Health & Care FuturesHealth Service Challenges: East & West

Dr Catherine Calderwood (CC), Professor of Practice, University of Strathclyde, Glasgow. Dr Nicholas Chew (NC), Chairman of the Medical Board, Woodlands Health Campus, Singapore. Facilitated by Alec Morton (AM), Professor in Strathclyde Business School, and Visiting Professor, School of Public Health, National University of Singapore.

Welcome, Catherine and Nicholas. It's great to have you here. Could you each briefly share your current roles and what led you to them?

NC: Certainly. I have a background in consultation liaison psychiatry and education. In the early 2000s I started a service to look after patients with HIV and psychiatric conditions. Later I took a journey into education for 10-12 years. I looked after residency and undergraduate education within the National Healthcare Group as the Group Chief Education Officer for about 6 years. I transitioned into hospital management as Chairman of the Medical Board, overseeing the setup of a new hospital, which has been a lengthy process due to pandemic-related delays.

CC: I'm an obstetrician/gynaecologist who ventured into government policy while maintaining my clinical role. I became interested in government policy and went into the government as a women and children's advisor initially while maintaining my clinical role in in 2010. Eventually, I became the Chief Medical Officer for Scotland, advocating for healthcare policy change based on frontline experiences.

Both Scotland and Singapore are grappling with the challenges of an aging population and increasing chronic conditions. How are your respective governments and medical professions addressing these issues?

CC: What we would like is to have people living longer but healthy lives. It's very important then to have older people staying active, eating healthily, but many of our public health measures are targeted at younger people.

The next real issue is going to be looking at nursing home care and care for people when they can't care for themselves. There's a big drive at the moment then for keeping people out of hospital and looking after people at home. Supporting our workforce is a huge issue. If we don't look after our workforce and those doing the caring, they can't look after the people that need care.

NC: Healthier SG is a new movement that started by the Ministry of Health where we are trying to get every citizen to sign up with a GP. Most elderly are used to seeking ad hoc care. We are also shifting the focus of care from the acute hospital to primary care.

Within the hospital I think we've done quite a lot over the years to address the aging population. It is frequently the psychosocial frailty that makes care so much harder. The lack of social support, not having somebody looking after them at home, leads to the complications and decompensation in chronic disease. So, we have in place programmes aimed at better caring for patients in the community following discharge.

In the community and social care setting, the National Healthcare Group has set up communities of care (COCs) where we extend services into groups of around 10,000 residents within a neighbourhood. We work with local partners, health advocates and community nurses to reach out to residents. Through social prescribing, we link our elderly with social services and healthy living programmes like exercise and diet in order to keep them well within the community and reduce social isolation.

Through social prescribing, we link our elderly with social services and healthy living programmes like exercise and diet in order to keep them well within the community and reduce social isolation.

The COVID-19 pandemic underscored the importance of mental health. How are your countries addressing this growing concern?

NC: Mental health is definitely rising to the top of the health care agenda. During the pandemic, social isolation led to an increase in anxiety and mood disorders presenting to primary care and tertiary care. But we also saw existing patients become unwell because they were isolated and unable to access their support and care systems. For all the efforts that we've been putting in to destigmatising mental health over the last 20 years or so – I don't think it we have succeeded as much as this generation of post-millennials.

CC: I'll focus a little on our workforce and the burnout we saw in our NHS. People were thrown into roles that they were not prepared for. Somebody who'd been nursing outpatients for many years was expected to go and care for people who were very significantly unwell in intensive care, for example. We're seeing a lot of people having worked through that and come out the other side are still suffering from the trauma of what they were expected to do, with very little preparation. We're seeing a lot of mental ill health and distress amongst workforce at all grades and of all roles in the multidisciplinary team. In recognition of that we've set up our NHS practitioner health service which is a UK wide service. It’s able to be accessed by the workforce themselves and offers a wide range of help including self-help, nursing and medical input.

Transitioning from clinical to managerial roles can be challenging. What are some insights you've gained from this experience?

CC: I feel strongly that it's very important that the clinical voice is heard. Scotland has not traditionally had clinicians in the leadership roles of hospitals so I really noticed when I visited Singapore that a lot of the chief executives of the hospital systems were clinicians. One thing for somebody thinking of going into management to be really prepared that people think you've “crossed over to the dark side”. That phrase is terrible – there's ‘them and us’. And that's very destructive – in all walks of life we need managers. A lot of what you will do is breaking down barriers between the non-clinical managers and the clinicians, helping to understand each other’s roles more fully. Communication is absolutely key.

NC: We do have a lot of doctors who are in hospital management and it does bring a certain perspective that prioritises patient care. The downside is that most of us enter medical schools not thinking about being in administration and we are grossly unprepared for the roles that we are asked to play. Doctors tend to see themselves more as working in the business and then struggle to see how they can work on the business. There are two separate perspectives that need to be balanced most people tend to steer more to being on one side.

A lot of what you will do is breaking down barriers between the non-clinical managers and the clinicians, helping to understand each other’s roles more fully. Communication is absolutely key.

Creating a positive organisational culture is crucial for healthcare delivery. What strategies have been effective in fostering a healthy culture in your institutions?

NC: The challenge we have is to develop culture in groups of people who are working in different settings on a daily basis. We decided to focus on just three things we thought were important in developing the culture. The first was getting our staff to agree on the meaning and purpose of the work that they did. We also focus on participative management and we try to get people to understand that in this new environment we need everybody to show up at work and we need everybody to take discretionary effort to solve the problems that arise. And the last and probably the most important is psychological safety. The ability to speak out and not to feel embarrassed or that something bad would happen to me if I spoke out against the system.

CC: Yes, it is very important that the style of leadership is collaborative and compassionate, listening to people’s problems and being honest that sometimes you can't solve everything. The research shows when people are satisfied at work, it is the work that they're doing that they get satisfaction from but being dissatisfied is often to do with the environment they work in or with process and operational issues.

AM: Thank you both for this insightful discussion. It's clear that despite differences, the pursuit of quality healthcare unites us all.

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