Today is my first face-to-face workplan seminar presentation. Last year, I did it online so the feel is quite different. We are back here today at an inflection point because we are doing some important things in MOH that will change the path of healthcare in Singapore.
2. At last year’s Workplan Seminar, I spoke on two things. One was that we were at the height of COVID-19 and we had just started vaccination. We had not gone through the Delta and Omicron waves, but we were preparing for a big fight ahead. But at that time, because of vaccinations, we talked about living with COVID-19. I remember that we felt that it was possible to live with COVID-19 from the confidence of our online audience.
3. Secondly, I spoke about a sustainable healthcare system. I remember talking about how healthcare costs multiplied three times over the last 10 years, and it was going to multiply by another three times in the next 10 years. So, it is not just being financially sustainable, but the whole system must be sustainable. There must be enough young people to take care of older people living in our society. The healthcare system must be able to accommodate more sick people. Let me give an update on these two topics.
4. How are we living with COVID-19 today? People have been having gatherings. Our Muslim friends recently celebrated Hari Raya and visited one another. Our borders have opened and we are travelling again. In one year, things have changed.
5. But what is ahead? The pandemic is not over. The infection curve of South Africa shows that it has gone through five waves. They are now in their fifth wave which is driven by the Omicron variant or BA.4. and BA.5. But the good thing is it is short-lived. It hit a peak that was about a third of the original BA.1 Omicron wave and is starting to turn down. The second important thing to notice is that in terms of hospitalisation and deaths, we do not see a very sharp rise. So how did South Africa go through a wave like that? I think it is because they have a certain level of resilience from the four previous waves, as well as vaccination coverage.
6. If we imagine BA.4 or BA.5 will come to Asia, or Singapore, in a matter of months, maybe July or August. But looking at South Africa’s experience, we can be quietly optimistic because our resilience is high and our vaccination coverage is very high. We have gone through the Delta and BA.2 waves, which give us better protection than the BA.1 wave that South Africa has gone through. Plus, we still have our masks on as a layer of defence. So we feel BA.4, BA.5, are waves that we can ride through. But we must not be complacent and still be prepared for it.
7. We must make sure that regardless of whatever healthcare settings that we are in, we must be COVID-19 ready. We cannot afford another situation like Omicron, where many healthcare settings were unable to handle COVID-19 patients and had to send them to our hospitals. Nursing homes, for example, were unable to handle these patients. Private hospitals that were unable to handle COVID-19 patients had to send them to public hospitals. Every healthcare setting need to be COVID-ready and be able to handle infections and take care of patients. With vaccination, most will recover uneventfully.
8. We have to find more beds in case pressure starts to build up in our hospitals again, in order to relieve the hospitals. There are two major places the beds can come from. One is the home where we can provide home care services and nursing homes. Our hospitals still house many long-term stayers who are actually waiting for their nursing home place. If we can ramp up our nursing homes, we will be able to absorb and take in all these patients, and it will relieve our hospitals when the BA.4, BA.5 waves come.
9. Next, is our COVID-19 Treatment Facilities (CTFs) which were designed to take in COVID-19 patients. We need to change the concept so that it can take in any patient who does not require the same level of acute care as they would in public hospitals. It may mean consolidating the beds and manpower so that we can take care of patients.
10. Finally, what we must do is to get all our seniors vaccinated. Today, 88% of our seniors aged 60 and above who are eligible to take their booster have done so. But we still have 12% who have not taken it and when the wave hits, they are the most vulnerable. As they are not fully vaccinated, when they are infected, we still see quite a number of them going into ICU. If we do all this, I believe we can ride through the BA.4, BA.5 waves.
11. As for a sustainable healthcare system, we spoke to many people and put together a strategy called Healthier SG that was announced earlier this year in Parliament. Healthcare economics is complicated. As technology advances and pushes prices up, insurance gives people peace of mind. This creates a buffet syndrome which pushes up consumption. If you analyse the economics, it is really complicated. So we have to gate-keep with health technological assessments and make sure there is co-payment, even for insurance. But the simplest thing to do is to keep people healthy. Healthier SG aims to do that as it focuses on preventive care.
12. To do so, primary care becomes the most important part of the healthcare system. Primary care meaning family doctors, clinics and polyclinics. Private clinics, GP clinics and polyclinics become the most important part of our healthcare system. We must practise healthcare, not sickness care. We must practise healthcare in the community and our homes, and not in hospitals or the operating theatres. You can engage in refreshing activities, eat better, exercise better and live better. That will be the focus of Healthier SG.
