Sunday 17 November 2013

Redesigning primary care for the future

By Loke Wai Chiong, Published The Stratis Times, 15 Nov 2013

GOVERNMENTS all over the world are building more health-care facilities to cope with ageing populations and increasingly complex diseases. Amid such developments, it is crucial that primary care is not overlooked.

Primary care is first-contact care involving general practitioners (GPs). It lies between taking care of oneself at home and being cared for in a hospital.

When the primary care system of a country is strong, fewer people are needlessly sent to hospital for treatment. People also tend to live longer.

Studies in the United States show that member states with a higher ratio of GPs per person have fewer deaths from various causes such as cancers and strokes. In England, life expectancy is generally higher for people between the ages of 15 and 64 in areas that have more GPs.

But despite its importance, the delivery of primary care in many countries has not changed much from the traditional model.

Redesigning primary care around a few principles can go a long way towards supporting efforts to expand health-care capacity. These principles include enabling rapid access to specialist expertise, diagnostics and community services; the provision of goal-oriented care; greater recognition of general physicians; and greater use of technology.

Currently, primary care is usually provided by small medical practices working alone, with limited access to multidisciplinary specialists, and other diagnostic or community-based services.

Such fragmentation means patients may not get early access to specialists, and may not get treated or be diagnosed early enough.

Sufferers of chronic diseases may not be cared for properly either, resulting in unnecessary complications.

When redesigning a primary care system, it is important to move towards providing earlier and easier access to a multidisciplinary medical team.

In Singapore, newer care models, such as Community Health Centres (CHCs) and Family Medicine Clinics (FMCs), have been introduced to help private GPs treat chronically ill patients. CHCs act as resource centres that provide nursing and allied health support. FMCs gather multiple private GPs, nurses and allied health services into one-stop care centres.

The aim is to allow GPs in the community to tap the skills of hospital specialists and gain access to other support services so that patients benefit from better-quality primary care.

Better coordination can also help produce a situation in which treatment plans and goals are tailored for and agreed upon by individual patients.

Primary care can also become more specialised. In this way, doctors can focus on particular diseases and target specific results, instead of referring all patients directly to hospitals.

In Finland, health and care services are organised around municipalities. Each municipality has a health station which offers a wide range of primary care, including preventive care, specialist care and welfare services.

In Belgium, Community Health Centre Botermarkt offers a tailored service for people with multiple medical conditions. This involves longer consultations and a range of services to meet individual needs.

The training of GPs cannot be neglected either. Globally, postgraduate training in family medicine is still not as widely available as other forms of specialist training. It is also often not recognised as being on a par with other specialist expertise.

Formal vocational training for family medicine, leading to a postgraduate degree, started in Singapore only in 1993. The result is that fewer than half of the GPs in Singapore have gone on to complete postgraduate training in family medicine.

Currently, primary care in many countries (including Singapore) is available only during office hours on weekdays. In Singapore, this results in many patients visiting the hospitals' emergency departments outside office hours for relatively minor ailments. Primary care systems also usually do not provide medical and nursing advice to patients via telephone or e-mail.

Globally, many GPs are also still using manual pen-and-paper recording, even as hospitals have gone electronic and digital. GPs should instead use technology that enables health records to be shared. Doing so will make it easier for specialists to provide them with support. Such technology can also allow nurses and other carers to get timely advice or instruction.

In the Netherlands, Parkinson.Net enables specialists to share best practices, new ideas and patient data. It is a national structure of local networks reaching at least half of all Parkinson's patients in the country. Patients can choose their own doctors, set priorities and build their own networks of care. For the patients involved, the initiative has led to reduced hospital visits and a 50 per cent reduction in hip fractures.

In Singapore, the national electronic health record project aims to collate all the relevant information from a patient's medical consultations across the health-care system throughout his life. Each person will also have a personal health management Internet portal to help him manage his dealings with health providers.

Bold experiments are needed to help improve the provision of primary care. Leadership from within the GP profession, as well as the wider health-care and regulatory community, is also vital.

The writer is a director, Global Healthcare Centre of Excellence, at KPMG in Singapore.

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