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Primary healthcare system and practice characteristics in Singapore

Primary healthcare system and practice characteristics in Singapore It is crucial to adapt and improve the (primary) health care systems of countries to prepare for future patient profiles and their related needs. The main aim of this study was to acquire a comprehensive overview of the perceptions of primary care experts in Singapore about the state of primary care in Singapore, and to compare this nd with the state of primary care in other countries. Notwithstanding ranked 2 in terms of efficiency of health care, Singapore is facing significant health care challenges. Emails were sent to 85 experts, where they were asked to rate Singapore’s primary care system based on nine internationally adopted health system characteristics and six practice characteristics (response rate = 29%). The primary care system in Singapore received an average of 10.9 out of 30 possible points. Lowest ratings were given to: earnings of primary care physicians compared to specialists, requirement for 24 hr accessibility of primary care services, standard of family medicine in academic departments, reflection of community served by practices in patient lists, and the access to specialists without needing to be referred by primary care physicians. Singapore was categorized as a ‘low’ primary care country according to the experts. Keywords: Primary care, Practice characteristics, System characteristics, Quality, Singapore Background but in the community. However, the ageing population All health care systems across the world include primary and inevitable rising health care costs in Singapore sug- care. However, the level of development of primary care gests the necessity for an assessment of its current primary as part of the health care system varies substantially. In care system as a strong primary system could reduce cost strengthening primary care, lessons can be learned from and contribute to improvements in health [5]. In this other countries. This has become increasingly important paper, we sought the opinions of primary care experts in as various countries are instituting policies to hold primary Singapore where they rated the primary care system of the care practices accountable for managing chronic conditions country and to compare this with the state of primary care and meeting clinical standards. Also in Singapore this is the in other countries. case, the country ranked second amongst countries with In general, the primary care system should and has to most efficient health care [1]. become the mainstay in the long term management of Traditionally, health care systems of countries focused patients, such as those with diabetes, heart failure or on acute, episodic care, addressing the needs of inpatients. chronic lung diseases. Primary care can be defined as Many are now moving towards holistic care, to a health “that level of a health service system that provides entry care system that takes into consideration the ageing popu- into the system for all new needs and problems, provides lation and the corresponding increase in chronic diseases person focused care over time, provides care for all but [2-4]. Moreover, an ageing population would need regular very uncommon or unusual conditions, and co-ordinates care that should be available not only in acute hospitals, or integrates care provided elsewhere or by others” [6]. Primary health care would encompass primary medical * Correspondence: hwee_sing_khoo@nhg.com.sg treatment services, as well as education on preventive Saw Swee Hock School of Public Health, National University of Singapore, health care and health. However, it is not possible to create MD3, 16 Medical Drive, Singapore 117597, Singapore effective primary care systems using a “one size fits all” National Healthcare Group, Health Outcomes and Medical Education Research (HOMER), Singapore, Singapore approach, or put into practice one recipe, as systems are Full list of author information is available at the end of the article © 2014 Khoo et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Khoo et al. Asia Pacific Family Medicine 2014, 13:8 Page 2 of 8 http://www.apfmj.com/content/13/1/8 dependent on context. The development of a primary Gap between theory and practice care system would be shaped not only by the health A gap still remains between conceptual models of care problems the country faces, but also the country’s and existing provider practice despite a focus on im- historical background, and societal beliefs and values. proving primary health care systems to cope with the The strength of a country’s primary care system is hence increasing needs. It is however challenging to sustain reliant on how well the above primary care dimensions programs promoting integrated services to optimize develop within the context of a country’s health care resource utilization partly due to the difficulty in ac- system [7]. quiring the involvement and participation of health The increasing population, coupled with an ageing care professionals in the private sector, for instance, population, is a combined challenge for Singapore. The general practitioners (GPs). Interviews conducted by population has grown 25% over the past decade and will researchers in the United States with GPs revealed it is continue to grow. It is estimated that 20% of Singapor- difficult to care for elderly patients in practice environ- ean residents will be aged 65 and above by year 2030. By ments that do not provide the support and resources year 2100, Singapore is projected to have a median age required by such patients. The difficulty in caring for of 56.4 years, the highest of world population prospects. elderly patients was due to three main issues: 1) medical Comparatively, Japan has the highest median age of 45.9 complexity and chronicity as elderly patients are more in 2013, and is projected to have a median age of 51.8 in vulnerable to quick declines in their health conditions, th 2100, ranking 8 highest in the world [8]. This suggests 2) personal and interpersonal challenges, and 3) increased an increased and urgent demand for health care in the administrative burden [13]. Indeed, this reflects a lacuna future for Singapore as the elderly require more medical that should be filled, and highlights the need to provide care. Other than longer hospital stays, chronic diseases sufficient support to the primary care sector if their in- that require long term management from health care creased participation in caring for the elderly is viewed professionals also affect the elderly [9]. as a desired outcome in the future. It is crucial to continue to adapt and improve the In Singapore, primary health care is provided by govern- (primary) health care system in Singapore to prepare ment polyclinics and private general medical practitioner for future patient profiles and their related needs. It clinics. These health care professionals are usually the first would be more effective and sustainable to manage the point of contact with patients. The eighteen polyclinics chronic conditions of the elderly in the community provide about 20% of primary health care; while around than in acute hospitals in the long run. However, con- 2,000 private medical clinics provide the remaining 80%. tinuity of care appears to be low in Singapore, with There has however been an imbalance in the share of only 38.4% of residents indicating in a national health chronic disease management in the primary care sector in surveillance survey that they go to a regular family Singapore. Even though private general practitioners cur- doctor [10]. The main reason that patients seek treat- rently provide around 80% of primary care in Singapore, ment at the government run and subsidized polyclinic only 55% of chronic patients are managed by them, while is for chronic diseases [11]. This suggests that the costs polyclinics cope with the remaining 45% of chronically ill of services could be a factor for patients choosing subsi- patients [14]. dized services, since chronic