13. At today’s WPS 2022, I will be talking about two topics which are related to staying healthy. One is on end-of-life care and two, I will give you an update on Healthier SG.
14. I start with a quote that is commonly said in MOH. A doctor said that while it is important to live well, it is also important to leave well. An author, named Atul Gawande said that we think our job is to ensure health and survival, but it is larger than that. It is to enable well-being. Well-being matters not just at the end of life or when disability comes but along the way.
15. What defines good end-of-life care? For the person dying, you want to feel the love and warmth and it is best evoked when you are in a familiar environment and are surrounded by people you love. That is most important to many people who are dying. What benefits does that bring? Number one, higher quality of life. This means that towards the end of life, your pain and discomfort is well-managed as opposed to prolonged pain. Number two, lower the caregivers’ burden. I speak from experience. When my mother passed away, a palliative nurse guided me along and that lowered the burden, not just in terms of time spent to take care of my mother, but also psychologically on what to expect. That relieved the emotional burden and stress and brought about better peace of mind for everybody, especially the person dying. That is good end-of-life care.
16. We should not ignore the cost equation. If you do a full lifetime calculation, the cost in the last three months of one’s life is about 50% of the costs incurred by hospitalisation.
17. When we did a survey, 77% of Singaporeans said they preferred to be cared for at home at the end of their lives. However, in practice only 26% passed on at home. So there is a quite a big gap between what you wish for and what actually happens. More can be done to help the dying fulfil their last wishes.
18. We did a study together with the clusters and hospitals to look into the reasons that prevent people from having their wish to die at home with loved ones in a familiar environment. There are many reasons but one of it is due to low awareness and receptivity amongst family members, and very understandably so. Because when a person is sick and dying, many families will just want to do whatever they can to keep their loved ones alive out of love. Therefore, the cost goes up and so does the pain.
19. Number two, there are sometimes challenging discharge processes and protocols. Hospitals know that they can discharge a patient to palliative care or to a home but sometimes the place is not ready. The hospital may also have protocols that get into the way as the criteria may be too stringent. The last reason, but an important one, is low caregiver preparedness. We can do better and we will work together with all hospitals and our stakeholders to reduce end-of-life care and death in hospitals. There are four broad things that we are doing.
20. Number one, raise awareness of end-of-life care and pre-plan. A lot involves public education and I thank the media which have been highlighting this as an important thing to do. Secondly, doctors in our hospitals having honest conversations with the patient as well as their loved ones to say that this is an option. Change the mindset from “do whatever you can to keep my loved ones alive”, to “do whatever you can to make sure they pass on peacefully surrounded by loved ones, feeling the warmth and love before they depart the world”. Change that mindset.
21. Number two, smoothen discharges from hospitals, making sure equipment are ready, protocols are reviewed, and we make it easier. Number three, scale up palliative care capability and capacity. Finally, give better support for caregivers at home either through training or home respite care, or deploying more community nurses to support such families. All these are things that we can do and they are good low-hanging fruit that we can reap. So what is our aspiration after doing all this? We hope to reduce the number of deaths in hospitals within the next five years from 61% now to 51%. I think it is achievable.
22. That brings me to Part Two of today’s presentation which is an update on Healthier SG. Again we have a very poetic quote: “We are Ministry of Health, not Ministry of Sickness”. First, our health as a population is not too bad by world standards. We have one of the highest life expectancies in the world. In 2010, life expectancy at birth was 82.8 years. In 2019, it went up to almost 85 years.
23. But some say “so what if you are live longer if you’re sick and not enjoying life?”. So there is also the concept of health-adjusted life expectancy which means you are living and generally healthy. In 2010, it was 72.9 years. In 2019, it had gone up to 74.5 years. Also one of the highest in the world. By international standards, we are a healthy population.
24. But the signs are not good because chronic illnesses are getting worse. The three chronic illnesses or DHL – diabetes, high blood pressure, LDL cholesterol. For LDL cholesterol or hyperlipidaemia, in 2010, 26% of our population had it. In 2020, it had gone up to 37%. For high blood pressure, 20% in 2010, now 32% in 2020. Diabetes is the only slightly good news: 9% in 2010 and 8% in 2020. I think the War on Diabetes had some effect.
