TODAY, the provision of chronic care is divided between specialists in their specialist clinics and general practitioners in their private clinics or polyclinics.
The best way to treat the growing group of patients with chronic ailments is a holistic approach - specialist care when needed, GP or polyclinic care at other times, and even care by nurse practitioners in between for patients whose conditions are stable.
Such 'right-siting' of care has been the buzzword in health-care circles here for some years. Giving the proper level of care - and no more than that - is the best way to keep health-care costs down.
In theory, everyone agrees with this. In practice, it is more difficult to implement.
Part of the problem is that patients do not want to move down the expertise ladder once they are being treated by a specialist.
This is partly due to the belief that specialists give better care. But specialists are the first to admit that not all patients need the level of care they give.
Many sick people whose conditions are not severe, or are stable, can be treated by their family or polyclinic doctor. But public-sector specialists complain that they have a hard time discharging patients who refuse to leave their care - especially subsidised patients, who fear that once they are discharged from the Specialist Outpatient Clinic (SOC), they might have difficulty getting back in as subsidised patients should their condition deteriorate.
Add to that the very modest consultation fee of $20-$25 for subsidised patients seeing a specialist. This is close to what a private GP would charge. While polyclinics cost less, at $8 per visit, and half that for the elderly, the difference may not be too significant today.
Furthermore, patients, especially elderly ones who are more prone to chronic illnesses, are creatures of habit. Those who have been going to an SOC will want to keep doing so.
The solution appears obvious. Instead of moving patients from polyclinics to SOCs and back to polyclinics, why not have both specialists and family doctors operating from the same place?
Instead of keeping SOCs hospital-based, where the cost of space is high, why not move them out?
Similarly, polyclinics - originally meant to treat the poorest 20 per cent of the population for acute illness - are seeing increasing numbers of chronic acute patients.
Chronic-care centres housing both specialists and polyclinic doctors would solve several problems at the same time.
It would leave the polyclinics free to deal with acute illness and thus get rid of the long queues seen today.
Subsidised patients no longer need to decide whether to stick to a specialist or return to the polyclinic.
They go to this centre, get a quick check from the triage nurse who then gives them an appointment with either a general doctor or a specialist, according to the patient's need at the time of visit.
This way, fewer specialists will be needed to care for a larger pool of patients.
Even better yet, train more nurse practitioners who can see patients on alternate visits. Some polyclinics are already doing this. This practice should be extended to bring specialists into the loop as well.
Moving SOCs out of hospitals will have another benefit. It frees up expensive hospital space for inpatient care. Instead of expanding existing hospitals, build these chronic-care centres in large housing estates.
Specialists who have inpatients could spend half a day at the hospital and the other half at the chronic-care centre. Should the patient need to be hospitalised, he would be treated by the same specialist.
For patients, having a chronic-care centre that treats various ailments such as diabetes, hypertension and heart problems means going to just one place for all their needs.
The patient's files would be shared by all the doctors he sees at the centre, so they would know what other medicines he is taking.
This way, a patient who needs specialist care for a short period need not have to get a referral from a polyclinic doctor, then make an extra trip to a hospital to see the specialists. It can all be done during that one visit.
The pharmacy would also be able to double check to ensure that he is not given any medicine that would react adversely with something else he is taking.
Peripheral health-care services, such as podiatric care for diabetics, rehabilitation centres for recovering stroke patients or a gym for heart patients to get back into shape, could all be housed in the same place.
As the population ages, the number of people with chronic ailments will go up. If Singapore continues with its current pigeon-hole system, health care will remain fragmented.
Bringing the various services under one roof will give patients holistic care and free specialists to look after those who really need their level of expertise. It should also help to keep a cap on rising health-care costs.
salma@sph.com.sg
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