disease management requires For primary care in Singapore, a complete range of follow-up consultations. The rise in health care costs is medical care for both acute and chronic medical condi- another area that has to be monitored to maintain cost- tions are provided by the polyclinics, including medical fa- effectiveness, so that health care may stay affordable for cilities and comprehensive health care services including everyone [12]. Therefore it is of utmost relevance to assess outpatient medical care, health screening, education, and the current state of the primary health care system and vaccinations, and x-ray and laboratory services, allowing practice characteristics in Singapore to see if and how it them to be a one-stop health centre for the community can be improved. [15]. Private clinics could be made up of solo, small group The main aim of this study was to acquire a quick and or large health care group practices. These private clinics comprehensive overview of the perceptions of primary usually do not possess onsite investigative facilities and are care experts in Singapore about the standard of primary not subsidized by the government, unlike the eighteen care in Singapore, and to compare this with the state in polyclinics. Secondary and tertiary care is provided by the other countries. This study is the first to assess the over- eight national specialty centers and seven acute public all strengths, weaknesses, and characteristics of the pri- hospitals. As of 2010, there are 8,797 doctors active in mary health care model as part of the Singapore health Singapore: 5,362 in the public sector and 3,435 in private practice [16]. care system. The results may be used as a basis for com- parison with other Asian countries and to inform future The main difference between the polyclinics and private health care reforms and research. clinics is that patients are assigned any doctor from a Khoo et al. Asia Pacific Family Medicine 2014, 13:8 Page 3 of 8 http://www.apfmj.com/content/13/1/8 common group of medical officers and family physi- of primary care encompasses both health system and prac- cians, while there is usually one main family physician tice characteristics [26]. The primary care framework has at private clinics, ensuring a higher possibility of con- been applied in the different countries with varying pri- tinuity of care. Polyclinic patients may also choose to mary care systems. These characteristics contribute to the see the doctors from the Family Physician Clinic in the strength of primary care in countries. The nine health sys- polyclinic which ensures them care continuity from the tem characteristics include: 1) how much the distribution same doctor, at a higher rate, but still considerably sub- of resources throughout the country is controlled by the sidized [17,18]. While polyclinics are highly subsidized system, 2) how primary care services are financed, 3) the by the government, there is also a heavy patient load main type of primary care practitioner in the country - a where the polyclinic doctors see 58 patients each day, higher percentage of generalists would receive a higher generally resulting in a much longer waiting time for score, 4) the percentage of physicians in primary care as consultation, compared to 30 patients per day for a pri- compared to specialty care, 5) the ratio of professional vate clinic family physician [19]. GPs worked an average earnings of primary care physicians in contrast to special- of 52.5 hours a week (7.5 hours a day) [20]. Despite the ists, 6) the extent of cost shared by patients, 7) reflection long waiting time and low care continuity, chronic dis- of community served by practices in patient lists, 8) 24 hr ease patients sought treatment mainly from government accessibility of primary care services, and 9) the academic polyclinics, burdening the limited subsidized resources strength of primary care or general practice departments. of the polyclinics. This is mainly due to the higher cost The six practice characteristics include: 1) first contact of care at GP clinics as compared to subsidized treat- care (where a patient needs to be referred to a specialist ments and medication at polyclinics [21]. through a primary care physician), 2) longitudinality (person-focused care over time), 3) comprehensiveness Health care financing in Singapore of care, 4) coordination of care, 5) family-centeredness Singapore adopts a mixed health financing system that or care, and 6) community orientation (practitioners use emphasizes individual responsibility and an attempt to community data to plan or organize services, or identify avoid moral hazards that could be faced with pure na- problems). tional insurance schemes when health care is provided Following Starfield and Lei’s [28] paper, the information for free. Health care is funded jointly by the government on the nine health system characteristics and six practice and the individual through insurance, revenue from taxes, characteristics were acquired from primary care system as well as savings from each individual’s medical savings experts who have published in peer-reviewed journals on account (i.e. Medisave) [22]. To ensure that basic medical the primary care system in Singapore and/or general care is accessible to everyone, public hospitals, polyclinics, practitioners with more than 10 years of experience. as well as nursing homes are directly subsidized by the The primary healthcare experts were selected from both government (up to 80% of the total bill in acute public private and public sectors, where 32% are female. hospital wards) [23]. Emails were sent to 85 experts where 25 responses Singapore’s health care outcomes are comparable to were received, a 29% response rate. Respondents were other developed nations, considering that around 4% of allowed to mail hardcopy responses to the authors to Singapore’s Gross Domestic Product (GDP) is spent an- maintain their anonymity. As of 31 March 2012, there nually on health care as compared to the United States are 1572 registered members in the College of Family (17.9% of GDP) and the United Kingdom (9.6% of GDP) Physicians Singapore [29]. [24]. Singapore’s life expectancy from birth in 2011 is We corresponded individually with these experts currently 82 years for both sexes, compared to the re- through email to acquire ratings that were independent gional average of 75 years, and the global average of from each other. A standardized email was sent to all the 68 years old [25]. experts with step-by-step instructions regarding the rating At the polyclinics, Singapore citizens less than 18 years process. For each characteristic, comprehensive and expli- of age and above 65 receive up to 75% concessions in cit criteria were included on when the expert should as- consultation and treatment fees, while all other Singapore sign 2, 1, or 0 points. A characteristic is rated with a score citizens are given a 50% concession for their fees. of 2 for ‘high’ level of development, 1 for ‘moderate’ level of development, or 0 for ‘absence or low’ level of develop- Methods ment. The most frequently assigned score was selected as Our study made use of the primary care framework by the final score to achieve inter-rater agreement [6]. Fur- Starfield [26]. The framework has been administered in ther, the average sum score was calculated by dividing many countries including the United Kingdom, Denmark, the total sum scores by the number of respondents. The Netherlands, Japan, Australia, Sweden, the United Descriptive statistics were used to calculate overall States, Austria, and Germany [27]. Starfield’s framework scores using Microsoft Office Excel 2007. Approval was Khoo et al. Asia Pacific Family Medicine 2014, 13:8 Page 4 of 8 http://www.apfmj.com/content/13/1/8 attained from the Institutional Review Board of National for access to specialists via referral from primary care are University Hospital System for our study. considered most consistent with the first-contact aspect of primary care. The ability of patient to self-refer to special- Results ists is considered conducive to a