CENTRALISATION OF PODIATRY SERVICES FOR DIABETICS (Impact on the elderly)

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CENTRALISATION OF PODIATRY SERVICES FOR DIABETICS:

(Impact on the elderly): 10.

Mdm Halimah Yacob asked the Minister for Health whether centralising

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the provision of podiatry services for diabetics under one centre will affect convenience, accessibility and affordability for the elderly who frequently use the services.

Dr Balaji Sadasivan (for the Minister for Health): Mr Speaker, Sir, diabetes is a common problem among Singaporeans. About 9% of our adult population is diabetic.

To prevent foot complications, the blood sugar level must first be controlled. Doctors treating diabetics need to advise their patients to look after their feet carefully and take any complaints related to the feet seriously. The diabetics must then learn proper daily foot care. Foot screening and assessments are currently provided by trained nurses at our polyclinic.

These trained nurses are able to assess and educate on preventive measures, as well as provide treatment for our diabetic patients. Sometimes, patients develop complex ulcers and would require more specialised foot care. A podiatrist would then be needed. At other times, the problem may be even more complicated, and would need the expertise of an orthopaedic surgeon. Hospitals have podiatry and orthopaedic services.

The National Healthcare Group started a pilot project two years ago for podiatry service to be provided at its polyclinics. NHG polyclinics believed that the service would be cost-effective because they believed that they could market such services to the general practitioners. To introduce and popularise the service, they decided to charge the service at less than what it actually cost. However, despite this, the response was poor. The project ended in September 2004.

Podiatry services will continue to be available in the hospitals. Our hospitals

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and polyclinics will continue to pilot projects that try out new ideas.

Mdm Halimah Yacob: Sir, the Senior Minister of State said that one of the reasons why services are terminated at the polyclinics is because the response has been poor. I would like to ask the Senior Minister of State whether a survey has been done on why the people are not making use of the podiatry services at the polyclinic level. Is it because they are ignorant of the presence of such a service being provided at the polyclinics?

My second question, Sir, is whether cost-effectiveness should be the only criterion and basis in determining whether such a service should be provided at the polyclinics, bearing in mind that issues of convenience and accessibility are also essential, as such services are largely made use of by elderly people who may find going to the hospitals a lot more of a hassle for them.

Dr Balaji Sadasivan: Sir, we allow our clusters and hospitals to decide where to place services so that they can provide the services as efficiently as possible. For a podiatry service to function, it requires a certain critical mass of patients to come to that centre so that the service can be provided efficiently. When NHG decided to start podiatry service in one of its polyclinics as a pilot project, they made an assumption that there would be a majority of patients coming from general practitioners and others who referred their cases to their polyclinics. But it turned out that less than 1% of the patients seen at the podiatry clinics were cases referred to the polyclinics. This was despite the fact that they charged $8 for the podiatry service to try to popularise their service while other centres, like the NKF prevention centres, charged $25. They originally had planned to charge $20 for the service. But they brought it down to $8 to see if there was a demand for the service.

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So, if a service is not efficient and cannot be provided efficiently because the numbers are not there, then we allow our clusters to organise them in such a way that a critical number of patients are there. Currently, the podiatry services are in the restructured hospitals and if patients need these specialised services, they are referred to the hospitals. However, all our polyclinics still have nurses who are trained in foot care, which means that routine foot care for most diabetic patients would be looked after in the polyclinics. Only the specialised cases would go to the hospitals.

Mdm Halimah Yacob: Sir, I was told that in Geylang Polyclinic, they also provide podiatry services and they have been very well utilised. In fact, the frequency, in terms of podiatry services being provided, has to be increased. That suggests that such services are needed at the polyclinic level. Therefore, my question is: what are the reasons for the services not being well used in the other polyclinics? Has the Ministry made an attempt to find out the reasons? Is it because it is not well advertised?

My second question is this. The Minister recently said that as far as possible, we should try to keep people away from hospitals, suggesting that there should be more comprehensive services at the polyclinics. Is this decision then to centralise podiatry services at the hospitals a contradiction of this expressed policy?

Dr Balaji Sadasivan: The hon. Member may be mistaken. It is not a decision by the Ministry to centralise services. We are open to the clusters should they want to provide a service in the polyclinics if they think it makes economic sense for them to provide that service, if the numbers are there to justify it. So, should NHG again look at these numbers and

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want to try some other pilot projects where it can move services down to the polyclinic level, at Ministry level we will support it. And as a philosophy, we believe, as far as possible, we should bring services to as close to the patients as possible.

