Transforming Healthcare – The Role of Family Physicians and The Primary Care Sector
In a speech addressing medical students at the 1st National Medical Students Convention on August 26, 2017, Associate Professor Benjamin Ong, Director of Medical Services (DMS), Ministry of Health, spoke about the evolution of our healthcare system, our country’s changing healthcare needs and healthcare models, and its relevance to medical students today1.
The past, present and future
Assoc Prof Ong highlighted that the push for medical specialisation in our country started from 1970 onwards. From that time, hospital infrastructure and sophisticated medical equipment have progressively been introduced and developed. Today, the presence of a hospital-centric healthcare system is obvious to many of us, even though our government has also invested in public polyclinics (the primary care arm of the public healthcare system).
The disease burden has gradually evolved over decades from the predominantly communicable disease patterns to increasing numbers of chronic diseases like diabetes mellitus, ischaemic heart disease, chronic kidney disease, stroke and dementia. With a rapidly ageing population and the projected increase in chronic disease burden, Singapore faces a serious challenge in meeting the growing health needs. It is now well established that the solution cannot be based on a hospital-centric model of care.
Assoc Prof Ong further stated the “need to shift our healthcare delivery model from one that is centred around the hospital, to one that provides holistic and patient-centric care in a more sustainable manner, in the community”. This means primary care and family physicians will play increasingly important roles in the country’s healthcare transformation journey.
In addition, a press report2 of an interview with the deans of the three medical schools here reported that “Singapore needs more doctors who are “generalists” rather than specialists”. By “generalists”, the deans were referring to physicians trained in family medicine, internal medicine, geriatrics and palliative care. Clearly, these disciplines are essential in Singapore’s ageing population where the elderly are likely to be afflicted with multiple health issues. In future, we need more physicians who can deal with a wide range of medical conditions in a patient and who can focus on treating the patient as a whole.
The importance of primary care – What does the evidence show?
Increasingly, primary care is viewed as playing a crucial role in providing holistic care for the patients even as we try to shift healthcare beyond hospitals into the community.
In a landmark paper by Barbara Starfield et al3, the authors listed the four main features (or characteristics) of primary care that were internationally accepted by the Institute of Medicine, the World Organization of Family Doctors (WONCA) and the World Health Organisation. These features are first-contact access for each new need; long term person- (not disease) focused care; comprehensive care for most health needs; and coordinated care when it must be sought elsewhere. In addition, Starfield also emphasised the importance of an orientation towards the family and community. I can identify easily with the features of primary care that were listed by Starfield and her co-authors. These features have been a tremendous source of meaning and professional satisfaction in my 20 years of clinical practice as a family physician.
Firstly, Starfield et al cited evidence from studies that showed a correlation between primary care physician supply and better health outcomes – these include total and cause-specific mortality, low birth weight, and self-reported health. Secondly, the authors were mindful that a greater number of primary care physicians does not necessarily
mean that all people in the area have greater access to primary care services. So they studied analyses that considered people’s relationships to or experiences with a primary care practitioner to determine the association between primary care and health outcome. In other words, they compared the health of people who do or do not have a primary care physician as their regular source of care. The findings from studies of the impact of actually receiving care from a primary care source consistently showed benefits for a variety of health and health-related outcomes. Thirdly, tools have been developed to assess the adequacy of health delivery characteristics that define the practice of primary care. Using these tools, it was possible to do international comparisons and the authors cited several studies that showed the positive contributions of primary care to health in the United States and other countries.
Training the next generation of doctors
As a medical educator, I have always been impressed by the intellect and energy of our medical students. We owe it to them and to society to train and prepare them adequately for the tsunami of healthcare challenges that will hit us in the coming years. If we do it right and optimally, we will reap the rewards of a well-trained and well-prepared physician workforce.
The appropriate training of medical students and junior doctors, plus the appropriate siting and organisation of the physician workforce in the coming years will be a crucial piece of the strategy to cope with the healthcare challenges.
A recent article by Elizabeth Newbronner et al4 highlighted the results of their study on the impact of primary care-based undergraduate medical education on the development of medical students and new doctors as clinicians, and on students’ preparedness for practice.
The results showed that “primary care placements play an important part in the development of all ‘apprentice’ doctors, not just those wanting to become GPs. They provide a high quality learning environment, where students can gradually take on responsibility, build confidence, develop empathy in their approach to patient care and gain understanding of the social context of health and illness.” The study was not large – it involved only two medical schools in the UK. Nevertheless, my view is that if we believe that the direction is to shift healthcare delivery to the community in the coming years, it is essential that we consider providing longer primary care placements in our undergraduate medical education.
Moving forward
As we emphasise more on primary and community care in our healthcare transformation journey, with concurrent shifts in healthcare policy thinking, we need to articulate clearly our expectations of the role of family physicians and the primary care sector.
We should see the characteristics of primary care as strengths to be tapped, and leverage on these to help us meet the healthcare challenges in the coming years. Beyond policy formulation at the Health Ministry level, how we train our medical students and junior doctors is going to be an important game-changer, and it could well spell the difference between a successful healthcare transformation journey or a dysfunctional painful stagnation.
Dr Tham Tat Yean is a Family Physician and CEO of the Frontier Healthcare Group. He is also Adjunct Assistant Professor at NUS Medicine and Visiting Consultant Family Physician, Department of Medicine, National University Hospital
References
1. Ministry of Health. 30 Aug 2017. Speech by DMS – The future of Singapore healthcare and what it means to medical students today?
2. The Straits Times. 9 Aug 2017. More “generalist” doctors needed for S’pore, say med school deans.
3. Starfield, B., L.Y. Shi, and J. Macinko. 2005. Contribution of Primary Care to Health Systems and Health. The Milbank Quarterly Vol. 83, No. 3 (pp. 457–502).
4. Elizabeth Newbronner, Rachel Borthwick, Gabrielle Finn, Michael Scales & David Pearson. 2017. Creating better doctors: exploring the value of learning medicine in primary Care. Education for Primary Care, 28:4, 201-209.