出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : Singapore recognises that it faces an unprecedented convergence of factors in the near future that threatens its social fabric and economic survival. The population is rapidly ageing, second only to Japan within Asia. Because of its below-replacement fertility rate and despite the potential social unease, its population has had to grow for economic sustainability. Its leading-edge medical capabilities and excellent demographic indicators must be balanced with the cost of the medical advances that enable these outcomes. Already, Singapore has embraced elements of innovations in healthcare delivery seen in other countries like New Zealand, Sweden, the United States, and the United Kingdom, or in corporate entities like Geisinger and Kaiser Permanente. Through extensive study, study visits, and visiting experts, Singapore has set out to learn from the best around the world. Uniquely, Singapore has set up a public agency dedicated to supporting the implementation of Integrated Care, and even organised the inaugural World Congress on Integrated Care. Many programmes have been piloted and implemented, from internationally well-established care models quickly adapted to the local healthcare ecology, to homegrown innovative approaches requiring much outcome and impact evaluation. Many relate to direct care delivery but others include restructuring subsidies, establishing IT systems, inter-professional training, and regional systems. This presentation considers the relative roles of incremental quality improvement, straightforward implementation, simple copying or importation, to reverse engineering, and outright raw invention. Method : Through a review of current information, an inventory is compiled of the various Integrated Care efforts in Singapore. Their foundations, origins and backstories are clarified, where necessary, with principals. The results are then presented in a conceptual framework that systematically describes the common and less common processes for generating the impetus to and directions of change, and the factors that influence their adoption. Results : Recent changes in Singapore’s healthcare system at the macro, meso and micro levels are systematically described based on a conceptual framework that identifies and distinguishes the influence of efforts in other countries, and local adaptations and innovations. The description is illustrated with local examples of how such programmes are conceived, designed, implemented and evaluated. The predominant approaches are described in an alliterative fivefold categorisation of Improvement, Implementation, Importation, Imitation, and Invention. Discussion : Ultimately patients and the population must benefit from our efforts in Integrated care, but it is also useful to lift our thinking above the practical on-the-ground implementations to consider how we think about how we design and create such innovations. While our mental models are often accepting of “anything new” as being “innovative”, there are relatively few absolute inventions. Learning from these examples requires the student to be discriminating in terms of both what can be usefully imported and adapted, how these changes may be done, and what requires a change in the larger environment to successfully take root. Salient lessons are discussed. True innovations (ie the inventions) arise because of some critical insight that transform the mental framing or paradigm. Innovation is not about finding the better answer but seeing the better question.
