Singapore's public healthcare sector to be reorganised into 3 integrated clusters by 2018, new polyclinic group to be formed

Healthcare services will be streamlined into 3 clusters
Each will have full range of services, from polyclinics to general and community hospitals
By Poon Chian Hui, Assistant News Editor, The Straits Times, 19 Jan 2017

Singapore's public healthcare will undergo a major shift in the coming year, bringing the entire suite of medical services closer to people's homes.

The six regional health systems of today will be streamlined into three "integrated" clusters.

This will be done by merging three of the current clusters with larger ones, based on geographical location. Between them, the three new, beefed-up clusters will cover the entire island.

Every cluster will then boast a fuller range of services, encompassing general hospitals, at least one community hospital and several polyclinics. Each cluster will also have a medical school.



The move is meant to address future healthcare challenges, such as a greying society and more people with chronic ailments, said Health Minister Gan Kim Yong.

With each new cluster looking after more than a million Singapore residents - and offering the full range of medical services - people will find their healthcare needs being met closer to where they live.

This will mean mergers and consolidation within the existing six-cluster system that took shape between 2007 and 2009.

Singapore Health Services (SingHealth) will join forces with the Eastern Health Alliance, which oversees Changi General Hospital, to offer services in the east.

The National Healthcare Group (NHG) will merge with Alexandra Health System, which runs Khoo Teck Puat Hospital and Yishun Community Hospital, to handle the central region.

In the west, the National University Health System (NUHS) will be paired with Jurong Health Services, which manages Ng Teng Fong General Hospital and Jurong Community Hospital.

The three merged clusters will thereafter be known as SingHealth, NHG and NUHS respectively.

In line with the changes, the polyclinics will be regrouped.

Currently, SingHealth and NHG run nine polyclinics each. This would leave NUHS without any polyclinics. That is why a polyclinic group called National University Polyclinics is being formed. It will be operated by NUHS.

The move involves several polyclinics changing hands.

Two SingHealth polyclinics will be transferred - Geylang Polyclinic to NHG and Queenstown Polyclinic to NUHS.

Another four polyclinics, located in the west - Bukit Batok, Choa Chu Kang, Clementi and Jurong - will move from NHG to NUHS.

The public healthcare system has improved over the years, noted Mr Gan.

"Nevertheless, we cannot afford to stay still as there remain many challenges ahead, such as our ageing population, increased chronic disease burden and the need to manage future growth in healthcare manpower and spending."

The reorganisation will optimise resources, he said.

It is expected to be completed by early next year and will not disrupt existing services for patients.

"Patients will not need to make any changes, and can continue with their existing healthcare arrangements and appointments," said the Health Ministry (MOH).

No healthcare staff will be retrenched.

The building of new facilities will also carry on as planned. Some projects in the pipeline include Sengkang General Hospital and Bukit Panjang Polyclinic.

A medical school in each cluster may also offer more training op- portunities.

In the long run, patients can expect more seamless care.

A diabetic patient could be more easily linked up from a hospital to a primary care provider in a cluster or an external service provider, offering care closer to home.

"As with any reorganisation, change can understandably be uncomfortable and unsettling for some," said Professor Philip Choo, group chief executive of NHG. "That said, I strongly believe our patients will benefit."

Coming soon to a cluster near you: Seamless healthcare
Delivering integrated, comprehensive care a key focus in new geographical-based system
By Poon Chian Hui, Assistant News Editor, The Straits Times, 19 Jan 2017

Patients may find more comprehensive healthcare services anchored closer to their homes after the public sector transitions into a new three-cluster system.

The beefed-up healthcare group in their neighbourhood will also bring health promotion, disease prevention and rehabilitative care within their reach.

Singapore's public healthcare sector will be reorganised into three clusters, down from the current six.

Facilities across the country, including general hospitals and polyclinics, will be grouped based on their locations, so that each cluster oversees a specific area of the island.

Singapore Health Services (SingHealth) will merge with Eastern Health Alliance and take charge of services in eastern Singapore, including Changi General Hospital.

The National Healthcare Group (NHG), which will take Alexandra Health System under its wing, will cover the central region.

