Posted by: Tony Shannon | May 31, 2013

Healthcare Emergency : Lessons from the NHS – Learnings from Singapore

After what has been a particularly cold winter and spring here in England, we have also endured on the more difficult winters in the Emergency Departments of the NHS.

Aside from blaming the cold, there are a couple of other lessons to be learnt here.

The National Health Service in England, which has provided “free at the point of care” healthcare to its citizens for over 60 years is a noble institution of which folk are rightly proud.

In the last 10years I have been a witness to the tremendous and impressive changes within its Emergency Departments, with the advent of the 4 hour target/standard, which has transformed the approach to delivering care in EDs, with a focus of timely emergency care that only a time based measure could provide.

While it has been an honour to have witnessed and been part of that change, what has also become apparent has been, that despite/in spite/because of that standard and ambition to improve emergency care, that the population has voted with their feet and there has been a massive 50% increase in ED attendances since the advent of the standard.

One could argue that such an increase in business is a real vote of approval and confidence in the NHS EDs, though unfortunately aligned with the pressure to process patients from arrival to discharge in under 4 hours in 95% of the that time.. it has led to huge pressures within the departments and as a consequence a  real difficulty recruiting and retaining staff.

Other related have been raised in what is now been acknowledged as a current crisis in NHS Emergency Care..
-including the wisdom of providing entirely free healthcare, which some argue removes individual responsibility for managing ones own health
-and the challenge of the demographic timebomb in the western world, where limited resources are trying to fund the care of an increasingly aged population, which has led some to declare that the NHS simply cannot continue to the endless needs of an ageing population, i.e. it cannot continue to promise to offer to solve all the ills of all men.

Deep down, there is a more profound lesson to be learnt here, that if in the United Kingdom which has one of the most mature healthcare systems in the world, has despite targeted effort to radically improve its emergency services over the last 10 years, is back in a position of crisis.. what does that tell the rest of the world?

Surely, at least to my mind, it keeps coming back to the fact that the future lies in working smarter not harder. Throwing endless resource at the problem, current solutions and the current mindframes that have got the system where it is, simply will not work in future.

Radical, brave and far reaching change is needed, across the western world, in terms of what we promise and what we aim to deliver in healthcare.



Thankfully this month has also seen the publication of a related report which helps shine a light on a way forward..

Affordable Excellence: The Singapore Healthcare Story: How to Create and Manage Sustainable Healthcare Systems” by William Haseltine is a great exposition of a carefully considered and developed Healthcare system.

One of the key opening lines tell us a lot ..
“Today Singapore ranks sixth in the world in healthcare outcomes well ahead of many developed countries, including the United States. The results are all the more significant as Singapore spends less on healthcare than any other high-income country, both as measured by fraction of the Gross Domestic Product spent on health and by costs per person.”

In brief, the story outlines some of the key features of the Singaporean model of government that has lent itself to fostering such as a healthcare system. Those include objectives laid out in a governmental plan such as :

º Become a healthy nation by promoting good health
º Promote individual responsibility for one’s own health and avoid overreliance on state welfare or third-party medical insurance
º Ensure good and affordable basic medical services for all Singaporeans
º Engage competition and market forces to improve service and raise efficiency
º Intervene directly in the healthcare sector when necessary, where the market fails to keep healthcare costs down

The Singapore System offers 3 key approaches:

MediSave- which is a mandatory healthcare savings account, from where accumulated savings may be used to pay for healthcare expenses under established guidelines

MediShield – offers an insurance to protect patients in the case of catastrophic illness or injury

Medifund- which is another system safety net, designed to help the needy with their healthcare bills.

The Singapore system promotes high quality, safe, and cost effective care via a national approach to guidelines for care, while recognising the importance of information to underpin such a system, through their recognised leadership in Electronic Patient Records.

Several of these lessons strike a chord particularly – the coordinated approach that recognises the need for both public and private players/ encouraging individual responsibility while offering a safety net where needed/ fostering good quality, safe care and the power of information.

The rest of the healthcare world has much to learn from the lessons from this small but smart leader in the field…I can commend it to you.

(BTW On the subject of small, smart, leadership and making a difference in the healthcare world, more on a career move of my own coming soon..)




  1. […] out from my early days as a doctor was the information intensive nature of work at the frontline. Every shift I have done has reinforced the point that to bring emergency medicine into the 21st cent… My interest in this challenge meant that I slowly and steadily moved into medical leadership roles […]

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