LONG QUEUES AT SPECIALIST OUTPATIENT CLINICS

[Mr Speaker in the Chair]

Dr Lily Neo asked the Minister for Health (a) what are the reasons for the long queues at specialist outpatient clinics of restructured hospitals; and (b) whether any steps are being taken by his Ministry to improve the situation.

The Minister for Health (Mr Lim Hng Kiang): Mr Speaker, Sir, our Specialist Outpatient Clinics (SOCs) see a disproportionately large number of patients, some of whom could have been treated by their family physicians. This situation arises because patients, by and large, prefer to be seen by the specialists and the charges at the SOCs are not significantly higher than those charged by the family physicians.

Patients therefore may experience long queues and waiting times at the SOCs from time to time for the following reasons:

(1) Patients' preference to be seen by certain specialists who have a long waiting list. To shorten the appointment waiting time for patients, the clinic sessions for these specialists are therefore overbooked, which would invariably contribute to a longer queue and waiting time;

(2) Appointments made at the SOCs are scheduled assuming that they are "normal" cases with average length of consultation time. However, in the clinic situation, some consultations turn out to be more complex and require more time. This leads to a cascading effect whereby the waiting time for consultation for subsequent patients would be affected;

(3) From time to time, a patient's medical condition changes or deteriorates such that he requires to see the specialist earlier than the given appointment date. In such instances, based on medical need, the SOC may have to arrange an urgent appointment for the patient even though the specialist is already fully booked for the day; and

(4) Occasionally, the specialists are called away to attend to emergencies in the ward or operating theatres.

The Ministry and the public hospitals have instituted the following specific measures to improve the waiting times at the SOCs:

(1) To increase the number of clinic sessions for specialists with long waiting lists;

(2) To extend clinic operating hours for specialists with very high patient-load; and

(3) To initiate an active discharge plan for patients no longer requiring specialist care for follow up by their family physicians.

These are, however, short-term palliative measures to deal with the high patient load at our SOCs. We need to do a more fundamental review of outpatient care by specialists and family physicians to achieve our objective of ensuring that patients receive care appropriate to their needs. Ideally, patients should turn to their family physicians first when they are ill. The family physicians will manage their medical condition with appropriate referrals and collaboration with the specialists. However, this is a complex issue which would involve patient education, ensuring high quality of family physicians, and review of the specialist referral system and fees charged. With the formation of the two networks, we will make a start by interfacing the polyclinics with the SOCs. Where the patient is adequately looked after by the polyclinics, it will be done there, and not at the SOCs. The networks will extend this collaboration to the private family physicians subsequently.

Dr Lily Neo (Kreta Ayer-Tanglin): Mr Speaker, Sir, I would like to declare that I am a doctor in private practice. May I ask the Minister why specialist outpatient clinics take appointments from any patient who so wishes through the phone and without any referral? Would not such practice run counter to the basic tenet of cost efficient and effective medicine? Surely not every sickness needs the care of specialists?

Mr Lim Hng Kiang: Mr Speaker, Sir, I agree entirely with the Member. Ideally, every patient should be managed by his family physician, and see the family physician first and if the condition requires the care of a specialist, then he should be referred to the specialist.

In Singapore, we do not enforce a compulsory referral system. We encourage referrals by the polyclinics and family GPs. We do not make it compulsory that if a patient is not referred by a private sector GP, he is not allowed to see the specialist. This is the situation today. I think we have to work on the education of the general public that they should see their family physicians first.

Dr Lily Neo: Would the Minister condone such referrals? Would not such referrals to specialist outpatient clinics cause an inappropriate use of medical facilities, and tax our public hospitals unnecessarily and frivolously?

Mr Lim Hng Kiang: Sir, compulsory referral is the ideal situation, but I think we want to be more flexible. In some cases, patients make appointment with the SOCs. In some cases, they are discharged from the hospitals and they have recovered. But if they think that something has recurred, they may want to make an appointment with the SOCs.

Today, we have adopted a more flexible approach. Unlike some countries, for example, they may insist on a compulsory referral. We have not reached the stage where we feel we need to insist on a compulsory referral situation.

Dr Lily Neo: Mr Speaker, Sir, I think the Minister did not get me correctly. I did not mean subsequent check-ups with the specialist where they can go back any time. I am talking about first-timers who just call up the outpatient clinics for an appointment and they just walk in to see the specialist.