National University Health System (NUHS), to be paired with Jurong Health Services, will helm the west. The new clusters, to be known as SingHealth, NHG and NUHS, will cover about 1.1 million to 1.5 million Singapore residents in each region.

Several polyclinics will be transferred across the groups, so that every cluster has primary care services.

After the changes, the different types of public healthcare facilities near one's home are more likely to come under the same management, compared with now.

Healthcare adviser Jean-Luc Butel said that the mergers should make it easier to strategise and implement decisions across the various institutions.

"You can now make decisions over broader areas of the system," said Mr Butel, who is president of consultancy firm K8 Global.

"For example, the application of best practices across the system should go more easily."

Staff will also be able to respond more quickly and decisively, such as when implementing new programmes for patients.

The transition is expected to be completed by early next year.

In outlining their visions, the leaders of the new clusters said that one key focus is on delivering integrated care for patients.

Professor John Wong, who will lead the merged NUHS as its group chief executive, said that the reorganisation allows longstanding partners in the west to come together to provide "seamless care from prevention to home care".

The six regional health systems each have their own strengths.

Some have formed strong primary care networks, while others are stronger in education or research.

The new entities can tap the combined strengths of the original clusters, said MOH.

Professor Ivy Ng, group chief executive of SingHealth, said: "Changi General Hospital's leadership in disciplines like geriatrics, sports medicine, emergency medicine and others will complement SingHealth's range of clinical services."

Similarly, NHG group chief executive Philip Choo said there will be more concerted efforts in wellness and preventive care.

Some hospitals also have existing tie-ups with service providers, such as voluntary welfare organisations, to run programmes for patients.

Such services could be scaled up under the expanded cluster, so residents in a wider area can tap them.

Dr Lee Chien Earn, who heads the Eastern Health Alliance, noted that the cluster has worked on disease prevention and early detection and treatment to help keep people in the community healthy.

A scheme, called Eastern Community Health Outreach, helps residents detect and manage chronic diseases early. It is currently available only in neighbourhoods in the east such as Tampines Central and Bedok.

With the merger, Dr Lee said that such successful programmes could be expanded "at pace and scale as part of a larger health cluster".

Additional reporting by Linette Lai

No changes to roles and salaries for most staff: MOH
By Linette Lai, The Straits Times, 19 Jan 2017

The vast majority of healthcare staff will remain in their current roles after the mergers of regional clusters, the Health Ministry (MOH) said yesterday.

It also said it did not expect to see any changes made to the monthly salaries for most employees.

"Almost everyone within the public healthcare sector will continue in their current roles, within their current teams," said a ministry spokesman. He noted that the public healthcare groups are already "broadly aligned" where pay is concerned, so salaries are unlikely to change.

However, "a small number may eventually be redeployed, as the merged clusters better optimise their manpower", he added.

"In such cases, staff will be offered jobs that match their experience and skill sets without any changes to their current salaries. The clusters will consult with the union and staff on these changes."

The reorganisation will see the existing six regional health systems streamlined into three clusters, and also see the National University Health System take over the management of five existing polyclinics.

All 18 polyclinics are now managed by either Singapore Health Services or the National Healthcare Group.

Dr Lew Yii Jen, who will be stepping up to be the chief executive of the new National University Polyclinics, said he would ensure "minimum disruption" to workflow as the polyclinics are handed over, and make sure staff have opportunities to raise any concerns.

The ministry did not say how many public healthcare staff will be reporting to a new employer by early next year, when the entire transition is completed.

What is known is that three of the current six group chief executives - Mr Liak Teng Lit, Mr Foo Hee Jug, and Dr Lee Chien Earn - will no longer hold their current positions. MOH said they have all been offered senior positions in public healthcare.

In a separate statement yesterday, Ms Diana Chia, general secretary of the Healthcare Services Employees' Union, said it would work to make sure that workers' terms of employment are not adversely affected by the changes.

"The union will continue to hold engagement sessions with our members to address their concerns and clarify queries regarding the change," Ms Chia said.

"We will also continue to work with the relevant stakeholders to facilitate the transition of the affected healthcare workers."