speciality-oriented health For all but one item, the majority of experts rated items system, and is rated low. Community orientation describes having low level of development (6 items) or modest level whether the doctor actively seeks to understand important of development (5 items) and three items were rated of health problems in the neighborhood. Low ratings are low or modest level by an equal number of respondents. assigned when there is little or no attempt to use data Lowest ratings were given to: earnings of primary care from the practice to plan or organize services and identify physicians as compared to specialists, requirement for priorities for care. 24 hr accessibility of primary care services, standard of family medicine in academic departments, reflection of Discussion community served by practices in patient lists, and “first The results of our preliminary study suggest that improve- contact” (the need to be referred to a specialist by the ments could be made to the primary care system in primary care physician). Most experts rated main type Singapore, and much more work needs to be done. Based of primary care practitioner the highest, where the high on the average sum score (10.9, over a total of 30 possible score of 2 is given if the main type of primary care prac- points), Singapore can overall be considered a ‘low pri- titioner in the country are generalists, while the low mary care country’ when compared with other countries score of 0 is given if the main type of primary care prac- that utilized the same assessment tool [28]. See Table 3 titioners in the country do not focus solely on family [28] comparing Singapore with other countries [28]. medicine. Table 1 presents the frequency of scores by Among the 15 dimensions measured, six had scores of the experts. Table 2 displays the health care system and zero. These dimensions included measures that point to primary care practice characteristics, along with an ab- the status of primary care compared to specialist care, breviated description of the characteristics, followed by accessibility of care (24 hrs), as well as measures of ac- the final score. The descriptions of the characteristics cess and care continuity. The latter group of measures were derived from literature about Singapore’s health are particularly pertinent to the care of patients with care system as well as comments from the experts. chronic and complex conditions. The inevitable increase Singapore received an average of 10.9 out of 30 possible in the elderly population with chronic diseases will place points (271/25). Nine characteristics were rated as ‘0’ and pressure on the health care system. If the primary care one characteristic received a high rating of 2 points. The system, as reflected by the low scores in care continuity, health system characteristics were rated an average of 6.3 does not develop in the areas of care continuity, care for out of 18 possible points by the experts (157/25). Under the elder patients with chronic diseases will likely be the “type of practitioner” system characteristic, generalists suboptimal. arethe main type of primarycarepractitioners in Regarding the low score of 24 hr accessibility of care Singapore, and this characteristic received a high rating in Singapore, the US and Canada similarly do not have of “2” from the experts. The practice characteristics policies for after-hours coverage [30]. In a 2012 inter- were rated an average of 4.6 out of 12 possible points by national survey of primary care doctors conducted by the experts (114/25). The practice characteristics of “first the Commonwealth Fund, only 34 percent of US prac- contact” and “community orientation” both received low tices have arrangements for their patients to see their scores of “0” from the experts. First contact implies that doctors or nurses without going to a hospital emergency decisions about the need for specialty services are made department. This is in contrast to countries such as the after consulting the primary care physician. Requirements Netherlands, New Zealand, and the UK, where more Table 1 Frequency of scores by experts Item# 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 2 points 3 4 13 8 2 1 0 0 1 3 1 7 1 2 3 1 point 14 15 11 15 3 12 698 10 12 16 12 23 8 0 points 8 6 1 2 20 12 19 16 16 12 12 2 12 014 Final score (mode) 1 1 2 1 0 - 0 0 0 0 - 1 - 1 0 Sum score (Item x point) 20 23 37 31 7 14 6 9 10 16 13 30 14 27 14 Average (sum score/25) 0.8 0.92 1.48 1.24 0.28 0.56 0.24 0.36 0.4 0.64 0.56 1.2 0.56 1.08 0.56 Total sum score 10.9 Bold numbers represent tied scores. Khoo et al. Asia Pacific Family Medicine 2014, 13:8 Page 5 of 8 http://www.apfmj.com/content/13/1/8 Table 2 Primary care health and system characteristics scores Item number Characteristics Description of characteristic Final score Health care system characteristics 1 Type of system Polyclinic locations are regulated by the government to provide sufficient care 1 around Singapore 2 Financing Partly tax based. A combination of government subsidies, an individual 1 compulsory medical savings account, and a low cost insurance scheme 3 Type of practitioner GPs in the country are mainly generalists focusing on family medicine, and not 2 specialists in other disciplines. 4 Percentage who are specialists 38.77% of doctors in Singapore are specialists [16], indicative of an orientation 1 toward primary care 5 Primary care physicians Specialists earn more than primary care physicians 0 earnings compared to specialists 6 Cost sharing A combination of government subsidies, an individual compulsory medical - savings account, and a low cost insurance scheme 7 Patient Lists There is no requirement to sign up with a personal GP. 0 8 Requirement for 24-hour No regulated requirement for 24 hour primary healthcare. Patients may visit 0 coverage 24 hr A&E (accident and emergency) departments when necessary. 9 Standard of family medicine Family medicine in Singapore is given low priority. 0 academic departments Practice characteristics 10 First contact Patients may choose to be referred by a primary care physician or choose to go 0 to a private specialist directly. 11 Longitudinality Patients do not get to select their doctors when they visit a polyclinic, and - there is no system to enroll patients (patient lists) for private general practitioners. 12 Comprehensiveness Polyclinics and private group GPs have a comprehensive range of services and 1 facilities. Community Health Centres provide off-site ancillary support services to GPs without full facilities. 13 Coordination Poor coordination and information transfer between primary, secondary and - tertiary levels of healthcare 14 Family-centeredness Family members are informed of medical decisions in hospitals 1 15 Community orientation Data from practitioners not analyzed or used to identify priorities of care for the 0 community than 90 percent of physicians reported having after-hours report with related health information will be sent to coverage in place [31]. The low percentage reported by them after their patients saw a specialist, less than 20 Canadian and US physicians suggest that after-hours percent of physicians in the US, the Netherlands, and coverage develops slowly if it depends on solo practices, Germany reported that they received a relevant health [32] as compared to requirements such as national help report from the specialist [31]. lines in the UK, and payment incentives to physicians to In Singapore, there is no patient list system and pa- provide after-hours care in Australia. tients have the freedom of selecting any doctor they Care coordination is a major challenge for primary wish to see. Patients therefore have direct access to spe- care systems, especially with the increase in the elderly cialist care. Such health systems are described as more population and the attention and long term management expensive as compared to a system where patients have required for chronic diseases that are commonly afflict to be referred through the primary care system [33]. the elderly. While this dimension received a tied score This is also related to the