25. But all in all, it is not a pretty picture. We are not getting healthier. Even if you strip out the effect of age, it is still quite an alarming increase. And that is something we need to worry about and this is actually one of the impetus for Healthier SG. We are ageing and getting less and less healthy. So making sure the population is healthy becomes our top priority. I have described how Healthier SG should work in Parliament recently. There are five components. Let me just recap them briefly for our audience today.
26. If you want the population to stay healthy, primary care is essential because that is where preventive care can be practised. So number one, mobilise our network of family doctors. GPs as well as polyclinic doctors. Once we mobilise them, bring them into the public health system.
27. Number two, they need to be equipped with Health Plans to advise their patients. What is in a Health Plan? We are working out different Health Plans for different chronic diseases, but by and large they include things like regular scheduled check-ins with doctors so that they can see how you are doing, and making sure that you go for your vaccinations and screenings that are scheduled. They include chronic care management for those who have already had onset of sickness and that includes medication and adjustments to your lifestyle such as different diet and exercise regime, and sleeping better. All these are important ways to adjust your lifestyle to manage your chronic illnesses.
28. Number three, if you need to adjust your lifestyle, the doctor’s clinic is not enough. The doctor needs to refer you to community activities. That is where we need community partnerships, with different partners to organise different kinds of activities so that the patient can participate and it makes it easier for them to adjust their lifestyle.
29. And number four, if we can have 1-2-3 in place, then we are ready to launch the Healthier SG enrolment programme. We are targeting everyone 40 years and above to go to a GP of your choice and enrol. And once you are enrolled, you will get your Health Plan and you will follow your Health Plan and stay healthier.
30. Number five, in the background we need complex support structures in manpower, financing and IT systems. I will not go into that today because each is a huge topic. But we need all this in the background in order for 1-2-3-4 to work. This is essentially Healthier SG in a nutshell.
31. Today, since all our stakeholders are here, I want to look at Healthier SG from a different perspective. Not from the perspective of the working components, but from the perspective of all our stakeholders. What do you do? What is your role in Healthier SG? And I assure you, everyone has a critical role.
32. This diagram roughly illustrates it. Our key stakeholders on the left are the hospital clusters. Hospital clusters will drive Healthier SG implementation. Their key point of contact on the top are family doctors in GP clinics as well as polyclinics who will in turn work with eldercare centres, as well as community partners. We also need some enablers such as the Primary Care Network, our IT systems, and very importantly, the Agency for Integrated Care (AIC). This is in a nutshell how I think each stakeholder fits in. Today I will take you through stakeholder by stakeholder and how I think your life will be different once Healthier SG comes about. Your life will be different in a good way.
33. Let me start with the clusters. Today our clusters are providers of acute care services and they do a very good job. But now they have to take on another role, where they are accountable for population health as regional health managers. Number two is a big change and I really thank our clusters for agreeing to this and looking at things from a long-term perspective. It is to transit their budgetary calculation from a workload-funded model to a capitation-funded model. The budget stays the same, in fact it is slightly more, but the basis of calculation changes to a capitation mode. If I look after 1.5 million people, each one gets a certain budget, I get the full budget based on the population I look after. But once that basis is changed, the clusters’ instinct changes to one where I will try my best to invest in preventive care. Keep the population I am looking after healthy. The healthier they are, the healthier my budgetary position. This will really spur our clusters to collaborate with GPs and their own polyclinics to provide greater support to community partners and various agencies. This is a big change for the clusters.
34. I should highlight one special role that the clusters will perform in this whole scheme of things, which is that our clusters will be the ones with the data. The way we designed our IT architecture, data will end up aggregating and residing in the clusters. Data is very powerful. With data, our clusters will be able to have a sense of the state of population health and health trends in the population. Number two, they will be able to make sense out of it and see which intervention measures are more effective. With that data, they can guide polyclinics, GP clinics, community partners on how to shape and review their programmes. So clusters play a very critical role because they have the data.