Yishun Community Hospital chief executive Pauline Tan, as well as other senior executives in the sector, said that the changes would give employees more opportunities for learning and professional development.

The community hospital will soon come under the National Healthcare Group.

"The larger cluster, with its combined strengths and resources, will provide wider career options, professional development and learning opportunities for our staff," Dr Tan said.

"This will enhance our appeal as an employer of choice."

Three-cluster health system: It's about integration, not competition
By Jeremy Lim, Published The Straits Times, 21 Jan 2017

"Old wine in new bottles" was the cynical reaction to the news that the six public healthcare clusters would be merged into three - Singapore Health Services (SingHealth), National Healthcare Group (NHG) and National University Health System (NUHS).

This is understandable. After all, SingHealth and NHG were established in 2000, bringing together almost 20 public healthcare institutions under two clusters before they splintered into six.

Now they are reclustering into three? On the surface, it does look like an expensive 17-year journey to get to the same place. But it's not.

This time, it is different.

WHY RECLUSTER?

Let's first review the reasons for the clustering back in 2000. Then Health Minister Lim Hng Kiang explained the benefits of vertical integration, saying clustering would "provide more integrated and better quality healthcare services through closer cooperation and resource sharing".

Subsequently, Mr Khaw Boon Wan, who was Health Minister from 2004 to 2011, also noted the policy intent for "the two clusters to compete more actively to provide better care at lower cost to their patients".

In the intervening 17 years, three paradigmatic shifts in medicine and society have become obvious.

Firstly, the "silver tsunami" is well and truly upon us. In 2000, only 7.3 per cent of Singapore residents were aged 65 and above.

Today, this number is 12.4 per cent. By 2030, a mere 13 years away, one in five Singaporeans will be elderly.

Secondly, chronic diseases are rampant - if left unimpeded, we face a potential future where Singapore's diabetic population will grow from today's 440,000 to a million.

Finally, government spending on healthcare has burgeoned. The Ministry of Health's (MOH) budget grew from $1.2 billion in 2000 to a whopping $11 billion last year.

RECLUSTERING: AN OPPORTUNITY FOR TRULY INTEGRATED CARE

"More of the same" will doom Singaporeans to a gloomy, disease-filled future and Singapore to a funding crisis. We need to transform our care models, emphasising population health, preventive care and a truly integrated health system.

This reorganisation is an integral part of this transformation.

What's different this time is that clustering is less about competition and more about integration. What's different this time is also that integration is across healthcare and community services, focusing on health and healthcare.

Imagine a future where a Singaporean who breaks his hip is taken by ambulance to the nearest general hospital, undergoes hip replacement surgery the next day, and after another day of convalescence, is transferred to an adjacent community hospital for rehabilitation.

Instead of staying for a month there, he goes home after a week and enjoys the convenience of a day rehabilitation centre just across the road. His kopitiam friends pop in during his rehabilitation to cheer him up.

Two months later, he's walking independently, unlike his aunt, who never walked again after she broke her hip, was on the waiting list to enter a community hospital and died in a nursing home less than a year after the accident.

In this same future, a Singaporean diabetic wakes up every morning, heads downstairs for an hour of exercise with her neighbours and, after that, learns healthier ways of preparing her favourite foods.

Every day, she checks her blood sugar using a cluster-provided device which wirelessly transmits the data to her healthcare team. An alert is sent if anything is amiss.

Her mother developed kidney failure five years after being diagnosed with diabetes. It has been 15 years since her own diagnosis during a routine community screening, and her kidneys are functioning just fine.

We all have to die but we don't have to live in poor health for years before death. This is what our health system has to support every Singaporean to achieve, and achieve at reasonable costs, and organising into integrated clusters is the way to achieve this.

This week's announcement about the reorganisation is hence necessary. But it is also insufficient.

The reorganisation addresses only the public healthcare components of the ecosystem and does not formally involve the private or the equally important voluntary welfare organisation (VWO) sectors.

Secondly, patients are still free to "cross clusters", for example, seeking care in Yishun Polyclinic (NHG) and having elective surgery in Singapore General Hospital (SingHealth) even if he lives in Jurong (NUHS geography).

