Ophthalmic primary care in Singapore: Considerations for review

Abstract

Ophthalmic primary care (OPC) of Singapore residents is mainly provided for by trained specialists. This is due both to the current nature of the public healthcare system as well as societal perceptions and preferences, and it imposes a heavy burden on the country’s ophthalmologist resource. Changing population demographics, escalating costs as well limitations to medical manpower growth have necessitated a shift in Singapore’s healthcare strategy to focus on primary and preventive care. This national policy change further emphasizes the need to invest in OPC as a more structured service. Revisiting the principles of primary care and how they apply to ophthalmology will be an important first step in a timely review of the country’s OPC system.

Introduction

Primary care, as defined by WHO, is “essential health care made universally accessible to individuals and families in the community by means that the community and country can afford. It forms an integral part both of the country’s health system of which it is the nucleus and the overall social and economic development of the community”. ¹ In ophthalmology, the American Academy of Ophthalmology (AAO) describes ophthalmic primary care (OPC) as “the provision of appropriate, accessible and affordable care that meets patients’ eye care needs in a comprehensive and competent manner”. ² Importantly, both AAO and the United Kingdom’s National Health Service (NHS) describe OPC as the first contact for eye care. ³

In Singapore’s public healthcare system, only doctors’ referrals are accepted for patients who require specialist care in public healthcare institutions. These doctors include primary care providers like family physicians practicing in government polyclinics and private general practitioners. Although they are the first point of contact for patients requiring eye care, it is arguable whether they provide OPC. Because of the limited and short undergraduate training in ophthalmology during medical school, and the lack of equipment like slit lamps or tonometers, primary care physicians are unable to perform comprehensive ocular examinations or conduct basic investigative tests that would allow them to diagnose ophthalmic diseases, let alone treat them. As a result, the majority of patients who present with ocular complaints are referred to public hospital-based ophthalmologists.

To aid in the management of patients with eye complaints, ophthalmology departments promulgate referral guidelines to serve as reference for appropriate referring of patients by primary physicians to ophthalmologists. These guidelines however do no mitigate the lack of community based OPC as they are developed with consideration for the level of ophthalmic assessment and care that family physicians can provide. This in turn perpetuates the lack of impetus to develop OPC in the community.

On the other hand, licensed optometrists in Singapore are trained in performing eye examinations and investigative tests to detect common eye conditions such as cataract, glaucoma, diabetic retinopathy and age-related macular degeneration. ⁴ They however do not possess therapeutic prescription privileges and hence are unable to provide treatment or act as step-down care providers for patients with stable eye diseases. Community optometrists are also unable to refer patients directly to ophthalmology services in the public healthcare institutions but must instead direct them to primary care physicians to obtain such referrals. In addition, optometrists in Singapore are more often perceived as specialized retail workers in optical shops rather than healthcare providers and patients seldom opt to see them for their eye care needs. Because of these reasons, the services provided by community optometrists do not constitute effective OPC.

The need for review

Without the care provision and gate keeping functions of an effective community based OPC, hospital ophthalmology departments across the country are inundated by large and increasing patient numbers. This manifests as long waiting times for ophthalmology appointments of between 4 to 6 months at the time of this writing. Furthermore, Ansah et al. showed that Singapore’s aging and growing population will result in an almost doubling of the number of Singaporeans with eye conditions, a significant increase in public sector eye care demand and, consequently, a greater requirement for ophthalmologists by 2040. ⁵ In a scenario where the eye care delivery model remains unchanged, the required number of ophthalmologists is projected to increase by 117% between the years of 2015 to 2040. ⁵

Singapore had 314 registered ophthalmologists ⁶ serving a population of 5.64 million in 2022. Amongst developed countries, it has one of the lowest ophthalmologists per capita of 56/million. In countries with significant aged populations, the numbers of ophthalmologists per capita are significantly higher, for example, at 109/million in both Japan and France and 81/million in Germany. ⁷ Moreover, in a number of western countries like England ⁸ and Australia, the provision of OPC by community optometrists is well established. As Singapore is at the cusp of seeing the impact of its aging population in the coming decade, the number of ophthalmic patients per ophthalmologist will increase significantly.