practice characteristic of “first between 0 and 1 from the primary care experts in access”, where the primary care system is rated well if Singapore, the 2012 Commonwealth Fund survey re- patients need to be referred by primary care physicians vealed that care is generally not well coordinated in the to a specialist. Looking at this from the perspective of ten countries surveyed. Besides physicians from France health care finance, the variation in our findings as well and Switzerland, where more than 50 percent said that a as the comments provided by the experts indicate that Khoo et al. Asia Pacific Family Medicine 2014, 13:8 Page 6 of 8 http://www.apfmj.com/content/13/1/8 Table 3 Primary care scores Country System score Practice score Total score Total average score (Characteristics 1–9) (Characteristics 10–15) (max. 30) (max. 2) Low primary care Belgium 5.6 0.0 5.6 0.4 France 5.0 0.0 5.0 0.3 Germany 6.0 0.0 6.0 0.4 United States 4.0 1.5 5.5 0.4 Intermediate primary care Australia 10.0 7.0 17.0 1.1 Canada 11.5 6.0 17.5 1.2 Japan 8.5 4.0 12.5 0.8 Sweden 10.0 4.0 14.0 0.9 High primary care Denmark 16.0 10.0 26.0 1.7 Finland 15.0 7.0 22.0 1.5 The Netherlands 13.0 10.0 23.0 1.5 Spain 12.5 8.0 20.5 1.4 United Kingdom 18.0 11.0 29.0 1.9 Scores in Table 3 are obtained from Starfield & Shi [28]. there is not a consistent judgement on what might be One example of the FMC initiative would be Frontier the right model of health care finance in Singapore. In a FMC (a private GP clinic) in Singapore. In collaboration sense, Singapore has shown that it is possible to achieve with the National University Health System (NUHS), it an efficient health care system at lower cost. In terms of is applying the Patient Centered Medical Home concept Starfield’smodel,the “financing” health system character- (PCMH) [36] in Singapore, based on AAFP’s (American istic could be revised to accommodate more permutations Academy of Family Physicians) joint principles of PCMH of health care financing. Different financing combinations [37]. It is expected that patients with chronic conditions might be more suitable for different countries based on (i.e. diabetes, hypertension, stroke and asthma) who no every country’s unique characteristics. The health care sys- longer require specialist care can enjoy shorter waiting tem of Singapore is currently in transition, [34] and in line time when they seek outpatient treatment and follow up with this, the Ministry of Health recently presented a at the Frontier FMC in the community. Frontier FMC ‘Health care 2020’ Masterplan comprising of a set of strat- was opened in the first week of April 2013 [38]. Besides egies to guide Singapore towards an inclusive health care encouraging information transfer between GPs and spe- system for the future [35]. The aim is to enhance accessi- cialists, at the same time, through team based care, it is bility, quality, and affordability of health care for all people expected to slow down disease progression, reduce com- in Singapore, and the further development of primary care plication rates and in turn, minimize referrals to hospi- is a part of this strategy. Besides the plan to increase sub- tals. Since it is the first implementation of the PCMH in sidies from the government for chronic outpatient treat- Singapore it is yet unclear how the proposed solutions to ment at GPs for low-income and middle-income families, improve chronic illness care will play out. Important most significantly, three new primary care models will get components of the new approach include: team based developed: Family Medicine Clinics (FMCs), Community care, electronic health record shared between NUHS Health Centres (CHCs) and Medical Centres (MCs). The and Frontier FMC, and a referral system for those with different models are meant to be all encompassing to cater complex care needs. to patients with different profiles and preferences. This Finally, another two characteristics that scored zero (primary care physician earnings as compared to specialist, is a step towards improving system and practice charac- teristics such as “patient lists”, “coordination”, “compre- and family medicine as academic department) indicate the hensiveness”,and “family centeredness”.Itisexpected need to raise the profile of family medicine and the role primary care physicians play in overall health care delivery. that with these models more patients can be cared for outside the hospitals’ specialist outpatient clinics by Even with an optimal health care finance mechanism and GPs in the community. an integrated care system in place, the relatively low status Khoo et al. Asia Pacific Family Medicine 2014, 13:8 Page 7 of 8 http://www.apfmj.com/content/13/1/8 of primary care education and research will impede the According to primary care experts from Singapore, the development of a stronger primary care delivery system strength of its primary care system is low. This is an im- in Singapore. portant concern considering the developments in its Thereareacoupleof limitations we should note for population. The study provided us with a comprehensive this study. First, the response rate to our study was overview of the standard of primary care in Singapore as relatively small. Despite the relatively small response, perceived by primary care experts in Singapore, and also the variability in scores between respondents suggests allowed us to compare the state of primary care in that the study group varies in their opinions about pri- Singapore with other countries. The results can be mary care as one would expect (from previous studies used as a basis to inform future health care reforms in other countries). Second, Singapore’sscorescould and research, for comparison with other (East) Asian not be compared directly with the scores from other countries, and to assess trends in time if the survey countriesasthere were differences in opinions about would be applied again in the future. the characteristics, unlike the scores attained by Star- Competing interests field and Shi [28] where it was noted that informants The authors declare that they have no competing interests. had “no disagreements” in the scoring of the characteris- tics. This was also the reason we decided to use average Authors’ contributions sum scores instead of relying on the modal score. Our KHS contributed in the conception and design of the survey, data collection, drafting the manuscript and making critical revisions. LYW contributed in the scores for both system and practice characteristics were conception and design, data collection and critical revisions. H Vrijhoef also attained primarily from experts in primary care in contributed in conception and design, and critical revisions. All authors have Singapore, while the system scores in Starfield & Shi [28] given final approval of the version to be published and agree to be accountable for all aspects of the work. were mainly obtained from the Organization for Economic Cooperation and Development (OECD) [39]. Author details The assessment of health care quality, especially re- Saw Swee Hock School of Public Health, National University of Singapore, MD3, 16 Medical Drive, Singapore 117597, Singapore. RAND Corporation, garding chronic diseases, has more often been based on Santa Monica, California. Scientific Centre for Care and Welfare (Tranzo), the perspectives of the care provider or the health care Tilburg University, Tilburg, The Netherlands. National Healthcare Group, Health institution than the experience of the patient [40]. The Outcomes and Medical Education Research (HOMER), Singapore, Singapore. terms patient perception and patient satisfaction have Received: 8 November 2013 Accepted: 27 June 2014 often been used in place of each other, [41] but it should Published: 19 July 2014 be noted that satisfaction is one way of describing and not the only illustration of a perception. Despite this, References 1. Bloomberg.com: 2013. Retrieved from: http://www.bloomberg.com/visual- patient satisfaction has been a main feature in quality data/best-and-worst/most-efficient-health-care-countries. Accessed 19 care assessment studies. Annual patient satisfaction sur- October 2013. veys have been conducted in Singapore, but these sur- 2. Bodenheimer T, Wagner EH, Grumbach K: Improving primary care for patients with chronic illness. JAMA 2002, 288(14):1775–1779. veys are usually unable to capture the full spectrum 3. 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Primary healthcare system and practice characteristics in Singapore