Unless patients stick to the same cluster for virtually all their healthcare needs, the complexity of coordinating across clusters will defeat the purpose of reorganising.

Also, making structural changes without aligning incentives will not change behaviours.

Why would specialists work with GPs differently after the reorganisation? Or GPs bother with tele-health? Financial and policy levers will in time be needed to encourage providers, whether public, VWO or private, to work together seamlessly with each other and with patients, and for Singaporeans to remain within the geography of their clusters.

Finally, the question: Why three and not two clusters?

Well, we can only speculate, but one major difference since 2000 has been the development of another two medical schools.

Practically, it would be difficult to reconcile two medical schools with vastly different pedagogical methods and objectives within the same cluster.

Besides, with roughly 1.5 million to two million people each, the three clusters have sufficient numbers to justify a full complement of specialists across the major disciplines and a network of primary care facilities.

In announcing the reorganisation,MOH took pains to reassure patients that they "will not need to make any changes, and can continue with their existing healthcare arrangements and appointments".

This sets the bar too low. Patients should expect more than just "existing healthcare arrangements".

Singaporeans should hold MOH and the health system accountable for building on the scaffolding that this reorganisation provides and quickly realising a future where our health system truly is, as NHG's tagline promises, "adding years of healthy life".

The writer is partner and head of health and life sciences for the Asia-Pacific at management consulting firm Oliver Wyman.

Heathcare changes: 3 clusters offer more 'firepower'
That's how one health expert describes the new system that will consolidate public healthcare into three large groups. The key this time is a focus on primary care, Insight finds.
By Linette Lai, The Sunday Times, 22 Jan 2017

For 71-year-old Lim Ah Sai, a double amputee who has five chronic illnesses, including glaucoma, healthcare gets very complex.

Three times a year, he goes to Toa Payoh Polyclinic to make sure his diabetes, high blood pressure and high cholesterol are in check.

He also has an appointment every two months at the National Skin Centre in Novena so doctors can keep tabs on his eczema.

Almost every day, he goes for day care at voluntary welfare organisation SPD - which cares for people with physical disabilities - or visits the senior activity centre run by Touch Community Services near his home in Geylang Bahru.

Mr Lim and his wife - who is working and cannot care for him - have no children.

"It's simple because they (all) arrange transportation for me," Mr Lim says. "But if they didn't, how would I get anywhere?"

Last week, the Health Ministry (MOH) announced a set of changes to the healthcare landscape that might make life simpler for people like Mr Lim who have multiple appointments around the island.

But at first glance, the changes make it look as if history is repeating itself.

The six healthcare clusters, formed in the late 2000s when two bigger groups were split up, are merging again. By next year, after the transition is complete, there will be three large groups overseeing public healthcare - SingHealth, the National Healthcare Group (NHG) and the National University Health System (NUHS).

As familiar as this landscape appears, experts are quick to point out that Singapore today is not the same country it was in the 1990s - and that makes all the difference.

Reshaping the healthcare scene is meant to solve problems the Republic didn't have before, especially that of a growing senior population making frequent hospital trips for relatively minor ailments.

"At present, some patients have to make multiple trips to hospital specialist clinics for chronic disease management," says Dr Tan Wu Meng, an MP for Jurong GRC, who is on the Government Parliamentary Committee (GPC) for Health.

"But what if we could empower more family physicians to manage more such patients in the community closer to home - with specialist opinions in the same cluster just a phone call, an instant message, or an e-mail away?"

This is exactly what MOH hopes to achieve with its emphasis on primary care as part of the merger.

Primary care refers to polyclinics, general practitioners (GPs) and family medicine clinics - the first ports of call for most people when they fall ill.

LESS TO-ING AND FRO-ING

Having three large clusters rather than six smaller ones will make it easier to coordinate between hospitals and primary care doctors, says a ministry spokesman, and help to "anchor care in the community as a collective force".

"Primary care is the bedrock of a good healthcare system," the spokesman adds. "A patient with a chronic disease may require treatment at an acute hospital for a serious complication, but should ideally be able to be managed close to home by his regular family doctor over the longer term."

