Tan D,AM, MBBS, MMed (IntMed), FRACP

Madam Minister of State, Mr. President and Members of the College of General Practitioners, Ladies and Gentlemen.

I am not sure whether I should thank the College for inviting me to speak today because this oration has given me many sleepless nights.

Not having any experience of general or family practice, I was not at all convinced that I have anything to say which would have relevance to your practice. Worse yet, I may presume to tell you about things, which you in your wisdom and experience already know, will not work.

However, you may know that I have in the past gone "where angels fear to tread" in the areas of special education and politics, so allow me to try my hand in the area of family care. It could be that, looking in from the outside, I may see trends and patterns which you, in the busy life of attending to patients, may not have had time to think about.

The Ideal Family Physician is able to diagnose every ailment under the sun. He (includes she) is able to treat medically, surgically and to do obstetrics and gynaecology too. With his trusty stethoscope in his pocket, he is ready to answer house calls anywhere at any time. He needs no rest or vocation. He is wise, patient and sympathetic at all times. I put up this description with tongue in cheek, but it comes fairly close to some real-life doctors.

With such doctors around, why do we need team care? I think that in today's complex world, no one professional is able to provide the multifaceted care which families need. Not to respond and change with the times would in the long term hurt the role of the family physician.

Doctors should be aware of the availability and the roles of other professionals in the overall care of patients. I note that many other organisations have been included in this conference, and that is a good start.

Why do I talk about families rather than individuals? Because most individuals live in family units. The individual's health affects the wellbeing of other family members. Most importantly, families share common denominators, which affect their health status, such as income and housing; diet, smoking and other habits; mutual support and the network of extended family and friend.

Having explained the reasons for favouring team care, let us look at the professionals who will give this care. They are well known to us, but allow me to put them up for consideration as team members.

The Physician does diagnosis and treatment, and in the present era, also does health screening.

The Pharmacist ensures standards of drug usage and dispensing.

The Nurse Practitioner, not to be confused with the doctor's assistant, can carry out various nursing procedures and is also able to undertake health education such as breast-feeding, infant care and feeding, special care such as care of the skin, bladder and stoma.

The Social Worker investigates socioeconomic problems, arranges for families to obtain help from agencies, and is able to undertake interventions such as family therapy.

The Psychologist investigates and assesses psychological and developmental problems. Where necessary, he is able to intervene in behavioural problems such as eating disorders, drug and alcohol addiction.

The Therapists are all involved with rehabilitation — physical, occupational, speech. We are very short of such workers and the need for them will grow as our population grows older.

Dietitians and Nutritionists have come into their own since the realization that certain diet patterns are harmful whilst other eating habits offer protection against various diseases. They have a big part to play in health education and they can offer advice for abnormal nutritional states.

Dentists nowadays are able to conserve even the most carious tooth but we can be most proud of the excellent dental care, which all our school children receive.

Volunteers are wonderful people. They provide a whole range of help in the many voluntary organisations. All voluntary agencies lean heavily on them to run their programs and to raise funds. Many hospitals in other countries also have such groups. Since some volunteers have earned the nickname "professional beggar", I feel justified in including them as professionals.

The concept is that all these professional services should be available to families according to their needs; and that these services should be co-operative and co-ordinated. Of course, not every person or family will need care from every professional, but every one of the professionals should be aware of the services given by the others and be willing to collaborate with any of them as necessary.

This diagram (Figure 1) illustrates a family surrounded by the various professionals who are ready and able to serve their needs. The professionals link up their services as required for each case.

Let us now look at the structures within which the professionals can deliver their services in the context of team care.

Structures, which are already with us, include the polyclinic, the medical centre, hospitals, family service centres, scattered medical practices and home nursing teams. They are all tried and tested institutions, which we can use effectively for team care.

In the Medical Centre, professionals generally work independently. Coordination regarding patient care is usually by telephone or at the bedside. The patient shuttles about and pays multiple fees, and this is a disadvantage.

The Polyclinic offers one-stop care and a single bill, which is a great convenience. It tends to have a pyramid hierarchy, which is usually headed by a doctor. The pyramid structure may not make optimum use of all professionals, and it is difficult to include a large range of services in the usual smallish organisation.