Mr Lim Hng Kiang: I think the Member also did not get my answer. We do not enforce a compulsory referral system. Today, we are a bit more relaxed and we allow patients to refer themselves to the SOCs. Of course, we can adopt a compulsory referral system, meaning that if a patient is not referred by a private sector or a polyclinic GP, then he is not allowed to see the specialist. We can discuss and see whether that is indeed a better system. But today, the practice is that we allow Singaporeans the flexibility to go to the SOCs. In a way, I think it serves us well. Of course, it leads to a longer queue in the SOCs, but this is the trade-off. And Singaporeans seem prepared to accept this trade-off. If the feedback from all the Members is that Singaporeans want to have a compulsory referral system so that the queues in the SOCs will be shortened, I am prepared to consider that.

Dr Lily Neo: Can the Minister be more explicit in his reply, Sir? How do we expect patients to know the severity of their illnesses to warrant specialist care all the time if we just allow them self-referrals?

Mr Lim Hng Kiang: Sir, I think we have to be quite pragmatic about the situation. Singaporeans now serve the Net. They read all kinds of things on the Net. They do quite a bit of self-diagnosis. It is not the ideal thing to do. But when Singaporeans think that they have a problem with, say, incontinence, they would want to see a specialist first. They do not want to see their GP. Unless we say no, that is not allowed, and we change to a completely different regime, but today the rules allow them to go to the specialist and we accept that practice.

Mr J. B. Jeyaretnam (Non-Constituency Member): Mr Speaker, Sir, as I understand the Minister, he seems to attribute the long queues partly and for a greater part to the reluctance of people to go and see their own family physicians. Does he think that perhaps cost may be a factor in this? Has his Ministry ever considered getting private doctors into a scheme of voluntary service? The specialists outside could help and the Government could subsidise their fees, if they would only collect a certain amount from the patients. Has the Minister thought about this at all?

Mr Lim Hng Kiang: Mr Speaker, Sir, in my answer, I attributed to two main reasons for the long queues in the SOCs. One, is the tendency for people to want to see the specialists rather than their family physicians. And I agree with Dr Lily Neo that it is not the ideal practice. In fact, my Ministry encourages and is putting in place measures to encourage Singaporeans to see their family physicians first before seeing the specialist. The share of the workload between the family physicians and the specialists today is weighted to the specialist, because Singaporeans operate on the understanding that if they have a specific problem, they want to see a specialist before seeing the family physician.

The second point which I put in my answer is cost. Not that it is more expensive to see a specialist, but that the cost of seeing a specialist in our SOCs is not significantly higher than seeing a private sector GP. So the price differential between a private sector GP and SOC is not so big that Singaporeans will be encouraged to see a family physician first before seeing SOCs. Singaporeans can afford to see a specialist. The differential is not so high. So they go straight to the specialist.

The Member suggested getting doctors to provide voluntary services. I am sure if doctors are prepared to do so, we will work with them.

Mr Jeyaretnam: Have you suggested a plan?

Mr Lim Hng Kiang: We have to be quite realistic. The specialists in the private sector run their clinics. They charge private sector fees. Many of these specialists are involved in community work and we encourage them to do so. But to expect private sector specialists to run voluntary clinics on a fee or subsidised basis is something that is not so pragmatic.

Dr Tan Cheng Bock (Ayer Rajah): Mr Speaker, Sir, the Minister may not be aware that the practice of referral to see a specialist in the past was actually by way of a referral system through the general practitioner. My question is: is this change from the previous type of practice, where referral is through a general practitioner, a way for the restructured hospital doctors to get more income? That is one thing.

The other thing is this. Is the Minister aware that it is not affordability that should allow people to go and see a specialist on their own? I think it is the proper approach to the whole healthcare delivery system that the Ministry of Health is trying to put out. This means that patients should actually get the correct information, the correct direction from his general practitioner before seeing the appropriate specialist. They might see the wrong specialist.

Mr Lim Hng Kiang: I agree entirely with Dr Tan Cheng Bock. That is the ideal practice. We are actively encouraging it. But we have not made it compulsory that if a patient does not come with a referral, we will turn him away. So we are still flexible. If people do not come with a referral, we will, of course, counsel them and say, "Next time, please see your family physician." But we do not turn them away if they do not come with a referral.

I think it is a multi-faceted problem. At the same time, we must get our GPs and our family physicians to upgrade themselves, so that they offer such a good level of service that Singaporeans have a very high level of confidence that their overall medical needs can be looked after effectively by their family physicians. So it is not just making it compulsory for the patient to see the family physician. I think the family physicians themselves must also upgrade and do continuing medicare education, so that the level of expertise, the level of skills and the confidence can also be raised. Then I think we will reach a situation where people want to see their family physicians and not be forced to see their family physicians.