This means the changes could save people time and money - for if they find that they can rely on doctors near their homes, they have less reason to travel further and pay more for care in a hospital clinic. And it is not just savings in terms of transport expenses, but also in medical costs, as seeing a specialist is generally more expensive than going to a polyclinic doctor.

Comparing the healthcare system to a pyramid, Mr Roy Quek, chairman of private healthcare group Thomson Medical, says: "You want to catch people at the base of the pyramid first, rather than all the way at the top where the costs are much higher."

Mr Quek, who used to be deputy secretary of health policy at MOH, adds: "Primary care is always going to be our first line of defence - but it must be able to link back to the larger system."

WHAT BROUGHT ABOUT THE CHANGES

The changes will see the newly formed National University Polyclinics, managed by NUHS, take over the management of five of the 18 existing clinics - meaning all the new clusters will have their own set of polyclinics.

In 1999, the nation's public healthcare facilities - general hospitals, specialist centres and polyclinics - were divvied up more or less equally between SingHealth and NHG.

But under then Health Minister Khaw Boon Wan, they were hived off into six smaller clusters, each in charge of a specific geographical region, the idea being that these smaller clusters - each anchored by a general hospital - would have more room for innovation and become more independent.

However, last Wednesday, MOH announced the merger once again of these clusters, in anticipation of the growing complexity of healthcare needs. Each cluster will look after more than a million Singapore residents and partner with one of the three medical schools here.

Moving to a system where clusters cover broader areas makes it easier for institutions to work together and provide seamless care, says Dr Loke Wai Chiong, healthcare sector leader at Deloitte South-east Asia.

This means making it simple for patients - and their medical records - to move between institutions with the minimum amount of fuss. "If you think about seamless patient care, it happens only when you have the various care providers sitting down together to organise things," Dr Loke says.

"I think there is a recognition that collaboration is easier if there are fewer clusters, and between and within these three it will hopefully be easier to agree on workflows and processes, and ultimately standardise (them) at the national level."

MOH has said that the vast majority of healthcare staff will retain their current roles, with no changes to their monthly salaries. If people have to move, they will be offered jobs that match their skills and experience, and at the same pay.

However, the merger means many employees will get better opportunities for career progression and development, says Dr Lee Chien Earn, group chief executive of the Eastern Health Alliance, which will soon come under the management of SingHealth.

Each organisation that is now part of a larger whole will also have access to a wider range of facilities, services and networks.

HOW THE NEW SYSTEM WILL HELP

For example, says Health GPC member Dr Tan, polyclinics would be able to do more for patients with all the "firepower" of a large cluster behind them. "(This is) whether it's a remote consult with a specialist, being able to restock complex prescriptions without the patient going to hospital, or arranging tests and scans and being able to readily download the images and results."

Of course, it goes beyond just polyclinics and acute hospitals leveraging on one another's strengths. It also includes community hospitals and the national specialist centres. And it means that organisations formerly from different clusters will be able to tap one another's community networks - such as GPs in private practice, voluntary welfare organisations or nursing homes - to, and from which, so many referrals are typically made.

How all this potential will pan out in the next few years remains to be seen, although experts agree it should improve efficiency in the system, especially when it comes to planning and innovations.

"The gains may not be so immediate in terms of things like waiting times," Dr Loke says. "But the system now is less complex and there is more scale. Scale helps - it's hard to do things like telemedicine and telemonitoring without it."

And Mr Quek adds: "It should lead to greater efficiency when you consolidate manpower over a larger, integrated footprint."

Changes to system are a healthy move
Four health ministers, four reorganisations. Senior Health Correspondent Salma Khalik explains why the restructurings have been a necessary process for Singapore.
By Salma Khalik, Senior Health Correspondent, The Sunday Times, 22 Jan 2017

Since I started covering the Health beat for The Straits Times 17 years ago, I have seen four health ministers leading the ministry - and each, some time during his tenure, reorganised the public healthcare system.

