Image adapted from https://www.healthiersg.gov.sg/
It is no news that Singapore’s population is ageing. Right now in 2022, nearly 1 in 5 Singaporeans is aged 65 and above. By 2030, that will be 1 in 4 Singaporeans. With an ageing population, comes an increased disease burden and increased healthcare utilization. If all resource allocation stays the same as it is, healthcare institutions and facilities will definitely be overwhelmed.
Healthier SG is the biggest healthcare transformation in Singapore’s history. It involves the mobilization of a large number of resources and manpower in the next decade forward, with one goal – making Singapore Healthier. The key features of how this can be achieved can be found here and the White Paper can be found here.
How will Healthier SG look like to Singaporeans?
Quoting Health Minister Mr Ong Ye Kung, Healthier SG means “One Person, One Doctor, One Care Plan”. Sometime in mid-2023, each Singaporean will be invited to enrol with a family physician of their choice. This family physician will be the go-to doctor for anything related to the health of the enrolled Singaporean. And it really means anything, ranging from preventive health check-ups, and vaccinations to chronic disease management and even advance care planning. While patients with advanced organ dysfunction, such as kidney failure and heart failure, may continue long-term follow-up with their specialists in the hospitals, the family physician will continue to monitor and manage other concurrent medical conditions in between. He/she will also be the key personnel in coordinating and rationalizing the overall health care plan for the patient.
For instance, this is how a health check schedule will look like for a 74 year-old patient, who may be seeing 4 different teams of doctors in different centres for different issues. She may be seeing an oncologist in a specialised cancer centre for surveillance of the recurrence of breast cancer and seeing a nephrologist in a general hospital to monitor her kidney function. On top of that, she may also be seeing an orthopaedic doctor in another general hospital for an upcoming total knee replacement. At the same time, while she is also on follow-up with the polyclinic for blood pressure and diabetes.
This is what her insanely confusing schedule may look like. Plus, to make things even more confusing, these appointments are not going to be written in chronological order all in one place. That is because the information from the specialised cancer centre, general hospital A and B, and polyclinic, is not going to be printed on the same piece of paper for her:
Will she and/or her family know when to show up at which appointment? Will her family have time to take leave from work to bring her to these appointments? What happens if she misses the oncology appointment because she was still recovering at home from the total knee replacement? Will she how to navigate the healthcare system and then call back to the specialised cancer centre to reschedule the appointment?
The family physician is the go-to person, to help her to navigate through the system and rationalize the overall care plan for the patient. He/she can also take over the monitoring of the kidney function (and refer to a specialist when needed), and management of high blood pressure and diabetes, making the care more streamlined for the patient. This will already help her by reducing the overall number of appointments and the locations that she has to go to.
What does it mean for Family Physicians?
With Healthier SG, it means the family physicians will be the guardians of the overall health for each Singaporean enrolled in their care. In Healthier SG, there are also enablers to help family physicians accomplish this role, including IT infrastructure, access to medications at a lower price in order to keep costs low for the patients and establishing partnerships with key community players to engage the community.
In addition, the number and medical complexities of patients to be seen by family physicians are likely going to exponentially increase. Patients will now be coming in not only for acute issues like cough, cold and flu and stable chronic conditions; but also possibly also with mild fluid overload and COPD exacerbations. The time needed to be spent with each patient will likely be increased, due to the number of health-related problems that need to be worked through, together with the patient and family.
What is the role of Allied Health Professionals in a Collaborative Care Approach?
With Healthier SG, patients’ medical conditions managed in the community will become more complex, and thus, the level and diversity of the required care services increase as well. For instance, patients with diabetic foot ulcers may require more specialised wound and foot care by a podiatrist. For an elderly patient with mild dementia and poor appetite, a review by a dietitian may be beneficial in improving the overall nutrition status. Or for an elderly who fell earlier last week, will likely benefit from rehabilitation sessions with a physiotherapist. The accessibility of these allied health services must be made available to the patients in the community.
What about Pharmacists?
Pharmacists are medication experts, and in the past decades, increasingly, clinicians. Clinical pharmacists are skilled in monitoring and management of chronic conditions with the use of medications, such as high blood pressure, diabetes, kidney disease, heart failure, ischemic heart disease, anticoagulation, etc. Besides, pharmacists are ideal personnel to provide reliable and contextualised drug information and medication management in accordance with the patient’s disease state.
Past data has shown that multidisciplinary collaborative care in partnership with pharmacists in public health institutions improves patient outcomes such as better control of diabetes, and chronic conditions and all at the same time, saving costs[i]. Shifting this model to Healthier Sg, can we then partner pharmacists with family physicians? Can clinical pharmacists run a clinic alongside family physicians, focusing on the following?
1) Stable chronic disease management
2) Provision of education to patients on how to manage their health conditions
3) Screening and provision of vaccinations
4) Provision of drug information to the family physicians
This will definitely relieve the family physician so that he/she can focus on the patients with acute conditions and those who need a higher level of medical attention. This will also increase the capacity and skillsets of the clinic team.
This model is not perfect and is indeed fraught with many challenges that may lie ahead, including the familiarity with the strengths of pharmacists, the acceptance of family physicians and patients, and the ambiguity of the medicolegal responsibilities of clinical pharmacists. And of course, the million-dollar question, who will fund this model? Can it be the Ministry of Health (MOH)? The healthcare clusters in the geographical area? The Primary Care Network (PCN)? The family physicians themselves? The patients themselves? This is an extremely difficult question that we can’t have an answer to right away.
Healthier SG is definitely a much-needed national healthcare transformation and we need all hands on deck. All healthcare professionals have a part to play in order to keep Singaporean healthier. Mobilizing the help of family physicians is definitely key to the success of this transformation. Allied health professionals, including pharmacists, do have a significant role to play, to support family physicians in helping Singaporeans in their journey to being healthier.
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