But this was a pilot project. A pilot project is a project that tries out new ideas to see if it works. In this particular case, NHG reported that the idea did not work. They have, therefore, stopped the project. They can review the project again. And if they think that there need to be changes before they introduce it, we will not stop them. But we do not micro-manage these services at the cluster or the hospital level. We leave it to our clusters and hospitals to decide how and when to best place services.

Dr Ong Seh Hong (Aljunied): Mr Speaker, Sir, the Senior Minister of State mentioned that actually the prevalence of diabetics is 9%, which means almost one in 10 Singaporeans in the community actually has diabetes. So I am very surprised to hear that there is no demand at the community level for these podiatry services.

The reason is that GPs are not referring cases to the polyclinics for diabetic foot care. Then should NHG find out what are the reasons GPs are not referring the cases to them? Is it because GPs are not aware? Or is it because the diabetic patients are not aware of the services? Or is it because GPs are afraid that when they refer cases to the polyclinics, the patients get snatched away by the polyclinics and they lose the patients?

Dr Balaji Sadasivan: I do not think that is the mental thinking of our practitioners. But what you have to understand is that there is a gradation of care. Things that are complicated are often seen by an orthopaedic surgeon. Things that are

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simple are often seen by the general practitioner. And in the same way, in the nursing care, nurses trained to look at diabetic feet take care of a lot of simple problems. When something is very complicated, like if there is a diabetic ulcer, then an orthopaedic surgeon would see it and would often get a podiatrist to look at the foot. And this is how care has been provided for many, many years. The innovation is taking the podiatrist who usually looks after complex problems and putting the podiatrist in a position where there are common problems, that means, normal uncomplicated feet are being seen. So, although 9% of adult Singaporeans may be diabetics, it does not mean that 9% of Singaporeans are walking round with a diabetic ulcer. So should we take someone with this additional skill and put him in a polyclinic setting to look at problems that may not require that degree of expertise? Because the skills of podiatry are between the skills of an orthopaedic surgeon and that of a trained nurse who looks after diabetic foot problems, the exact definition of where their skill should start and where their skill should end is not clearly defined.

So in providing this service, trying to define where the podiatry service should be, is a new idea. It is a new innovation. So that is why it is a pilot project. And in the whole scheme of things, it appeared that the general practitioners and the other polyclinic doctors did not see the need for it, that is, if they thought a problem was going to be a little bit more complicated than what they usually look after, they would rather send him to an orthopaedic surgeon to look at the foot and have the podiatrist see with the orthopaedic surgeon, rather than sending the patient to the podiatrists. So these are the details of medical practice that are best managed by people on the ground who know these things and will decide how to site these services better so that the patients get the best care, and ensure that is also provided in the most cost

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efficient manner. And this is something that is better done at that level than at the Ministry's level with the Ministry dictating that resources be placed at a physical location based on a theoretical model.

Mr Speaker: Last supplementary question on diabetes. Mdm Halimah.

Mdm Halimah Yacob: Thank you, Sir. The Senior Minister of State says that this is a matter that should be decided by NHG cluster, and not a matter for the Ministry to decide, as a matter of policy. At the same time, we also know that the Ministry has a policy that, as far as possible, people should be kept away from the hospitals, services should be consumed at the community level. So my question is: how does the Ministry then ensure consistency between what the clusters do, podiatry may be one service, and its overall policy on the manner in which healthcare is to be provided?

Dr Balaji Sadasivan: Sir, we encourage our clusters and the hospitals to move as many services as possible to the outpatient level. For example, there is going to be a pilot project to bring chemotherapy to the outpatient level. It is a pilot project because we do not know whether it is the best thing to do. Chemotherapy involves giving very strong drugs. There may be complications from it. There may be a need for other special services that the patient needs suddenly because he is getting chemotherapy. On paper, it looks like it is a project that could work and be tried out. But suppose we have chemotherapy services in the polyclinics and patients do not want the polyclinic chemotherapy because, every time there is a problem that they have to, besides going to the polyclinic, get referred to the hospital. And let us say, it happens once in three times, the patients may decide to have their treatment at a hospital setting than in a polyclinic

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setting. So to see whether such things would happen, we would run a pilot project.

When you run a pilot project, you must run it with an open mind, not on the basis that if I start a pilot project, its conclusion must be what I have decided at the start of the pilot project. So with podiatry service, it was a pilot project and the conclusion that was decided at the end of the pilot project was that it was not a good way of providing the service. So they have reverted to the previous way that they ran it. They may relook at it and see if they can better reorganise the foot services for diabetics, and we would encourage it. As a philosophy, we encourage our hospitals and clusters to bring as many services as possible as close to the polyclinic level and as close to the patients as possible.