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What Britain should learn from Singaporean healthcare

How Singapore spends less and sees better outcomes

Singapore, a small Southeast Asian city-state of 5.4 million people, is often considered to have the world’s most efficient health care system. Health care spending typically takes up a larger share of GDP as economies grow, but Singapore spends less per person on health care than the UK, despite being much richer. Perhaps surprisingly, though, it achieves outstanding outcomes. Infant mortality is half that of the UK; life expectancy is 83 (in the UK it is 81); cancer survival rates, while lower than those in the US, are similar to those in Western Europe. 

But when commentators praise the Singaporean model, they only describe part of the system. When Wes Streeting, the Shadow Health Secretary, recently visited Singapore General, he marvelled at its use of medical technology. But Singaporean public hospitals do not deliver substantially lower costs than Western countries. Tim Harford has written about how Singapore charges patients to access health care services. While this reduces demand, Singapore does not charge more than countries like Switzerland and Portugal. Low health utilisation is largely determined by factors like culture and population health, which are difficult to emulate.

What then are the real lessons for the British system?

First, British citizens should be allowed to make better use of the Singaporean system. I recently met with the CEO of the largest telemedicine provider in Singapore. He casually mentioned that many UK patients were already using his service. This was surprising: Singapore is 8 hours ahead of the UK. But the reason is obvious. At a time when many in Britain struggle to get a GP appointment, Singaporean appointments are less than half the price of the UK.  

The most affordable online appointment I found in the UK was £29. Many providers charge significantly more — for instance, Babylon Health lists its price for private GP appointments at £59. In contrast, Doctor Anywhere, Singapore’s leading telemedicine provider, offers services for just £12. 

Yet Singaporean doctors cannot currently write prescriptions for UK patients. Building on an EU Directive for cross-border prescriptions, the UK government should grant prescribing rights to Singaporean doctors.  

Second, Britain should emulate the Singaporean polyclinic system. Many of the key problems faced by the UK GP service — balancing timely access for acute conditions with continuity of care for chronic patients, providing quality health care to underserved communities — are the same challenges faced by Singapore. The difference is that Singapore runs polyclinics, which provide a combination of diagnostic and primary care services. Polyclinics date from the 1920s, when most of the population could not afford expensive hospital care. Polyclinics now provide publicly subsidised primary care services to 20 per cent of Singaporean citizens, focusing on low-income patients with chronic health conditions. 

Singaporean polyclinics use a “teamlet” model. Patients with multiple chronic health conditions sign up to a “teamlet” of two doctors, a nurse, and a health coordinator.  Consultation rooms are connected by sliding doors and doctors see multiple patients at once. While the health coordinator is seeing a patient in one room; the doctor can attend to a second patient in another.  

Health centres that combine elements of primary and secondary care are not a new concept. Politicians have been talking about variants of the polyclinic since the foundation of the NHS. In July 1948, an NHS pamphlet stated, “special premises known as health centres may later be opened in your district.  Doctors may be accommodated there to provide you a wide range of services …including dentistry and other services on the spot”.  

Professor Lord Darzi, Parliamentary Under-Secretary for Health under New Labour, is the last in a long line of politicians who have tried and failed to introduce health centres in the NHS. Lord Darzi’s review of London’s health care system modelled large cost savings from delivering care in new health centres. It estimated that polyclinics could replace 8 per cent of inpatient, 50 per cent of hospital accident and emergency, and 41 per cent of hospital outpatient services, saving £1.4 billion. The plans were abandoned at an early stage. 

Unlike Darzi-era polyclinics, Singaporean polyclinics separate acute and chronic patients. This allows them to see more patients. Doctors that cater for walk-in patients see 56 acute patients a day, during regular working hours. Contrast that to Britain, where The British Medical Association recommends GPs see no more than 25 patients each day (most GPs see more).

Polyclinics keep costs low by staffing the urgent care clinic with junior doctors, who are required to work for the government for five years after graduation. (Unit costs in Singaporean polyclinics are lower than English GP practices.) Teamlets often employ three senior doctors, and at any given time one of these doctors supervises the urgent care clinic. Urgent care doctors can book follow-up appointments as required. Teamlet doctors see complex chronic patients and therefore operate at lower volumes (35 patients a day), but after a successful trial, polyclinic managers are encouraging doctors to sign up less severe patients and increase patient volumes. 

Singaporean polyclinics achieve lower costs and pay their doctors more than NHS GP practices

Data from National Healthcare Singapore polyclinics and The University of Kent shows that Singaporean polyclinic doctors earn slightly more than the average English GP.  Cost per appointment is also lower in Singapore than in England.  The cost of a “Moderate Chronic Health Patient” (2-3 conditions) is 40 per cent less than the cost of an English GP appointment. The cost of an acute visit with no chronic conditions is less than half the English average. Because of this efficiency, Singapore is expanding the number of clinics. There are currently 23 polyclinics; by 2030 there will be 32.

Singaporean polyclinics achieve lower costs and pay their doctors more than NHS GP practices. What could be better than that? NHS England should therefore trial Singaporean-style polyclinics in communities with poor access to primary care services.

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