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Springer Journals
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Copyright © 2014 by Khoo et al.; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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Abstract

It is crucial to adapt and improve the (primary) health care systems of countries to prepare for future patient profiles and their related needs. The main aim of this study was to acquire a comprehensive overview of the perceptions of primary care experts in Singapore about the state of primary care in Singapore, and to compare this nd with the state of primary care in other countries. Notwithstanding ranked 2 in terms of efficiency of health care, Singapore is facing significant health care challenges. Emails were sent to 85 experts, where they were asked to rate Singapore’s primary care system based on nine internationally adopted health system characteristics and six practice characteristics (response rate = 29%). The primary care system in Singapore received an average of 10.9 out of 30 possible points. Lowest ratings were given to: earnings of primary care physicians compared to specialists, requirement for 24 hr accessibility of primary care services, standard of family medicine in academic departments, reflection of community served by practices in patient lists, and the access to specialists without needing to be referred by primary care physicians. Singapore was categorized as a ‘low’ primary care country according to the experts. Keywords: Primary care, Practice characteristics, System characteristics, Quality, Singapore Background but in the community. However, the ageing population All health care systems across the world include primary and inevitable rising health care costs in Singapore sug- care. However, the level of development of primary care gests the necessity for an assessment of its current primary as part of the health care system varies substantially. In care system as a strong primary system could reduce cost strengthening primary care, lessons can be learned from and contribute to improvements in health [5]. In this other countries. This has become increasingly important paper, we sought the opinions of primary care experts in as various countries are instituting policies to hold primary Singapore where they rated the primary care system of the care practices accountable for managing chronic conditions country and to compare this with the state of primary care and meeting clinical standards. Also in Singapore this is the in other countries. case, the country ranked second amongst countries with In general, the primary care system should and has to most efficient health care [1]. become the mainstay in the long term management of Traditionally, health care systems of countries focused patients, such as those with diabetes, heart failure or on acute, episodic care, addressing the needs of inpatients. chronic lung diseases. Primary care can be defined as Many are now moving towards holistic care, to a health “that level of a health service system that provides entry care system that takes into consideration the ageing popu- into the system for all new needs and problems, provides lation and the corresponding increase in chronic diseases person focused care over time, provides care for all but [2-4]. Moreover, an ageing population would need regular very uncommon or unusual conditions, and co-ordinates care that should be available not only in acute hospitals, or integrates care provided elsewhere or by others” [6]. Primary health care would encompass primary medical * Correspondence: hwee_sing_khoo@nhg.com.sg treatment services, as well as education on preventive Saw Swee Hock School of Public Health, National University of Singapore, health care and health. However, it is not possible to create MD3, 16 Medical Drive, Singapore 117597, Singapore effective primary care systems using a “one size fits all” National Healthcare Group, Health Outcomes and Medical Education Research (HOMER), Singapore, Singapore approach, or put into practice one recipe, as systems are Full list of author information is available at the end of the article © 2014 Khoo et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Khoo et al. Asia Pacific Family Medicine 2014, 13:8 Page 2 of 8 http://www.apfmj.com/content/13/1/8 dependent on context. The development of a primary Gap between theory and practice care system would be shaped not only by the health A gap still remains between conceptual models of care problems the country faces, but also the country’s and existing provider practice despite a focus on im- historical background, and societal beliefs and values. proving primary health care systems to cope with the The strength of a country’s primary care system is hence increasing needs. It is however challenging to sustain reliant on how well the above primary care dimensions programs promoting integrated services to optimize develop within the context of a country’s health care resource utilization partly due to the difficulty in ac- system [7]. quiring the involvement and participation of health The increasing population, coupled with an ageing care professionals in the private sector, for instance, population, is a combined challenge for Singapore. The general practitioners (GPs). Interviews conducted by population has grown 25% over the past decade and will researchers in the United States with GPs revealed it is continue to grow. It is estimated that 20% of Singapor- difficult to care for elderly patients in practice environ- ean residents will be aged 65 and above by year 2030. By ments that do not provide the support and resources year 2100, Singapore is projected to have a median age required by such patients. The difficulty in caring for of 56.4 years, the highest of world population prospects. elderly patients was due to three main issues: 1) medical Comparatively, Japan has the highest median age of 45.9 complexity and chronicity as elderly patients are more in 2013, and is projected to have a median age of 51.8 in vulnerable to quick declines in their health conditions, th 2100, ranking 8 highest in the world [8]. This suggests 2) personal and interpersonal challenges, and 3) increased an increased and urgent demand for health care in the administrative burden [13]. Indeed, this reflects a lacuna future for Singapore as the elderly require more medical that should be filled, and highlights the need to provide care. Other than longer hospital stays, chronic diseases sufficient support to the primary care sector if their in- that require long term management from health care creased participation in caring for the elderly is viewed professionals also affect the elderly [9]. as a desired outcome in the future. It is crucial to continue to adapt and improve the In Singapore, primary health care is provided by govern- (primary) health care system in Singapore to prepare ment polyclinics and private general medical practitioner for future patient profiles and their related needs. It clinics. These health care professionals are usually the first would be more effective and sustainable to manage the point of contact with patients. The eighteen polyclinics chronic conditions of the elderly in the community provide about 20% of primary health care; while around than in acute hospitals in the long run. However, con- 2,000 private medical clinics provide the remaining 80%. tinuity of care appears to be low in Singapore, with There has however been an imbalance in the share of only 38.4% of residents indicating in a national health chronic disease management in the primary care sector in surveillance survey that they go to a regular family