35. I move on to the next set of stakeholders, our family doctors in polyclinics, as well as GP clinics. How will life change for them? A new focus anchoring well residents to primary care even before they fall ill. There is a huge mindset change. In the past, if you are a GP, you wait for sick people to come to your clinic. Now the government will make them enrol and you are seeing healthy people. They may have something underlying waiting to pop up, but we want them to see you. Beyond the cough and cold business, you are going to get a lot more people coming to you who look quite healthy but your job now is to prevent them from falling sick years down the road. This means the shift in workload from an episodic short-term care of people with acute illness to something holistic and long-term. And that must be based on trust and relationship. That is why the resident must commit to seeing one doctor because that is how you build trust. And in such a mode, you do not just prescribe medicine. We also believe family doctors will prescribe social prescriptions. What are social prescriptions? Healthy lifestyle, sleep, eat, exercise better. And once you do this holistic way of taking care of patients instead of operating as singletons, you work with and are supported by partners. Our polyclinics and clusters are practising this. I believe almost all of our polyclinics have teamlets looking after complex chronic cases and in a team, they are a lot more effective than one doctor to one patient.
36. Private GPs will be supported by a fee-based preventive care role. Today, the revenue of a GP comes from consultation and selling medication. We will build up another revenue stream which is fee-based, based on preventive care under Healthier SG. It is not an alien concept for GPs because during COVID-19, if you are part of our healthcare system, diagnosing people and sending them home to recover and supporting them, it is a fee-based model. So our GPs are very familiar with this model.
37. Third, community partners such as the Health Promotion Board, People’s Association, Sport Singapore and many other agencies which organise activities on the ground. What is different under Healthier SG? They will now partner clusters and primary care providers to create effective lifestyle programmes. I think one of the important things to change or improve is to make sure all the activities we organise are more welcoming and accessible. When you organise a brisk walking group, after a while it becomes a bit exclusive and the same people keep coming. We have to have activities that are welcoming, and anyone can join. It is not exclusive but very inclusive, such that when a doctor says that you need to do brisk walking at least twice a week, here is a contact. When you call the contact, you are included with open arms. That must be how we organise activities on the ground.
38. Therefore make family doctors your partners. Do not just print a poster, call this number and put it up at the clinic. But talk to the doctor to say, what is the demography here? More seniors who need brisk walking. That is my brisk walking expert, this is his handphone number. Have a relationship with the family doctor and integrate your programmes into Healthy 365. Healthy 365 must become the companion of every resident to keep yourself healthy. And so, if that is the companion of a resident, when you develop a programme, you must somehow integrate Healthy 365 into your programme.
39. We have two important icons in your handphone, if you have not downloaded them, please do so. One is HealthHub, and the other is Healthy 365. HealthHub contains your medical information, vaccinations and test results. It is very much medical and is linked to our national database. Healthy 365 on the other hand, monitors your lifestyle. It contains all your lifestyle activities. Your diet, your steps, activities that you have taken part in. We will have to upgrade Healthy 365 to take in all these functions.
40. The good thing is that there is an explosion of health apps and wearables in the market now. We want to make Healthy 365 compatible with all of them. Regardless of what you use, whether it is FitBit, Garmin, Apple, LumiHealth, it can talk to Healthy 365 and your activities can be captured under Healthy 365. It is important. We want it to be a window for residents to access all the Healthier SG programmes. It is a repository for lifestyle data, so that when a resident, having participated in all these activities, can capture all of them in Healthy 365. And when you see a doctor next time, you can show it to the doctor. The doctor can review it and say you have done well, you have not done well, or you need to do more, or you need to change your activities.
41. The next stakeholder are our eldercare centres (ECs). Eldercare centres are a very significant asset on the ground. We have 119 of them, all over Singapore. It is a port of call for the seniors, for them to access what we call ABC activities: Active ageing, Befriending, and Clinical referral, so that if you are sick, the eldercare centre may refer you to the right healthcare setting. We are changing that, to improve them further with more scale and more scope.
42. More scale. We will increase 119 ECs to 220 by 2024. More scope, because other than the ABC activities that I talked about, the eldercare centres can do more under Healthier SG. So for example, there can be more programmes and community activities for seniors. And very importantly, you can do health monitoring. Health screening can be done at the eldercare centres for seniors. You can get vaccinations there; you can do some simple rehabilitation programmes there and you can think about what other clinical services can be done in eldercare centres. And imagine that there are 220 of them around Singapore. It is a lot more accessible for our seniors.
43. If we do all these activities on the ground, they need not be led by doctors. I think we should let them be led by nurses and allied health professionals.
44. The next stakeholder is AIC. Playing a very critical role is the lubricant that lubricates everything. AIC plays three important roles – an Integrator, a Connector and a Partner.
45. An Integrator integrates social and health services in the community. Especially when it comes to seniors, there are many who are difficult to find. AIC is able to find them with their team of Silver Generation Ambassadors, so that we can connect them to the right continuum of healthcare services to let them age in place.
