Singapore's overburdened primary health care system

I read this over at channelnewsasia

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."

62 patients a day per doctor in 7.5 hours. That works out to about 7.5 minutes per patient.

Well for any doctor out there, this sort of news is not new. We've been seeing that number of patients for years. In fact things have gotten better in recent years. It used to be much worse in the past.

Interestingly I knew of some Army camp Medical Officers who had to see 100 patients in 5 hours from Mondays to Fridays!

Frankly speaking there is a problem in the way MOH utilizes our medical manpower resources.

There is a relative shortage of doctors in the polyclinics if you consider the sheer number of patients they have to see a day. They are overworked quite simply put. Patients also are not satisfied with the level of care from the overworked doctor. The doctors of course don't like being overworked. So they leave. What MOH has done to overcome this exodus of doctors to the private sector as well as overseas is to bring in foreign doctors from the Philipines, Nepal, Pakistan and India.

Singaporean doctors prefer not to work in the polyclinics because it is clearly not safe being asked to see that many patients everyday. Most GPs who leave the polyclinics for the private GP market are not leaving for more money. In fact most would probably make about the same if not slightly more but have much better working conditions.

It just makes things more sensible. Having enough time to see patients, talk to them, counsel them etc. It takes even more time if the doctor cannot speak the same language as the patient (as in the case of Dr Diana Santos and a 88 year old dialect speaking chinese lady). Frankly which doctor wants to work like that?

Lately many private GP clinics have been experiencing hard times. Patients are not willing to see them because the price of seeing a doctor is too expensive for them. But is it really that expensive? I know many clinics charge $10 for consultation. Total bill usually comes to about $20-$30 with generic drugs.

I wonder what the cost of seeing a patient at the polyclinic is to MOH? I would suspect that it would not be much further from $20-$30.

MOH offers susbidies for patients visitng the polyclinic. Patients pay $4 for consultation vs $10 in the private GP clinics. There are also subsidies for medicines partly because the health groups bulk buy.

Perhaps what MOH can do is the following :

1) Work out and be transparent what the subsidy is like per patient with common conditions visiting the polyclinics. Eg Colds, Diarrhea, Sprains etc.

2) Offer the same subsidies for patients with these common conditions visiting private GP clinics. While there will be clinics that charge differently, the patients can "claim" back the subsidy from MOH (or get the clinics to claim from MOH). This can be offset from the clinic bill and the patient pays the balance (if any)

What this would do is allow patients the option of going to the private GP clinics and enjoying the subsidies from MOH. After all the subsidies are meant for sick citizens. Why should it be restricted only to the polyclinics? This would better utilize doctors who are in the private sector and lessen the load at the polyclinics.

In Australia, a similar system is in place. There are clinics which are called "bulk billing" clinics where patients see the doctor and essentially don't have to pay anything, because the clinic would bill the government. There are other clinics where the patients have to pay and extra seperate private charge while the clinic still bills the government the standard fee.

Right now in Singapore we are seeing polyclinics filled beyond their capacity, foreign doctors being roped in to work under insane conditions, medical errors being committed as a result , patients dying as a result of the medical errors, a distinct sense of unhappiness among the people, patients and medical community.

All this for what? To save money?

Perhaps MOH's philosophy is to make the polyclinics as inconvenient and as uncomfortable as possible such that only the very needy and desperate will go there for the subsidized treatment.

Is that the way to go?