Singapore. Even though private general practitioners cur- doctor [10]. The main reason that patients seek treat- rently provide around 80% of primary care in Singapore, ment at the government run and subsidized polyclinic only 55% of chronic patients are managed by them, while is for chronic diseases [11]. This suggests that the costs polyclinics cope with the remaining 45% of chronically ill of services could be a factor for patients choosing subsi- patients [14]. dized services, since chronic disease management requires For primary care in Singapore, a complete range of follow-up consultations. The rise in health care costs is medical care for both acute and chronic medical condi- another area that has to be monitored to maintain cost- tions are provided by the polyclinics, including medical fa- effectiveness, so that health care may stay affordable for cilities and comprehensive health care services including everyone [12]. Therefore it is of utmost relevance to assess outpatient medical care, health screening, education, and the current state of the primary health care system and vaccinations, and x-ray and laboratory services, allowing practice characteristics in Singapore to see if and how it them to be a one-stop health centre for the community can be improved. [15]. Private clinics could be made up of solo, small group The main aim of this study was to acquire a quick and or large health care group practices. These private clinics comprehensive overview of the perceptions of primary usually do not possess onsite investigative facilities and are care experts in Singapore about the standard of primary not subsidized by the government, unlike the eighteen care in Singapore, and to compare this with the state in polyclinics. Secondary and tertiary care is provided by the other countries. This study is the first to assess the over- eight national specialty centers and seven acute public all strengths, weaknesses, and characteristics of the pri- hospitals. As of 2010, there are 8,797 doctors active in mary health care model as part of the Singapore health Singapore: 5,362 in the public sector and 3,435 in private practice [16]. care system. The results may be used as a basis for com- parison with other Asian countries and to inform future The main difference between the polyclinics and private health care reforms and research. clinics is that patients are assigned any doctor from a Khoo et al. Asia Pacific Family Medicine 2014, 13:8 Page 3 of 8 http://www.apfmj.com/content/13/1/8 common group of medical officers and family physi- of primary care encompasses both health system and prac- cians, while there is usually one main family physician tice characteristics [26]. The primary care framework has at private clinics, ensuring a higher possibility of con- been applied in the different countries with varying pri- tinuity of care. Polyclinic patients may also choose to mary care systems. These characteristics contribute to the see the doctors from the Family Physician Clinic in the strength of primary care in countries. The nine health sys- polyclinic which ensures them care continuity from the tem characteristics include: 1) how much the distribution same doctor, at a higher rate, but still considerably sub- of resources throughout the country is controlled by the sidized [17,18]. While polyclinics are highly subsidized system, 2) how primary care services are financed, 3) the by the government, there is also a heavy patient load main type of primary care practitioner in the country - a where the polyclinic doctors see 58 patients each day, higher percentage of generalists would receive a higher generally resulting in a much longer waiting time for score, 4) the percentage of physicians in primary care as consultation, compared to 30 patients per day for a pri- compared to specialty care, 5) the ratio of professional vate clinic family physician [19]. GPs worked an average earnings of primary care physicians in contrast to special- of 52.5 hours a week (7.5 hours a day) [20]. Despite the ists, 6) the extent of cost shared by patients, 7) reflection long waiting time and low care continuity, chronic dis- of community served by practices in patient lists, 8) 24 hr ease patients sought treatment mainly from government accessibility of primary care services, and 9) the academic polyclinics, burdening the limited subsidized resources strength of primary care or general practice departments. of the polyclinics. This is mainly due to the higher cost The six practice characteristics include: 1) first contact of care at GP clinics as compared to subsidized treat- care (where a patient needs to be referred to a specialist ments and medication at polyclinics [21]. through a primary care physician), 2) longitudinality (person-focused care over time), 3) comprehensiveness Health care financing in Singapore of care, 4) coordination of care, 5) family-centeredness Singapore adopts a mixed health financing system that or care, and 6) community orientation (practitioners use emphasizes individual responsibility and an attempt to community data to plan or organize services, or identify avoid moral hazards that could be faced with pure na- problems). tional insurance schemes when health care is provided Following Starfield and Lei’s [28] paper, the information for free. Health care is funded jointly by the government on the nine health system characteristics and six practice and the individual through insurance, revenue from taxes, characteristics were acquired from primary care system as well as savings from each individual’s medical savings experts who have published in peer-reviewed journals on account (i.e. Medisave) [22]. To ensure that basic medical the primary care system in Singapore and/or general care is accessible to everyone, public hospitals, polyclinics, practitioners with more than 10 years of experience. as well as nursing homes are directly subsidized by the The primary healthcare experts were selected from both government (up to 80% of the total bill in acute public private and public sectors, where 32% are female. hospital wards) [23]. Emails were sent to 85 experts where 25 responses Singapore’s health care outcomes are comparable to were received, a 29% response rate. Respondents were other developed nations, considering that around 4% of allowed to mail hardcopy responses to the authors to Singapore’s Gross Domestic Product (GDP) is spent an- maintain their anonymity. As of 31 March 2012, there nually on health care as compared to the United States are 1572 registered members in the College of Family (17.9% of GDP) and the United Kingdom (9.6% of GDP) Physicians Singapore [29]. [24]. Singapore’s life expectancy from birth in 2011 is We corresponded individually with these experts currently 82 years for both sexes, compared to the re- through email to acquire ratings that were independent gional average of 75 years, and the global average of from each other. A standardized email was sent to all the 68 years old [25]. experts with step-by-step instructions regarding the rating At the polyclinics, Singapore citizens less than 18 years process. For each characteristic, comprehensive and expli- of age and above 65 receive up to 75% concessions in cit criteria were included on when the expert should as- consultation and treatment fees, while all other Singapore sign 2, 1, or 0 points. A characteristic is rated with a score citizens are given a 50% concession for their fees. of 2 for ‘high’ level of development, 1 for ‘moderate’ level of development, or 0 for ‘absence or low’ level of develop- Methods ment. The most frequently assigned score was selected as Our study made use of the primary care framework by the final score to achieve inter-rater agreement [6]. Fur- Starfield [26]. The framework has been administered in ther, the average sum score was calculated by dividing many countries including the United Kingdom, Denmark, the total sum scores by the number of respondents. The Netherlands, Japan, Australia, Sweden, the United Descriptive statistics were used to calculate overall States, Austria, and Germany [27]. Starfield’s