In the 1990s, each hospital was run separately. In 2000, when Mr Lim Hng Kiang was at the helm, polyclinics, hospitals and national centres were grouped into two clusters. Then in the late 2000s, the healthcare system was put into six regional groupings under Mr Khaw Boon Wan.

The latest move to group healthcare institutions into three clusters comes about five years after Mr Gan Kim Yong took over as health minister in 2011.

Explaining the move to have three clusters this time, the Health Ministry says each will have polyclinics, community hospitals, a general hospital and even a medical school. Specialist centres will be an exception - they will be shared by the whole nation as Singapore is not big enough to have, for example, three skin centres.

Three large clusters will also give healthcare professionals more opportunities to progress and move into areas they prefer.

Were these multiple reorganisations over the decades necessary? Did they improve the public healthcare system, or were they just about ministers trying to stamp their mark on healthcare, and in so doing cause a lot of unnecessary fuss?

I would argue that the changes in the past three decades have contributed to improving the healthcare system - resulting in Singapore today being acknowledged internationally as having one of the best healthcare systems in the world. Not every move was perfect, to be sure, but they have improved the system.

Singaporeans' long life expectancy and low infant mortality also attest to that.

THE FIRST RESTRUCTURING

This happened in the late 1980s, when public hospitals were "restructured", which led to them having their own boards, and being able to decide - within limits - how they rewarded staff. Then Acting Health Minister Yeo Cheow Tong said this should lead to greater efficiency and better service.

Previously, all hospitals - except for the National University Hospital, which was owned and run by Temasek Holdings - were run by the Government.

Restructuring gave each hospital the leeway to manage its own affairs within certain parameters, such as providing subsidised care. Each had its own board of directors, could set its own fees and could recruit the doctors it needed. They continued to receive government funding for subsidised patients.

Each hospital could set its own priorities. They became more efficient, since money saved could be used to further their own goals, such as to boost training, get better equipment or do more research.

Singapore benefited as treatments and procedures improved, with hospitals taking ownership and competing to provide better service - where previously, the bottom line was not such a concern.

Through annual reports, each could also see how well the others were doing in comparison - and try to do better.

TWO CLUSTERS

When Mr Lim took over the Health portfolio in 1999, he decided to group all public healthcare assets into two huge clusters - SingHealth in the east and the National Healthcare Group (NHG) in the west. Each cluster consisted of acute hospitals, some specialist centres and half the polyclinics.

Mr Lim did that to reduce the "compartmentalisation" of various institutes. Before, the clusters, polyclinics, hospitals and specialist centres were run separately, and competed for patients. Integrating various facilities forced them to work together. It was also good for patients with complex ailments, who could get care from doctors at clinics or hospitals in the same cluster.

Where previously, polyclinics and hospital specialist centres might compete, say, for a diabetic patient since they received a government subsidy for the patients under their care, the subsidy now went to the cluster - regardless of whether the patient was treated by a specialist or a polyclinic doctor.

It made sense then, for the patient to be treated at the level most appropriate. So a diabetic patient might be seen by a specialist when his condition was unstable. But when he was better, he would be cared for at a polyclinic.

On the flip side, the clusters fostered a competitive pressure, with each vying for talent.

AND THEN SIX

When Mr Khaw took over, he broke up the clusters into regional groupings within Singapore, each headed by a hospital.

This was because he wanted to regroup both the public and private sectors in healthcare. The duo-cluster system had affected only public hospitals and polyclinics.

Mr Khaw wanted to involve the private sector. In Singapore, general practitioners account for 80 per cent of primary care. Community hospitals and the majority of nursing homes meanwhile were run by voluntary welfare organisations.

Mr Khaw wanted health practitioners and planners to go beyond the public sector, to work more closely with the private and charity sectors in their geographical location.

Four regional groups were set up. The number was expanded to six when the Khoo Teck Puat and Ng Teng Fong hospitals opened. A seventh was slated for when the hospital at Sengkang opens next year.

Each of the six regional groupings was headed by a general hospital. Two had polyclinics but the rest didn't. The plan was for each group to team up with private and charity players in their region.

Changi General Hospital, for example, formed the Eastern Health Alliance, which included Saint Andrew's Community Hospital, Peacehaven nursing home and daycare facilities, GPs in the east and polyclinics.

