Beyond coughs and colds - getting more GPs involved in chronic care
By Qasim Hussaini, third-year Duke-NUS MD student
Mrs Tan came to the A&E last night with a fever and a foot ulcer that just wouldn’t heal. She has diabetes and is now in an advanced stage of kidney failure with one leg already amputated for gangrene. This isn’t her first visit to the A&E. She is, in the informal hospital vernacular, a frequent flyer.
Like most of us, Mrs Tan doesn’t like to go to the doctor. She’s frugal, and even though she has benefits from her Pioneer Generation card, she isn’t keen on doctors.
One solution is to create an entity to address her needs, what might be called “enhanced primary care." This would offer maximum convenience, while addressing Mrs Tan’s needs for both preventive and chronic care to reduce the progression of her symptoms to advanced complications. Though she has lost one leg, she does have another leg, residual vision and kidney function, and young grandchildren that she wants to spend quality time with at home. With this solution, not only would Mrs Tan enjoy a better health outcome, but this would also represent a potential win for multiple actors in the healthcare system.
Primary care doctors can help to free up the emergency physicians and specialists, allowing them to focus on the acute services that they were trained to provide. By reducing avoidable complications, the acute hospital would be less crowded. And since acute services, which include specialty procedures, are the most expensive, overall costs would be reduced.
What are the key features of such a solution? Firstly, enhanced primary care would provide a clear point of first contact regardless of its presentation, be it acute or chronic. Second of all, the practices would offer a range of services covering acute, chronic, mental health and end-of-life care. Thirdly, an enhanced primary care site would serve as a connector, integrating together the specialists, hospitals, and other healthcare providers. Singapore is now looking at primary care models that involve family physicians leading primary care teams. These primary care teams may comprise nurses, allied health professionals and the relevant administrative support personnel.
This approach would be a substantive change from the current state of primary care. Let’s consider the range of services provided by primary care. More than 85% of Singapore’s primary care doctors work in the private sector and the rest in public polyclinics. In accordance with this percentage, 80% of acute care attendances are seen by private general practitioners (GPs). The majority of these private GP visits are for relatively minor acute problems. In contrast, with only 15% of the primary care workforce, polyclinic doctors see up to 45% of all chronic care visits. This discrepancy is problematic; but it also presents an opportunity for us to understand the obstacles facing private GPs in providing care for more complex patients, and to increase the uptake of GP-based primary care services.
Private GPs typically do not have access to resources that allow for the seamless coordination of chronic care, particularly if they are in solo practice. Access to facilities such as radiology, point-of-care lab tests, and early referral appointments in the public sector can often be difficult. Furthermore, the lack of electronic medical records (EMR) can hinder the high-quality delivery of chronic care to patients.
It is worth highlighting that many GPs do have the training and education to recognise and manage complex cases. Increasingly, GPs are pursuing postgraduate training in Family Medicine and are accredited by the Family Physician Register. Co-management with a specialist is also often possible given the right resources. Delivering-On-Target is an example of efforts to redirect patients’ care from the specialty clinics and polyclinics to a network of 120 GPs in the private sector. It has found some success, and now the questions to ask are: how do we expand similar programmes that allow for co-management and how do we attract more GPs to join such programmes?
A strong driver of the choices made by private clinics is economics. In the highly competitive primary care landscape, many private GPs experience difficulty in charging higher consultation fees, even when more time and expertise are involved in certain cases such as managing multiple co-morbid chronic conditions. As a result, GPs may rely on other souces of revenue, such as medication-dispensing and aesthetic procedures. Compared to their public counterparts, private GPs have limited funds to attend seminars or training workshops. It can also be difficult to hire someone as a locum to run the clinic while they are away. Government subsidies often drives the individual to a polyclinic over a private GP clinic. To some degree, the Chronic Disease Management Programme, Community Health Assist Scheme clinics, and the recent Pioneer Generation subsidies are aimed at alleviating this disincentive to provide care for those with chronic complex conditions.
Reinforcing the tendency for patients with more complex conditions to seek care in the public sector is the predominant mindset in local culture that a GP only treats coughs and fevers. Public education is often a crucial part of encouraging individuals to visit their primary care doctor. This involves educating patients in self-care and promoting their ability to interact effectively with the healthcare system. An example of this is the Self Care for Older Persons (SCOPE), a collaboration between Duke-NUS, the Tsao Foundation, and 14 Senior Activity Centres. Another strategy for establishing greater adhesion between patients and primary care providers is to employ technologies that can allow patients like Mrs Tan to carefully titrate her insulin to her needs with supervision from her GP.
Another strategy to more vigorously promote enhanced primary care is to formally empanel patients to physician groups. These providers would be incentivised to be efficient through a mix of fixed capitation and quality measures-based payment. This would also encourage them to offer a better care experience so that more patients would be attracted to the practice through word-of-mouth.
It is worth noting that Singapore has taken steps to improve the primary care system as part of its Healthcare 2020 Masterplan. For instance, the Family Medicine Clinic (FMC) is a relatively new model where hospitals jointly work with GPs, share a common EMR system and provide care to the elderly who suffer from co-morbid chronic conditions. In Mrs Tan’s case, such services would be key in slowing the progress of her disease and keeping her away from the hospital. Other improvements are targeted at training more physicians in family medicine, raising the quality of care offered, and moving towards a better coordinated team-based care.
The Primary Care Network (PCN) is another model currently being tested in the community for conditions like diabetes, hypertension, lipid disorders and asthma. A joint programme between the Frontier Healthcare Group and the Agency of Integrated Care, PCN is a network of 14 private GP clinics that share data on process indicators, patient outcomes and best clinical practices with the goal of improving GP chronic care management. A key aspect of this model is that the GPs in the PCN are directly supported by primary care team elements such as nurse educators, primary care coordinators and administrative personnel.
The Frontier FMC efforts demonstrate an example of primary care stepping up beyond the challenge of chronic care patients, and exemplifying the possible collaboration between specialists and the primary care team, with a focus on making the provision of care seamless and tailored to the individual patient’s needs.
Both the FMC and PCN models offer promising examples of enhanced primary care in Singapore. Other important factors to consider are empanelment, innovative funding strategies, access to patient records, population education, and the promotion of trust between the public and private sectors.
For people like Mrs Tan who struggle with keeping control over their chronic conditions and maintaining their independence, beginning with getting more GPs involved in chronic care is a good start.
Qasim Hussaini is a graduate of Johns Hopkins University with a Master's degree in Biotechnology/Regulatory Affairs. He completed his graduate work in neuroscience at the Johns Hopkins School of Medicine and the Mayo Clinic. A Duke-NUS MD student from the Class of 2017, he is mentored by Professor David Matchar, Director of the Health Services and Systems Research Programme at Duke-NUS, who studies innovative models of service for an ageing population.