar queue when you're sick - outside a polyclinic. The wait could stretch for hours, and might go some way towards explaining exactly why the frazzled staff at Clementi Polyclinic ended up giving the wrong dosage of heart medicine to an 88-year-old woman, who eventually died. While recording an open verdict on the case, the State Coroner on Tuesday heard testimonies from pharmacy staff who spoke of the daily crush they faced. 

Even when a doctor changed a prescription, they could not afford to wait for the amended slip to reach them. Instead, they issued the medicine first - the amended slip could take up to two hours to reach them. "Of course we'd prefer to wait," said Mr Ja'al Maaruf. "But we can't force the doctor (to hurry up) and we serve hundreds of patients." Even though the possibility of a mistake in such situations cannot be ruled out, the staff have no choice as patients clamour to be served. The culprit, it appears, is the sheer load the polyclinics face. Officially, they open at 8am. 

"The queue starts before the clinic opens for registration," a former polyclinic doctor told Today. "It's like queueing for National Day Parade tickets at some polyclinics - people leave their slippers or belongings to 'chope' (reserve) the spot, go for the coffee, get a newspaper and then return nearer to opening time. "It's not just in the morning. When we close for lunch, we see people queueing for the afternoon session." Patients who arrive later are often subjected to long queues and the wait can be as long as four hours. 

Official figures from SingHealth Polyclinics show that bigger polyclinics see about 930 patients a day with 15 doctors serving them; this works out to 62 patients per doctor a day. At smaller SingHealth polyclinics, it's about 56 patients per doctor a day. At the National Healthcare Group (NHG), this number is 60. The numbers are higher than the average of 40 a day at a busy private GP practice. During peak seasons, some doctors said they could see up to 100 patients a day - all within seven-and-a-half hours. 

The pharmacy staff were equally hard-pressed. Serving more than 900 patients each day at the bigger SingHealth polyclinics are 10 to 12 pharmacy employees. They are supposed to be the second line of defence in checking a doctor's prescription. But sometimes, sheer numbers can overwhelm them. Communication lines can get crossed. In the case of Madam Koh Ah Tow whose case was heard by the coroner, the doctor said she had changed the dosage after a call from the pharmacy. However, two pharmacy technicians who packed and issued the medicine denied receiving the instruction. Madam Koh died 10 weeks later. 

At SingHealth Polyclinics, some two to three amendments are made per day at each polyclinic. At the NHG, there are two to four a day at each polyclinic. In an email reply to Today, SingHealth said that alterations are documented in the prescription and endorsed by the doctor. They are also recorded in the patient's case notes. Over at NHG, doctors now need to make amendments in black and white and not just over the phone. But as patients refuse to wait for the amendments to arrive in writing, it is possible for the wrong dosage of medicine to be dispensed. "We are humans and there is a limit to how much you can do with just one hand, one mouth and one pair of hands," said the former Polyclinic doctor. "But you just can't turn patients away if they are there to see you." 

Tan Hui Leng

Reply

Reply from MOH 

An unfortunate case of human error in prescribing a wrong dosage of medicine in a polyclinic has led to the article blaming overcrowding for the error ("Why those long polyclinic lines pose a health threat" TDY, June 29). In ("25 years on, the long queues remain", TDY, June 30) Dr Dana Elliott Srither commented that there has been minimal improvement in polyclinic service over the years with queues just as long. 

We do not condone medical errors and if there are systemic weaknesses which lead to errors, we should correct them. That is why we need to understand the causes of the incident so that the right solutions can be put in. It is important that we get the facts right. See also: Trend of public primary care clinic workload over the years 

In 1981, polyclinic attendances totalled 2.8 million, with a doctor seeing an average of 104 patients per day. Today, 25 years later, we serve 3.9 million attendences, with a doctor seeing 58 patients per day. So there has been significant progress over the years and we will continue to ramp up the number of doctors to match rising demand. 

Can queues in polyclinics be eliminated? We will like to but there are fundamental reasons making this a huge challenge. We heavily subsidise our polyclinic services, for all citizens, rich or poor. This has attracted great demand. Ironically, as we make progress in upgrading our polyclinic services, whether in terms of doctor-patient ratio, quality of care or physical amenities, we add to their attraction to patients. 

Nevertheless, our polyclinics will continue to improve work flow and processes, so as to render quality care and ensure patient safety at the same time. The unfortunate incident of drug overdose should be seen in this context. 

The polyclinics will learn from this incident. Work processes being improved include service quality training, better communications between staff and patients, and an electronic drug prescription system with built-in alerts on patient's drug allergies or dosage. As we step up recruitment of more doctors, we will also make better use of multi-disciplinary teams, including nurse clinicians and advanced practice nurses. 

For sustainable results, we will also need the patients' cooperation and understanding in working towards an effective partnership with their doctor. This will help us to achieve a polyclinic service that achieves its focused objectives and meets the needs of the patients.