Because it was responsible for that area, it moved beyond its hospital walls to provide health screening in the community, to keep residents healthy and out of hospital. Part of this was driven by the acute shortage of beds.

There was similar cooperation in the other regional groups between acute and community hospitals, nursing homes, rehabilitation and eldercare facilities, and GP clinics.

There were also greater link-ups with charitable organisations to help poorer patients, especially on their return home.

AND NOW, THREE CLUSTERS

What will this round of change bring?

While the regional clusters have seen a closer working relationship between the public, private and charity sectors, the growing number of clusters is beginning to fragment healthcare here.

What started as four regional groups has grown to six and, with hospitals in Sengkang and Woodlands being built, the number would increase to eight in six years' time.

This could become unwieldy.

Singapore's future healthcare needs will also be different. The population here is ageing rapidly. Today, there are 450,000 people aged 65 years and older; the number will double to 900,000 by 2030. Generally, older people require more healthcare services. Many will suffer from one or more chronic ailments, which will make their care more complex.

Mr Gan has said often that primary care has to be the cornerstone of a good healthcare system.

GPs and polyclinic doctors see patients at the start of their chronic ailments. If they are able to delay or prevent the progression of these diseases, people will stay healthier longer, and the need for hospital care will be reduced. Half the patients with chronic diseases are looked after by polyclinic doctors.

So how will having just three clusters help?

With the restructuring, each of the three clusters will have between seven and nine polyclinics (including five yet to open).

Each cluster will have a medical school, to improve professional training and research.

Specialists can move within a cluster - perhaps spending part of the week at a different hospital within the cluster, making it easier for patients to access them without switching to a specific hospital.

THE FUTURE DIAGNOSIS

There are no glaring problems that have fuelled the latest changes. Rather, things are still working well, but the restructuring is part of planning for future needs, and doing so before push comes to shove. Indeed, there is no urgency now, so the restructuring can be done slowly over a year.

But the reality is, in the future, Singapore will need to do more with less. Demands from a rapidly ageing population will outstrip the supply of medical professionals. Singapore is already recruiting many foreigners for medical roles.

This latest restructuring hopes to optimise available resources better. One way is to move care upstream, to prevent problems or to maintain patients so their medical issues do not deteriorate so rapidly. In other words, to try to keep them as healthy as possible for as long as possible. Hence the shift in focus to primary and preventive care, and the need to work with voluntary welfare organisations and others.

It remains to be seen, of course, just how the new cluster system - which will take a year to implement - can improve healthcare delivery.

Previous reorganisations made for a better system. Restructuring gave hospitals more autonomy. Clusters helped tertiary and community hospitals work with one another and with polyclinics. The setting up of regional groupings facilitated working across public, private and charity sectors.

As the healthcare landscape changes, so too must the way Singapore meets emerging needs.

Clusters for better coordination
The Sunday Times, 22 Jan 2017

1980s

Singapore began the process of "restructuring" hospitals in the 1980s.

Under restructuring, a public hospital is granted autonomy in its operations, though major issues or changes would require government approval.

This came after a successful pilot in 1984 during which National University Hospital (NUH) was run as a corporatised institution.

Singapore General Hospital (SGH) was the first to be restructured, in April 1989. This was followed by the then Kandang Kerbau Hospital - now known as KK Women's and Children's Hospital - and Tan Tock Seng Hospital.

NUH and the now-defunct Toa Payoh Hospital were also restructured. Alexandra Hospital remained a government-run facility.

The restructured hospitals were free to develop their own identity and make service improvements to draw patients.

But this competition led to some issues such as higher salaries.

2000: TWO NETWORKS

In 2000, the government reorganised the public health sector into two networks, National Healthcare Group (NHG) and Singapore Health Services (SingHealth).

It also announced that Alexandra Hospital, Woodbridge Hospital - known as the Institute of Mental Health today - and polyclinics would be restructured by April 2001.

These institutions were then integrated into the two networks.

Each network had a variety of services, from acute to primary care.