framework scores using Microsoft Office Excel 2007. Approval was Khoo et al. Asia Pacific Family Medicine 2014, 13:8 Page 4 of 8 http://www.apfmj.com/content/13/1/8 attained from the Institutional Review Board of National for access to specialists via referral from primary care are University Hospital System for our study. considered most consistent with the first-contact aspect of primary care. The ability of patient to self-refer to special- Results ists is considered conducive to a speciality-oriented health For all but one item, the majority of experts rated items system, and is rated low. Community orientation describes having low level of development (6 items) or modest level whether the doctor actively seeks to understand important of development (5 items) and three items were rated of health problems in the neighborhood. Low ratings are low or modest level by an equal number of respondents. assigned when there is little or no attempt to use data Lowest ratings were given to: earnings of primary care from the practice to plan or organize services and identify physicians as compared to specialists, requirement for priorities for care. 24 hr accessibility of primary care services, standard of family medicine in academic departments, reflection of Discussion community served by practices in patient lists, and “first The results of our preliminary study suggest that improve- contact” (the need to be referred to a specialist by the ments could be made to the primary care system in primary care physician). Most experts rated main type Singapore, and much more work needs to be done. Based of primary care practitioner the highest, where the high on the average sum score (10.9, over a total of 30 possible score of 2 is given if the main type of primary care prac- points), Singapore can overall be considered a ‘low pri- titioner in the country are generalists, while the low mary care country’ when compared with other countries score of 0 is given if the main type of primary care prac- that utilized the same assessment tool [28]. See Table 3 titioners in the country do not focus solely on family [28] comparing Singapore with other countries [28]. medicine. Table 1 presents the frequency of scores by Among the 15 dimensions measured, six had scores of the experts. Table 2 displays the health care system and zero. These dimensions included measures that point to primary care practice characteristics, along with an ab- the status of primary care compared to specialist care, breviated description of the characteristics, followed by accessibility of care (24 hrs), as well as measures of ac- the final score. The descriptions of the characteristics cess and care continuity. The latter group of measures were derived from literature about Singapore’s health are particularly pertinent to the care of patients with care system as well as comments from the experts. chronic and complex conditions. The inevitable increase Singapore received an average of 10.9 out of 30 possible in the elderly population with chronic diseases will place points (271/25). Nine characteristics were rated as ‘0’ and pressure on the health care system. If the primary care one characteristic received a high rating of 2 points. The system, as reflected by the low scores in care continuity, health system characteristics were rated an average of 6.3 does not develop in the areas of care continuity, care for out of 18 possible points by the experts (157/25). Under the elder patients with chronic diseases will likely be the “type of practitioner” system characteristic, generalists suboptimal. arethe main type of primarycarepractitioners in Regarding the low score of 24 hr accessibility of care Singapore, and this characteristic received a high rating in Singapore, the US and Canada similarly do not have of “2” from the experts. The practice characteristics policies for after-hours coverage [30]. In a 2012 inter- were rated an average of 4.6 out of 12 possible points by national survey of primary care doctors conducted by the experts (114/25). The practice characteristics of “first the Commonwealth Fund, only 34 percent of US prac- contact” and “community orientation” both received low tices have arrangements for their patients to see their scores of “0” from the experts. First contact implies that doctors or nurses without going to a hospital emergency decisions about the need for specialty services are made department. This is in contrast to countries such as the after consulting the primary care physician. Requirements Netherlands, New Zealand, and the UK, where more Table 1 Frequency of scores by experts Item# 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 2 points 3 4 13 8 2 1 0 0 1 3 1 7 1 2 3 1 point 14 15 11 15 3 12 698 10 12 16 12 23 8 0 points 8 6 1 2 20 12 19 16 16 12 12 2 12 014 Final score (mode) 1 1 2 1 0 - 0 0 0 0 - 1 - 1 0 Sum score (Item x point) 20 23 37 31 7 14 6 9 10 16 13 30 14 27 14 Average (sum score/25) 0.8 0.92 1.48 1.24 0.28 0.56 0.24 0.36 0.4 0.64 0.56 1.2 0.56 1.08 0.56 Total sum score 10.9 Bold numbers represent tied scores. Khoo et al. Asia Pacific Family Medicine 2014, 13:8 Page 5 of 8 http://www.apfmj.com/content/13/1/8 Table 2 Primary care health and system characteristics scores Item number Characteristics Description of characteristic Final score Health care system characteristics 1 Type of system Polyclinic locations are regulated by the government to provide sufficient care 1 around Singapore 2 Financing Partly tax based. A combination of government subsidies, an individual 1 compulsory medical savings account, and a low cost insurance scheme 3 Type of practitioner GPs in the country are mainly generalists focusing on family medicine, and not 2 specialists in other disciplines. 4 Percentage who are specialists 38.77% of doctors in Singapore are specialists [16], indicative of an orientation 1 toward primary care 5 Primary care physicians Specialists earn more than primary care physicians 0 earnings compared to specialists 6 Cost sharing A combination of government subsidies, an individual compulsory medical - savings account, and a low cost insurance scheme 7 Patient Lists There is no requirement to sign up with a personal GP. 0 8 Requirement for 24-hour No regulated requirement for 24 hour primary healthcare. Patients may visit 0 coverage 24 hr A&E (accident and emergency) departments when necessary. 9 Standard of family medicine Family medicine in Singapore is given low priority. 0 academic departments Practice characteristics 10 First contact Patients may choose to be referred by a primary care physician or choose to go 0 to a private specialist directly. 11 Longitudinality Patients do not get to select their doctors when they visit a polyclinic, and - there is no system to enroll patients (patient lists) for private general practitioners. 12 Comprehensiveness Polyclinics and private group GPs have a comprehensive range of services and 1 facilities. Community Health Centres provide off-site ancillary support services to GPs without full facilities. 