Letters to the Editor
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MEDICAL EXCELLENCE DEFINED
The motto, "Towards Medical Excellence" used to be printed with the Singa logo in Ministry of Healths publications. What exactly is excellence in health care? Is it just a slogan meaning different things to different people and nothing to most people? Does it give directions to how our healthcare system should evolve?
The recent publication of the Ministrys Mission in a pamphlet 1997 health facts of Singapore is therefore timely. The Mission enshrined in three succinct statements is "to promote health and reduce illness; to ensure that Singaporeans have access to good and affordable healthcare that is appropriate to needs; and to pursue medical excellence". Our people take centre-stage in our pursuit of health.The Excellence Movement
Tom Peters et al started the excellence movement in commercial enterprises 15 years ago with their seminal book, In Search of Excellence. They studied successful companies and came to the conclusion that the bases of success is staying close to customers, productive wandering around and people with zeal to excel. IBM was one such company put on a pedestal. Yet, it too has to re-engineer itself to meet the challenges of the 1990s.More than just bottom-line aggregates
While the outcome of these excellent enterprises can easily be measured in financial terms, it is a different ball game in healthcare delivery viewed in the perspective of a nation. How close we are to medical excellence certainly cannot be measured just by the bottom-line of aggregates of healthcare establishments, the form of juggernauts or the strutting of prima donnas.
The MOH mission statements now clearly set the goals for the nation to work towards and define the context of what medical excellence should be. The concepts behind these statements may be found in various government papers on Health, for example the White Paper on Affordable Health Care.
Parts of the operational framework are announced in various policy speeches in past months. Speaking on Trends in Medical Practice in November 1997, Mr Koh Yong Guan, Permanent Secretary said that good quality and affordability are not irreconcilable objectives. On the contrary, we can achieve both objectives together, provided we put in place the right regulatory and professional framework (SMA News November 1997). BG Lee Hsien Loong, Deputy Prime Minister described how our hospital system should work together (SMA News April 1998). Mr Yeo Cheow Tong, the Health Minister elaborated on the roles of the polyclinic and family doctors (SMA News May 1998). Recently, Dr Chen Ai Ju, the Director of Medical Services dealt with the professional aspects of training and audit in ensuring good quality care (SMA News May and June 1998). We too should reflect on the Ministrys mission statements.Promote health and reduce illness
In the long run, attention to risk factors, accurate diagnosis, early intervention, adequate rehabilitation and post-hospital care will result in reduced morbidity and mortality as well as reduced illness. This requires a lifetime of investment in healthy lifestyle and habits. It is pertinent to note that as a nation we have embarked on a healthy lifestyle decade since 1992. Such health promotion efforts will bear fruit in years to come.
As practitioners and close to patients, we too should aim to promote more health and not necessarily more healthcare. We need to work together as a team, doctors and patients, GPs and specialists to reduce illness from complications of chronic diseases such as diabetes. Emphasis must be made in prevention at every level. Treating complications must be seen as necessary salvage in our Sisyphus-like battle against diseases and not as ends unto themselves, however excellent.
Singaporeans are greying. Should we not strive for an elderly care system in health and in sickness, that is excellent because it is good quality, equitable and accessible? The recent setting up of geriatric networks and geriatric training at various levels are steps in the right direction.
Access to good and affordable healthcare that is appropriate to needs
Good access and affordability are important adjectives in health care delivery. There is a need to work towards affordable care. Such care should also be appropriate to the patients needs at a given point of time.
Medical excellence need not always be high-tech. What is appropriate varies from time to time. The illness cycle goes up and down. Thus, it is important that providers at different levels work closely together. The system must not only be centred on patients filtering up to obtain more complex care but also filtering down when such care is no longer needed. Funding, training and administrative policies must reflect this reality.Pursue medical excellence
In pursuing the Ministrys objectives, it is important to go beyond present mind-sets of professional roles as these are but functions of historical funding and training policies.
One example that comes easily is to mind the shared-care concept between the hospital-based and the primary care doctor. For the concept to succeed, it will also be necessary to work out meaningful professional roles depending on the medical needs in the patient illness cycle. Besides the sharing of professional burdens, financial and administrative aspects such as third-party subvention and reimbursement of services and drugs must be addressed. Clinicians can only do so much. More than the dissemination of knowledge through CME activities is needed.
The mission statements of the Ministry are therefore relevant both to the Singapore Medical Association and to each member of the medical profession. As a fraternity, we are helping to set the ethical fabric and practice discipline on which doctors can practice good medicine. As individuals, we should each work out our contributions in deeds, not words, not self-aggrandisement nor the bottom-line of our affiliation.K
DR CHEONG PAK YEAN