46. Number two, as a connector between residents across the continuum of care. In Healthier SG in particular, I will need the help of AIC with their Silver Generation Ambassadors to reach out to residents and ask them to go to their preferred GP and enrol in the Healthier SG National Programme.
47. And finally, AIC is a trusted Partner of GPs. When we consulted GPs on Healthier SG, one of the top feedback they gave us is: “Do I still get to work with AIC?” We assured them they will, because just like during COVID-19, AIC is the one that works with the GPs to troubleshoot programmes, makes sure everyone understands the rules, upgrades capabilities, provides grants, and just making sure things work. For Healthier SG, AIC will continue to play an important role.
48. And finally, the people in the middle, why we are doing all this, are the residents. How will life change for the better for residents? Number one, we would like residents to enrol and anchor with one family doctor. Try not to run around – one doctor for cough and cold, the other one for MC, another one for chronic diseases. Over the long term, it is a disservice to the residents.
49. Number two, actively improve your health with the help of your doctor, Healthy 365 and all the apps that you can tap on, instead of waiting passively for illness to happen. And to do so, tap into all the community resources that we are going to set up, with the help of all the agencies. And use HealthHub, Healthy 365 to monitor your health status and lead a healthier lifestyle. As I mentioned, there is an explosion of apps, with something for everyone which can prompt you to do the right things.
50. We have been consulting residents and hearing from them. What do they expect out of Healthier SG? I also noticed recently there have been a lot of letters in the newspapers giving us very useful suggestions and views on Healthier SG. This is a feedback direct from someone, 58 years old, diagnosed with high cholesterol. She said, “I follow up with my regular GP for high cholesterol and appreciate the long-term relationship we have. It gives me a peace of mind that my GP has a holistic view of my health. I’m comfortable with discussing my health concerns with him.” That is the trust relationship that you have when you commit to see one doctor. Doctors start to know you better and can help you solve your problems. So I am very happy to hear such a view.
51. And then we talked about using health points to nudge people to exercise more. We are very cheered and encouraged that we have got these two things. Talking about benefits, one said, “Have to see if the Health Plan is valid, before I look at the benefits”. I think he is right. If the Health Plan doesn’t work, what is the point of having the benefits and the health points? A second one, middled-aged male, “Incentives only work so much… if the user experience isn’t great, they will go like… ‘so what if you’re giving me this voucher?’” I am quite encouraged that success does not lie in simply giving vouchers and incentives. Success lies in having a good Health Plan, letting people know that they will get healthier, and making sure that the user experience is pleasant. These are within our control.
52. Finally on the sharing of medical records, there is this lady, diagnosed with high blood pressure who said, “We don’t have to repeat all that we need to share with polyclinics and doctors and specialists and different healthcare providers. For me, it’s good.” And that is what the National Electronic Health Record seeks to achieve.
53. To conclude, you would have heard of Forward Singapore, which was announced on May Day this year. It is by the 4G ministers, and we are working on this exercise to refresh the social compact between people, the government and between Singaporeans.
54. Healthier SG is a refreshed social compact and a very important prong of Forward Singapore, because it is a refreshed social compact for healthcare.
55. Looking at COVID-19, we managed it quite well by international standards, because the compact is strong. What is the compact during COVID-19? As individuals, we take our vaccinations, we observe the safe management measures, and do our part. On the government’s part, we make sure that the harm of the virus is minimised, reduce the number of severe illnesses and death, and when the time is right, we will restore life to normal. So that was the understanding, a clear understanding between people and the government, and we are able to get that to work.
56. Healthier SG is the same. We are an ageing society, things are getting unsustainable in terms of the cost burden. But we can solve this with a refreshed compact. As individuals, take care of your own health while it is early. As the government, we will mobilise all partners, especially family doctors, to support you to help you stay healthy. And if you unfortunately fall sick, we will make sure the health safety net will support you. Even in a society that is ageing, we will be able to do that with a refreshed compact.
57. At the end of the day, what will success look like for us, under Healthier SG? And we thought quite hard about it. There are so many Key Performance Indicators but I think it boils down to a few key outcomes. I will just list three. One, people taking ownership of their own health. That’s one outcome. Number two, one resident, one family doctor. Number three, reduction in chronic disease incidence, and that will inevitably lead to a reduction in hospital admissions. Three outcomes that I think are worth all of us working towards. Thank you very much.