In view of the changing population demographics, escalation of healthcare costs and limitations to medical manpower growth, Singapore’s government has embarked on a shift in the country’s healthcare strategy to focus on primary and preventive care. A similar approach of investing in OPC as a more structured service to tamper down the ophthalmologist requirements of the country will be crucial to meet the increasing eye care needs of its population.

Revisiting primary care and defining ophthalmic primary care

In addition to the WHO definition, primary care has also been defined in a variety of ways depending on the context. It has been described in terms of its workforce, activities, level of care, setting and as a strategy for organising a healthcare system. ⁹ Nonetheless, it is generally accepted that primary care is characterized by several attributes that are all required although they might overlap with other levels of care. These are (1) first contact, (2) accessibility, (3) continuity, (4) longitudinality (patient identifying with a source of care as their own), (5) comprehensiveness, (6) coordination, (7) equity, and (8) accountability of both the provider and patient.^10,11

In 2003, Riad et al. studied the role of OPC in the primary care-led NHS in the United Kingdom and developed a working definition to guide discussion and development of the service. ¹² It captures all the established attributes of primary care and takes into consideration the nature of the ophthalmic care ecosystem and the various parties involved.

“Ophthalmic primary care is the provision of first contact care for all ophthalmic conditions and the follow up, preventive, and rehabilitative care of selected ophthalmic conditions. It can be delivered in a variety of settings and by a diverse workforce, but in strict, efficient, and timely coordination, to attain the best clinical outcome possible for the patient. A service is designated as ophthalmic primary care, only if appropriately integrated with the patient’s main primary care provider, in order to ensure continuity, longitudinality, and comprehensiveness in the overall care of the patient. The primary care ophthalmic service itself should be accessible, equitable, knowledgeable, responsive, and efficient.” ¹²

In Singapore, family physicians do not provide comprehensive, continuous, preventive, or step-down eye care. Community optometrists are unable to provide treatment or coordinate care as efficiently as doctors and are poorly integrated with the rest of the healthcare system. With little societal acceptance as eye care providers, care from community optometrists is also not accessible from a patient perception perspective. Ophthalmologists in the public healthcare sector are not the first contact of patients requiring eye care, and whether the care they provide is accessible is arguable when patients’ first comprehensive ophthalmic assessments involve several months of waiting time. It is apparent then that no specific ophthalmic care entity in the country displays all the attributes of primary care.

Developing OPC in Singapore

Currently, ophthalmic care is provided by a variety of practitioners who differ significantly in their accessibility, expertise, equipping and integration with the secondary eye care system. To create a coherent OPC system in Singapore, possible approaches include (1) upskilling and equipping primary care doctors to deliver OPC, (2) empowering community optometrists and integrating them into the healthcare system, (3) introducing optometrists or ophthalmic nurses into the public primary care system and (4) a combination of the above. None of these are low hanging fruits with major challenges such as competing manpower demands, licensing and regulatory hurdles, lack of data connectivity as well as need for public re-education will likely prevent the re-structuring of OPC at a pace that is in keeping with the urgency of its need.

This highlights the importance for ophthalmology as a specialty to provide strong leadership in laying down the imperatives and driving the initiatives. It should also provide the professional oversight in OPC research, planning, training, and governance. In particular, the interface between primary and secondary ophthalmic care needs to be carefully delineated for the avoidance of gaps or overlaps that can affect patient outcomes and introduce inefficiencies. However, even within the specialty, there is a general lack of emphasis on OPC or general ophthalmology compared to its other subspecialties. Without an appreciation of its growing relevance in the country’s population health strategy and formal recognition as a distinct service component of holistic eye care, the goal of restructuring OPC would appear even more distant.

Conclusions

Ophthalmic primary care as a structured level of care is underdeveloped in Singapore. In the face of significant changes to the overall healthcare landscape, there is a pressing need to review and drive the development of OPC following the key tenets of primary care. Major obstacles to achieving the necessary level and scale of OPC exist, and a holistic approach will be needed to overcome them. Importantly, recognition of OPC as a critical component of the population eye health strategy will serve to set the impetus for a review of policy and planning.