Dr Lily Neo: Sir, the Minister said earlier that he agreed with me. Does it mean that he is going to stop this type of referrals to the specialist outpatient clinic now?

Mr Lim Hng Kiang: Sir, I agree with the Member that it is an ideal case, but I am keeping to the present system of having the flexibility.

Dr Lily Neo: Sir, could the Minister assure this House that he will ascertain that there are no inappropriate practices existing in the hospital now, and whether he could avert other unhealthy policies in the future, basing it on the fact of cost efficient and effective medicine?

Mr Lim Hng Kiang: Mr Speaker, Sir, I have got no idea what is the Member talking about. Could she clarify?

Dr Lily Neo: I will clarify. Certain practices surely must be based on criteria that are sound. Therefore, all the policies that are being adopted by the Ministry of Health should be based on certain basic principles and one of which, of course, is cost efficient and effective medicine. Are we not using our national funds and public funds unnecessarily?

Mr Lim Hng Kiang: I agree entirely with Dr Neo that we want to have a cost effective health care system. But as I said, the fee structure of our SOCs today is not so significantly higher than the private sector family physician. Singaporeans now are better educated. They want choice and, therefore, we have not moved to a compulsory system. Today, they have a choice. We discourage them. We try to educate them. We try to work with the College of Family Physicians to upgrade themselves so that the public can have more confidence in the ability of their family physicians. It is not just one side of the coin. I think the family physicians must also show to the public that they can handle a wide range of problems when a patient sees them, if not, the patient would want to see a specialist straightaway.

Dr Tan Cheng Bock: Sir, is the Minister aware that referral to a specialist is different from what he is trying to tell us that if a general practitioner is very well equipped, then there is less chance of him referring patients to the specialist? Yes, I agree with that. But there are certain situations ---

Mr Speaker: Order. Dr Tan, can you ask your question?

Dr Tan Cheng Bock: The Minister's argument is that if the general practitioners are very well trained, there is no need for us to refer patients to specialists. That is the impression I get. Is that correct?

Mr Lim Hng Kiang: Mr Speaker, Sir, I did not say that. I said that the family physician should upgrade himself so that he understands the full range of problems that the patient is likely to raise with him and be in a position to provide the confidence to the patient that he will refer him to the correct specialist. It must be cost effective for the patient to do so. If the patient thinks he has got a specific problem and the cost is not so significant in going straight to see a specialist, he will want to do so. We could make it a compulsory system to say that you are not allowed to see a specialist until referred to by a GP. We can do that. But today we are not doing that. We encourage everybody to do that, but we are not making it a compulsory system. So I am keeping the system as it is without making it compulsory. If all the MPs feel that this is crucial and that it will reduce health care cost by forcing everybody to the GPs first, I must be satisfied that the GPs can undertake their role. I do not want to force patients to the GPs if they are not equipped to handle their requirements.

Mr Bernard Chen (West Coast): I agree with the Minister on the need to retain flexibility. I think we should leave it to the patient. But can the Minister confirm that the rates that the patients are paying to the specialists are, in fact, market rates so that there is no subsidy by the Government on all these consultations and there is no impact on the cost efficiency?

Mr Lim Hng Kiang: Sir, I thank the Member for trying to help me out. There is a tremendous subsidy in our SOCs. More than half of the patients going to our SOCs enjoy a subsidy of 65% and all the rents and GST of our SOCs are fully subvented by the Government. Even for those who do not enjoy the subsidy, the so-called private patients in our SOCs, the fees which they are charged in the SOCs are much lower than the private sector. Therefore, as I have explained in my answer, one can understand why many Singaporeans troop to the SOCs straightaway without seeing the family physician. I am not saying this is a good practice. I am saying we are trying to change it through better patient education, through upgrading of the physicians. But to have an edict to say that, tomorrow, nobody is allowed to go and see the SOCs unless they are referred to by a family physician is a step which I am not prepared to take for the time being.

Mr Speaker: I will allow one last question. Mr Low.

Mr Low Thia Khiang (Hougang): Judging from the Minister's answer, is the Minister contemplating increasing the fee of SOCs?

Mr Lim Hng Kiang: As I have explained in my answer, it is a multi-faceted problem and we have to look at all avenues to solve the problem. One of the avenues we have to consider is adjusting the fees so that it reflects the value of the specialist.