13 Coordination Poor coordination and information transfer between primary, secondary and - tertiary levels of healthcare 14 Family-centeredness Family members are informed of medical decisions in hospitals 1 15 Community orientation Data from practitioners not analyzed or used to identify priorities of care for the 0 community than 90 percent of physicians reported having after-hours report with related health information will be sent to coverage in place [31]. The low percentage reported by them after their patients saw a specialist, less than 20 Canadian and US physicians suggest that after-hours percent of physicians in the US, the Netherlands, and coverage develops slowly if it depends on solo practices, Germany reported that they received a relevant health [32] as compared to requirements such as national help report from the specialist [31]. lines in the UK, and payment incentives to physicians to In Singapore, there is no patient list system and pa- provide after-hours care in Australia. tients have the freedom of selecting any doctor they Care coordination is a major challenge for primary wish to see. Patients therefore have direct access to spe- care systems, especially with the increase in the elderly cialist care. Such health systems are described as more population and the attention and long term management expensive as compared to a system where patients have required for chronic diseases that are commonly afflict to be referred through the primary care system [33]. the elderly. While this dimension received a tied score This is also related to the practice characteristic of “first between 0 and 1 from the primary care experts in access”, where the primary care system is rated well if Singapore, the 2012 Commonwealth Fund survey re- patients need to be referred by primary care physicians vealed that care is generally not well coordinated in the to a specialist. Looking at this from the perspective of ten countries surveyed. Besides physicians from France health care finance, the variation in our findings as well and Switzerland, where more than 50 percent said that a as the comments provided by the experts indicate that Khoo et al. Asia Pacific Family Medicine 2014, 13:8 Page 6 of 8 http://www.apfmj.com/content/13/1/8 Table 3 Primary care scores Country System score Practice score Total score Total average score (Characteristics 1–9) (Characteristics 10–15) (max. 30) (max. 2) Low primary care Belgium 5.6 0.0 5.6 0.4 France 5.0 0.0 5.0 0.3 Germany 6.0 0.0 6.0 0.4 United States 4.0 1.5 5.5 0.4 Intermediate primary care Australia 10.0 7.0 17.0 1.1 Canada 11.5 6.0 17.5 1.2 Japan 8.5 4.0 12.5 0.8 Sweden 10.0 4.0 14.0 0.9 High primary care Denmark 16.0 10.0 26.0 1.7 Finland 15.0 7.0 22.0 1.5 The Netherlands 13.0 10.0 23.0 1.5 Spain 12.5 8.0 20.5 1.4 United Kingdom 18.0 11.0 29.0 1.9 Scores in Table 3 are obtained from Starfield & Shi [28]. there is not a consistent judgement on what might be One example of the FMC initiative would be Frontier the right model of health care finance in Singapore. In a FMC (a private GP clinic) in Singapore. In collaboration sense, Singapore has shown that it is possible to achieve with the National University Health System (NUHS), it an efficient health care system at lower cost. In terms of is applying the Patient Centered Medical Home concept Starfield’smodel,the “financing” health system character- (PCMH) [36] in Singapore, based on AAFP’s (American istic could be revised to accommodate more permutations Academy of Family Physicians) joint principles of PCMH of health care financing. Different financing combinations [37]. It is expected that patients with chronic conditions might be more suitable for different countries based on (i.e. diabetes, hypertension, stroke and asthma) who no every country’s unique characteristics. The health care sys- longer require specialist care can enjoy shorter waiting tem of Singapore is currently in transition, [34] and in line time when they seek outpatient treatment and follow up with this, the Ministry of Health recently presented a at the Frontier FMC in the community. Frontier FMC ‘Health care 2020’ Masterplan comprising of a set of strat- was opened in the first week of April 2013 [38]. Besides egies to guide Singapore towards an inclusive health care encouraging information transfer between GPs and spe- system for the future [35]. The aim is to enhance accessi- cialists, at the same time, through team based care, it is bility, quality, and affordability of health care for all people expected to slow down disease progression, reduce com- in Singapore, and the further development of primary care plication rates and in turn, minimize referrals to hospi- is a part of this strategy. Besides the plan to increase sub- tals. Since it is the first implementation of the PCMH in sidies from the government for chronic outpatient treat- Singapore it is yet unclear how the proposed solutions to ment at GPs for low-income and middle-income families, improve chronic illness care will play out. Important most significantly, three new primary care models will get components of the new approach include: team based developed: Family Medicine Clinics (FMCs), Community care, electronic health record shared between NUHS Health Centres (CHCs) and Medical Centres (MCs). The and Frontier FMC, and a referral system for those with different models are meant to be all encompassing to cater complex care needs. to patients with different profiles and preferences. This Finally, another two characteristics that scored zero (primary care physician earnings as compared to specialist, is a step towards improving system and practice charac- teristics such as “patient lists”, “coordination”, “compre- and family medicine as academic department) indicate the hensiveness”,and “family centeredness”.Itisexpected need to raise the profile of family medicine and the role primary care physicians play in overall health care delivery. that with these models more patients can be cared for outside the hospitals’ specialist outpatient clinics by Even with an optimal health care finance mechanism and GPs in the community. an integrated care system in place, the relatively low status Khoo et al. Asia Pacific Family Medicine 2014, 13:8 Page 7 of 8 http://www.apfmj.com/content/13/1/8 of primary care education and research will impede the According to primary care experts from Singapore, the development of a stronger primary care delivery system strength of its primary care system is low. This is an im- in Singapore. portant concern considering the developments in its Thereareacoupleof limitations we should note for population. The study provided us with a comprehensive this study. First, the response rate to our study was overview of the standard of primary care in Singapore as relatively small. Despite the relatively small response, perceived by primary care experts in Singapore, and also the variability in scores between respondents suggests allowed us to compare the state of primary care in that the study group varies in their opinions about pri- Singapore with other countries. The results can be mary care as one would expect (from previous studies used as a basis to inform future health care reforms in other countries). Second, Singapore’sscorescould and research, for comparison with other (East) Asian not be compared directly with the scores from other countries, and to assess trends in time if the survey countriesasthere were differences in opinions about would be applied again in the future. the characteristics, unlike the scores attained by Star- Competing interests field and Shi [28] where it was noted that informants The authors declare that they have no competing interests. had “no disagreements” in the scoring of the characteris- tics. This was also the reason we decided to use average Authors’ contributions sum scores instead of relying on the modal score. Our KHS contributed in the conception and design of the survey, data collection, drafting the manuscript and making critical revisions. LYW contributed in the scores for both system and practice characteristics were conception and design, data collection and critical revisions. H Vrijhoef also attained primarily from experts in primary care in contributed in conception and design, and critical revisions. All authors have Singapore, while the system scores in Starfield & Shi [28] given final approval of the version to be published and agree to be accountable for all aspects of the work. were mainly obtained from the Organization for Economic Cooperation and Development (OECD) [39]. Author details The assessment of health care quality, especially re- Saw Swee Hock School of Public Health, National University of Singapore, MD3, 16 Medical Drive, Singapore 117597, Singapore. RAND Corporation, garding chronic diseases, has more often been based on Santa Monica, California. Scientific Centre for Care and Welfare (Tranzo), the perspectives of the care provider or the health care Tilburg University, Tilburg, The Netherlands. 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Asia Pacific Family Medicine – Springer Journals

Published: Jul 19, 2014

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