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PRIMARY HEALTH CARE FROM BEING JUST AFFORDABLE TO VALUE FOR MONEY 
 
Primary health care is synonymous with being affordable. The average visit to a private primary care clinic today is in the region of $20 - $25 for consultation and medicine. Some doctors charge less than that. A similar visit to a Government Polyclinic will be $7 for consultation. Add to this figure the medicine fee of $1.20 per item for a week for say, 3 types of medicine which will cost $3.60, the visit to the Government Polyclinic will be $10.60. Hence, there is about 50% of subsidy by the Government. For those older than 65 years and younger than 18 years old, there is a further reduction of 50%. A visit to the specialist will cost $70-$105 for consultation and $20-$30 for medicines. 

With this quantum of fees, the patient will choose the Government Polyclinic in place of the private primary care clinic since there is a 50% subsidy by the Government, all things being equal. In practice, the long waiting time serves to equilibrate the distribution of patients between the two primary care sectors. The patient has a choice of longer waiting time and cheaper charge at the Government Polyclinic or a shorter waiting time but unsubsidised charge at the private primary care clinic. 

In both settings the end result is each patient is given a short consultation but for different reasons. For the Government Polyclinic, the saturation point is reached when the crowd is just too big for the doctors to work any faster. For the private primary care clinic, the doctor is obliged to have a quick throughput in order to keep the waiting time short and also to see enough to meet the running costs and take home a reasonable income. Of course, doctors do try to do the best they can under the situation by spending more time with those patients with more difficult problems and make up by spending less time with the more straightforward ones. 

At any rate, under the present primary care setting, the average consultation time will be kept short. There are of course, exceptions. Other doctors may provide an attraction by being thorough and therefore attract a clientele who is willing to pay more in exchange for the longer time spent. 

A short consultation makes it difficult to delve in any extent beyond the acute problems. In practice, there are essentially up to four tasks that face the doctor. All will need to address the acute reason for encounter. Beyond that the consultation may indicate there are other tasks to fulfil: modification of help seeking behaviour, care of continuing problems and opportunistic health promotion. An example of modification of help seeking behaviour is the dissuasion of the patient from insisting on a course of antibiotics for a viral upper respiratory tract infection which is suggested by a running nose, against the constellation of cough and mild fever. An example of opportunistic health promotion is the smoking cessation counselling in a patient presenting with a respiratory complaint. Care of continuing problems will cover hypertension, diabetes mellitus, bronchial asthma and other similar conditions. Unless there is enough time, these other tasks will either be suppressed or inadequately dealt with unless they become key issues by their own merits. 

If primary care is to realise its true potential, several things must change. First, the fees must not be just based on being cheap. It must be enough to pay for the time to do the necessary tasks. In other words, it must be value for money. 

One way is to make the pricing structure of the Government Polyclinic close to the private primary care clinic. To fulfil its social obligations of caring those less able to afford, the Government Polyclinic could perhaps consider limiting the subsidy to children and the elderly as well as those who can prove that they are hardship cases. This will straightaway even the playing field to enable the primary care sector to establish a fee structure that provides enough time to deal with the tasks of opportunistic health promotion, modification of help seeking behaviour and care of continuing problems. It has been estimated that a time of 6-10 minutes will be needed to go beyond the acute problems. The guideline of fees of the Singapore Medical Association is $20-$25 consultation for a short consultation of up to 15 minutes. Perhaps, this could be working figure for both the sectors. The Government Polyclinic can further reduce this figure to subsidise the needy groups. 

A second thing to do is to encourage all primary care doctors to go beyond the acute problems to address the other tasks of the consultation. This is where the training in family medicine could put theory into practice.