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In a major policy speech on 6 November 1997, the Permanent Secretary (Health), Mr. Koh Yong Guan announced that “good quality health care and affordability are not irreconcilable objectives.” He added that, “On the contrary, we can achieve both objectives together, provided we put in place the right regulatory and professional framework”. This policy speech is reproduced in full in this Newsletter as the lead article.

The medical profession could help to shape this framework.  The Ministry of Health has now defined in concrete terms what the objectives of the health service should be. These are more understandable than the concept “Towards Medical Excellence”. In framing the regulatory and professional framework alluded to, we hope that three basic concepts are considered namely,  broad competency for all, a role for all and involvement of all.

Broad competency for all
Over time all people suffer from more than one disease. Their medical problems may involve more than one organ system. Also as people get older, multiple diseases become more prevalent. Therefore all doctors need to be trained to have a broad competency in good quality health care, irrespective of whether they are practicing as general practitioners or as specialists. For the general practitioner, the strategy is to achieve a high plateau of knowledge and skills of the breadth of medicine. The specialist needs to build pinnacles of expertise upon the broad base of his specialty.  This also applies to clinical teachers. In his SMA Lecture 1997, Dr Wong Heck Sing spoke of the ideal clinical teacher as one who has “a broad based training even if he decides later to branch into a narrower field.”

Through the attainment of broad competency for all, we do not always need a multitude of sub-specialists tending to the same patient most of the time. Such fragmented health care will neither be good nor affordable. Every doctor, be he a GP or specialist should be encourage to deal confidently with basic problems and not refer just because the ailment falls outside the confines of his chosen field of interest. The training at the undergraduate and postgraduate levels as well as continuing medical education programmes must bear this in mind.
Role for all
The health service must work towards a role for all. The statement made by Mr. Koh that “specialists should work closely with primary care physicians” is an important one. He said that, “one way is to establish shared care programmes, where the expertise, skills and strengths of both types of doctors are harnessed to optimise the benefits to patients. And patients should be discharged to their primary care doctors as soon as possible.” In such a health care system, there is role for all. 

Much more can be achieved if we ensure that both specialists and primary care doctors, in-patient and ambulatory services care for the same patient together. There will be appropriate care at the appropriate level over time. This paradigm will become more and more important in the years to come with the greying of our society and the shift of disease pattern to that of a developed nation. 

To control costs effectively, doctors need to work together with the patient at various health care levels. Diabetes mellitus is a good example. Better metabolic control remains the cornerstone for preventing and delaying complications. When complications occur, timely intervention by specialists will help to reduce the adverse consequences. When the complications are under control, the patient returns for continuing routine care. The organisation, training and financing of healthcare services must bear this in mind.

Involvement of all
There is a need to think in terms of the whole nation’s medical firepower and not just that of the public sector or the private sector disparately. For example, in formulating the professional framework such as clinical guidelines, available resources in all sectors must be taken into account and resources allocated appropriately. Only then can the health service be a national investment towards good quality care and affordable care. 

It is myopic to consider each sector hermetically. Thus, our government primary care is said to be affordable but there are doubts raised as to how this impacts on the overall quality and affordability of the whole system - a paradox highlighted in an article in this issue (N3). If perverse financial incentives exist that lead to inappropriate patients’ demands and care, then these demands may have to be modulated and utilisation pattern changed. More healthcare services do not necessarily equate with more health. More appropriate services on the other hand will. 

As a profession and as a nation, we need to strive towards good quality and affordable healthcare. We agree with the Permanent Secretary’s caveat that it is achievable “provided we put in place the right regulatory and professional framework”.