Public hospitals to streamline care teams, patients will see one 'principal doctor'

SINGAPORE: Instead of seeing multiple specialists, public hospital patients who have multiple health problems will soon only need to deal with one doctor who will oversee a streamlined team caring for them.

Announcing further details about the way hospitals will structure their teams on Saturday (Sep 20), Minister for Health Ong Ye Kung said this doctor – the principal doctor – will need broad-based competencies and experiences to coordinate and integrate care across specialists.

Many experienced specialists who have treated patients of varying conditions and beyond their area of specialty can be principal doctors, he added.

“That is, however, not enough. Now, we need to consciously train clinicians to acquire broad-based competencies, as a career pathway distinct from being a specialist,” said the health minister.

These changes were briefly announced earlier this year. The Ministry of Health (MOH) said in March that while public hospitals already have specialists who can manage specific organ systems, doctors will increasingly need to lead teams in coordinating and managing cross-specialty issues to consolidate their patients’ care needs.

By 2026, one in five Singaporeans will be aged 65 and above, and the country will become a “super-aged” society, expecting more elderly patients with multiple health conditions, said MOH on Saturday.

HOW DOES THE NEW SCHEME COMPARE?

Previously, if a patient presented with multiple conditions affecting different parts of their body, they would have to see multiple specialists, who would each lead their own team.

For example, an elderly patient may be hospitalised with a head injury after a fall, which was caused by giddiness. This patient may see a brain specialist or neurosurgeon to check if they have a blood clot in their brain, a lung specialist to check if they have pneumonia or fluid in the lungs that may have caused the fall, as well as a kidney specialist because they have underlying chronic kidney failure.

With three groups of specialists approaching the same patient, they may repeat the same history, or conduct duplicate examinations or blood tests to understand the patient’s condition, said MOH.

“Each specialist will tend to focus on his or her respective area of expertise. For the patient and his family, this may mean speaking to multiple specialists, repeating his symptoms each time, being prescribed many treatment plans and medications, and trying to make sense of them all,” said Mr Ong on Saturday.

“Upon discharge, he may have to navigate numerous follow-up clinic visits. Sometimes, patients may end up waiting a couple of hours for their turn to see the specialist, only for the consult to be over in a few minutes if his condition is stable. And this experience is repeated across clinics.”

With a streamlined, unified care team, patients will only need to see the principal doctor, said the Health Ministry.

The principal doctor may either be a specialist who has retained broad-based competencies or a hospital clinician who has been trained with the appropriate broad-based competencies.

Under this new structure, the same elderly patient who was hospitalised after a fall that was caused by giddiness would mainly see the principal doctor, who would decide how to manage their treatment.

This principal doctor would work with a team of healthcare professionals from different disciplines based on what the patient needs. The team could change if the patient’s needs evolve.

After the patient is discharged, they would continue to follow up with the principal doctor. Potentially, they would see fewer referrals and visits to different specialists, MOH said.

QUALITY NOT COMPROMISED

These changes have been progressively implemented in selected disciplines across all public hospitals since earlier this year, said Mr Ong on Saturday.

They were introduced across four disciplines – general medicine, general surgery, orthopaedic surgery and paediatric medicine. These four specialties account for more than half the specialist doctors in public healthcare institutions across Singapore, MOH said.

When asked about patients who may be concerned about the number of cases doctors are looking after, MOH stressed that this depends on the needs of the patients.

If a doctor’s patients have lower care needs, they may take on more cases, while doctors who have patients with higher care needs may take on fewer cases because their patients are more complex to manage.

In a typical inpatient setting, one doctor usually takes on eight to 12 patients, but this can extend to up to 20 patients depending on their needs, said MOH.

“The quality of patient care will not be compromised,” the ministry added.

The situation may also change depending on how the patient’s conditions change. In some cases, the principal doctor may be able to manage the patient’s care with expert input, MOH said.

But if a patient is diagnosed with an urgent new condition that needs to be settled during their current hospital stay, the principal doctor may transfer the case to another principal doctor who may be a specialist who can better manage this new condition.

This structure will also prevent excessive specialisation, MOH said. For example, an orthopedic surgeon is meant to perform all orthopedic-related clinical tasks, but some surgeons may start to only focus on spine surgery, and not consider other orthopedic conditions.

The Health Ministry also announced plans to enhance the progression of hospital clinicians, who are doctors with broader-based competencies across multiple domains.

The hospital clinician scheme – meant to cultivate doctors complementary to specialists – was first introduced in 2020, and there are currently about 150 doctors under the programme.

Currently, of the 12,000 doctors in the public healthcare system, about 5,000 are specialists, MOH said.

With the introduction of hospital clinicians, there are now three main career pathways for doctors in public healthcare – family physicians and family medicine specialists, who handle primary and community-based care, as well as hospital clinicians and specialists based in hospitals.

MOH will introduce a new apex grade for hospital clinicians who take on significant professional leadership responsibilities, similar to specialists and consultant family physicians, the ministry said, adding that it is reviewing the salaries of hospital clinicians.