The Government Polyclinics' have kept up with the changing pattern of disease in Singapore by introducing health promotion programs and screening for coronary heart disease in addition to their traditional activities of antenatal and well-baby care, and outpatient treatment of illnesses.

The present hospitals are mainly specialist hospitals. I have high hopes for the community hospital, which is in the pipeline. I believe that specialist and community hospitals will complement each other to provide comprehensive hospital care for the people.

I see the Community Hospitals playing a useful role in the following areas:

• continuation of patient management by family physicians of acute-on-chronic conditions in diseases such as diabetes mellitus and hypertension;

• care of patients where prolonged in-hospital convalescence is needed, for example following severe strokes and severe trauma; and

• rehabilitation, a specialty in its own right, which would be very suitably located in a community hospital to provide expert rehabilitation care for patients with strokes, myocardial infraction, severe trauma and other diseases such as rheumatoid arthritis. These are all common causes of morbidity for which rehabilitation services have yet to be made easily available.

Patients should be admitted to community hospitals when it is the best choice for their particular condition, but the opportunity of taking care of in-hospital patients will also hone the diagnostic and therapeutic skills of family physicians.

There are several Family Service Centres which are now in operation. They are doing good work and we need many more. Corney3 of the Institute of Psychiatry in London has noted that there is a large degree of overlap in the populations served by the social services and that of primary health care. It is obvious that many of the clients of family service centres have stress related or other illness, and many medical patients have family problems as a cause or effect of illness.

Scattered Clinics are the basic units and the backbone of primary health care for families. They bring the doctor to the patients where they live. However, there is a danger of professional isolation, which must be overcome by maintaining links with hospitals and current practice. I know that your College is aware of this and is actively providing continuing education. As I have just mentioned, the Community Hospitals could provide the hospital link.

Similarly, Home nursing brings the nurse into the home. Like the family physician, these nurses also face the danger of professional isolation. I would like to suggest that they, too, should have continuing education programs and hospitals links.

Hospice Care is a specialty in its own right. The Singapore group offers a range of services including home visiting, day care and residential care. They, too, feel that hospice care should be linked with hospital practice for the maintenance of high medical standards.

This picture (Figure 2) shows how the family has a choice of care from various organisations and institutions according to their needs.

To digress a little, I am sure that you would have observed certain recent trends in medical practice in Singapore.

Patients are more knowledgeable about diseases than they were, say, a decade ago. This is good because it makes it easier to explain diseases to patients and to get their co-operation in the management of their illnesses. It also means that doctors should spend more time in discussion with their patients, making the patient a partner in health care for themselves and their families.

Given the opportunity and support, patients can and should undertake a bigger role in decisions for investigations, treatments and changes in lifestyle for better health. This gives them a sense of control over their own lives, and makes for better overall results of treatment.

There has been a flow of patients away from family physicians to specialists, I think more than necessary for specialist consultation and treatment. I believe that this trend can be corrected by focussing on a high standard of professional service on the part of family doctors. Other things being equal, patients always prefer to see their family physicians.

Government departments are assuming a bigger role in preventive medicine, for example, in health screening and health education. It is good that Government initiates these services, but I see no reason why family physicians cannot provide this service just as well, by setting up preventive medicine centres, perhaps as joint ventures between a number of doctors.

In conclusion, let me return to the question "Why team care for families?"

Team care enables the skills of professionals in various disciplines to be harnessed for the optimal benefit of families.

Team care helps general practitioners to achieve a more satisfactory outcome for their patients and their patients’ families because of attention to their all-round needs.

Finally, I firmly believe that team care will help to enhance the role of the general practitioner in the provision of primary health care to the people and in the prevention of disease

REFERENCES

1. Development of Polyclinic Services. Personal communication from Dr Chen Ai Ju.

2. Concept paper on Community Hospitals. Personal communication from Dr Koh Thong Sam.

3. Corney RH: Social work and primary care—the need for increased collaboration: discussion paper. Journal of the Royal Society of Medicine, Vol 81,pages 29-30. Jan 1988.

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