There were two objectives for the change, according to the Government. One was to facilitate referrals between the different institutions and coordinate care for patients.

The other was to spur competition between the two groups to provide better care at a lower cost.

This system, however, mostly involved public health facilities and did not rope in the private sector.

LATE 2000s: SIX SYSTEMS

The move towards six regional health systems, each anchored by a general hospital, took place from 2007 to 2009.

Four regional groups were formed, centred on SGH, NUH, Tan Tock Seng Hospital and Changi General Hospital.

This was expanded to six when Khoo Teck Puat and Ng Teng Fong hospitals opened.

For the Eastern Health Alliance (EHA), which oversaw Changi General Hospital, there was a two-step process.

In 2009, the Changi General Hospital Board, a subsidiary under SingHealth, was established.

This was followed by the formal incorporation of the EHA in early 2011.

The regional groups worked with private and charity-run health providers.

For instance, EHA partnered St Andrew's Community Hospital, which is run by a voluntary welfare organisation.

However, services were uneven across the groups. For instance, only two had polyclinics under their management.

2017: THREE CLUSTERS

The latest reorganisation, announced last Wednesday, will see the six regional groups streamlined into three integrated clusters by early next year.

SingHealth will merge with the EHA, and NHG will join forces with Alexandra Health System, while National University Health System will be paired with Jurong Health Services.

Each cluster will offer a full range of services, including polyclinics and community hospitals.

*  Ministry of Health Work Plan Seminar 2021

No further review of 3-cluster healthcare system: Ong Ye Kung

Health Minister says MOH should press on with focus on general health, community care

By Ng Keng Gene, The Straits Times, 30 May 2021

The current three-cluster healthcare system here should not be further reviewed, Health Minister Ong Ye Kung said, as he laid out plans for the healthcare industry at the Ministry of Health (MOH) Work Plan Seminar last Tuesday.

The last reorganisation of these clusters was announced in January 2017, with six clusters merged into three - National University Health System (NUHS), National Healthcare Group (NHG) and SingHealth.

"There are pros and cons to being big or small. Big clusters have scale and comprehensive capabilities. Small hospitals can be agile and innovative," said Mr Ong, who took over the health portfolio on May 15.

"We should continue with the structure that we have."

He added: "Within each cluster, we will have to find ways to make space for skunkworks and make unorthodox ideas become mainstream. Bring out the best of both worlds."

As part of the last restructuring, three of the existing clusters in 2017 were merged with larger ones, based on location. This process was completed about a year later.

MOH had said in 2017 that the reorganisation would allow public healthcare institutions to deploy their resources and capabilities more efficiently, and also offer employees a wider and deeper range of professional development opportunities.

With the change, each of the three final clusters has offered a fuller range of services, encompassing acute hospital care, primary care and community care. Each cluster has a medical school.

For instance, NUHS currently runs the National University Hospital and six polyclinics in the west, NHG operates Tan Tock Seng Hospital and six polyclinics in the central region, while SingHealth runs Singapore General Hospital and eight polyclinics in the east.

All three clusters are expected to grow, with NHG set to operate Woodlands Health Campus, which will include an acute hospital and a community hospital, when it opens progressively from 2023.

SingHealth will run a similar integrated facility in Bedok North from around 2030.

Meanwhile, 12 new polyclinics will be added to the current 20 by 2030. These include Bukit Panjang Polyclinic, which will open by the end of this year and be run by NUHS.

Mr Ong said that rather than spending time reviewing the current cluster system, the ministry should press on with approaches it first laid out in 2016. The approaches seek to shift the focus towards general health instead of healthcare, allow patients to receive care in the community and avoid hospital admissions, and increase care quality while ensuring value for money.

These will help to address long-term issues like rising government healthcare expenditure and heavily loaded hospitals.

Mr Ong said healthcare expenditure is set to hit $59.1 billion in 2030, up from $20.7 billion in 2018 and $10.5 billion in 2010. The 2030 figure will form about 16 per cent of the Government's yearly Budget, up from 12 per cent currently.

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Reorganisation of healthcare system into three integrated clusters to better meet future healthcare needs -18 Jan 2017