Dr Gerard Ee
Chairman, Agency for Integrated Care (AIC)
Friends and colleagues from the Community Care sector
Ladies and gentlemen
1. I am very happy to join you for this instalment of AIC’s Community Care Work Plan Seminar. It has been a difficult year for the whole sector due to the COVID-19 pandemic.
2. We all know that the virus affects seniors the most. That means that the community care sector bore disproportionate responsibility, burden and stress during the pandemic.
3. We sometimes read stories of how the COVID-19 pandemic swept through the nursing homes (NHs) in some countries, leading to many deaths and casualties. In Singapore we have largely avoided that. Because MOH, AIC, our hospitals and NHs have worked closely together, and have protected our seniors as best as we can, primarily through infection control measures and more importantly, vaccinations.
4. At some point, after speaking to leaders of NHs, MOH decided to back up the sector with Vaccination-Differentiated Safe Management Measures (VDS) to encourage residents to receive their vaccinations, so that they can receive visitors. That was during the height of the infection waves. And that, I believe, encouraged more of our residents to take up the vaccinations. Some of the responses to this policy were very negative and sharp, but it was the right thing to do and probably saved many lives.
5. Today, we have rolled out COVID-19 vaccinations to over 90% of eligible NH residents and Senior Care Centre (SCC) clients, as well as over 10,000 home care clients.
6. A great part of our success in responding to COVID-19 therefore depends on how we have protected our seniors. So I want to start by thanking everyone for your tremendous effort and sacrifices over the past two and a half years. It was an exemplary demonstration of dedication, commitment and professionalism of the sector.
Preparing for the Next Infection Wave
7. The pandemic is however not over. We must expect new infection waves, new variants of concern, and at some point, even a new pandemic.
8. In the short term, we should expect a new infection wave, and we think it is likely in July or August this year. This is because our current high level of immunity, accumulated from both vaccinations and natural infections from the recent Omicron BA.2 wave, will start to wane. When it does, the most dominant prevailing COVID-19 strain, most likely BA.4 or BA.5, will start to multiply and drive infection numbers.
9. But infection numbers matter much less than the number of people who fall severely ill and need to be hospitalised. So long as we can protect our hospital capacity, we will be able to ride through a new infection wave smoothly, without imposing any significant social restrictions. That should be our aim.
10. Remember, vaccinations give our bodies a few layers of defense. Even if the first layer to prevent infections wanes after a few months, there are further layers to prevent us from falling very sick if infected.
11. International evidence and our own data show that protection against severe illness and hospitalisation continues to be very strong many months after the first booster shot.
12. We will monitor the situation closely and stay prepared. MOH will also need the help of the community care sector to undertake three key tasks in preparation of the new infection waves.
13. First, every healthcare setting will need to be COVID-19 ready. During the recent Omicron Wave, NHs worked tirelessly with AIC to look after their infected residents on site, under the Care@NH initiative.
14. You had to swiftly set up cohort spaces, step up care protocols to intensify monitoring of infected residents, provide stepped-up medical treatment, swiftly triage and escalate cases, and manage the concerns of anxious loved ones and next-of-kin (NOK).
15. Apex Harmony Lodge (AHL), Sunlove and Surya were one of the first NHs to care for infected residents on-site. They felt that their residents, who are persons with dementia, would recover better in a familiar environment, rather than being transferred to a hospital which can be stressful and confusing. Such resident-centric consideration is a key motivation of NHs who have similarly stepped up to Care@NH.
16. Since February this year, over 4,700 residents infected with COVID-19 have been cared for on-site in NHs. Imagine if they had all been transferred to hospitals. Our hospitals were very strained, but they were not overwhelmed.
17. Currently, over 80% of NHs, including the two inpatient hospices, are on board the Care@NH programme. MOH will work with the remaining homes, so that by the time the next wave arrives, they are all ready. For residents who are at higher risk or have more complex conditions, be assured that they will still be escalated to acute hospitals.
18. Second, we need NHs to continue to actively accept transfers of patients from acute and community hospitals. There are still many patients who no longer need acute care in hospitals, but nevertheless are staying in hospitals while they wait for vacancies at NHs.
19. Since April this year, we have opened more NHs, and the sector is collectively accepting about 300 new admissions each month from acute and community hospitals. I thank you for your support, especially in the face of a bad manpower crunch, but please continue to work closely with our hospitals.
20. Third, and probably most importantly, we need to ensure that all our residents get their booster shots. Although we gain fully vaccinated status after two shots of mRNA vaccine, against the Omicron variant, we, and especially the seniors amongst us, need three shots of mRNA vaccine.
21. Let me cite you some numbers. For those above 60 years old and have not received their primary series, the incidence of severe illness and death after Omicron infection is almost four in 100. For those not boosted nine months after their primary series, incidence rate is one in 100. For those boosted, the incidence rate drops to three in 1,000. The booster shot is critical, especially for our seniors.
22. Omicron is therefore a dangerous disease for seniors who are not fully vaccinated and boosted.
23. In the next one month, we need to work hard to get all our seniors boosted with a third shot. For those who are older or immune-compromised, we recommend a fourth shot. For the minority who may be concerned about receiving another mRNA shot, we now have a good alternative in the Novavax vaccine, which is based on more traditional technology.
24. Let us work together closely, to get these critical tasks done.
Major Roles of Community Care in Healthcare
25. Let me now go beyond COVID-19, to talk about the role of the community care sector in healthcare, especially in the light of the Healthier SG strategy.
26. It is a role of rising importance, because of our ageing population. There will be many more aged sick, who need to be looked after within families, in hospitals, communities and NHs.
27. Some have asked me: What is the role of the community care sector in Healthier SG? Healthier SG is very much a strategy to address the escalating strains of an ageing population. So to be honest, the community care sector will actually bear the brunt of this tremendous demographic change. You are front and centre of this national challenge!
28. Just look at the capacity expansion of the sector to get a sense of the scale of this challenge. Between 2010 and 2020, we expanded NH beds from about 9,600 to 16,200 – a 70% increase. In the next 10 years, we plan to increase capacity by close to another 100%, to more than 31,000.
29. MOH constantly asks ourselves: Is this rate of increase sustainable? Other than expanding NH beds, we need to take decisive steps to right site aged care, away from acute hospitals, community hospitals and NHs.
30. I believe Healthier SG will work to ensure that more seniors can age healthily, live independently and happily. We need new senior care models to allow more seniors, even those who require assistance with daily activities, to age and be cared for in their own homes or in the community. We also need to support caregivers, physically and emotionally. They are making great personal sacrifices and are often under-appreciated by families and the society.
31. One important move is to expand both the scale and scope of the services of Eldercare Centres (ECs), to support ageing in place, in communities and our own homes. It is not a panacea, but will help anchor and support care in the community.
32. We have already rolled out 119 ECs so far. It is the largest ground community asset that MOH has. ECs are important community touchpoints for healthy and pre-frail seniors. They help seniors meet their ABC needs, i.e. active ageing, befriending, and referral to care services.
33. By 2025, we aim to almost double the number of ECs to 220, to ensure sufficient coverage across the island.
34. In addition, we will increase the scope of services in ECs. For instance, seniors today may visit their GPs and polyclinics once every few months for their chronic conditions. In between these visits, seniors can visit the ECs to engage in health-related activities or enrol in active ageing programmes. In time, we would like ECs to help seniors monitor their vitals, do simple health screenings that do not require the presence of doctors, and link up with other service and healthcare providers.
35. Eventually, each EC should be responsible for the 1,000 to 4,000 seniors under their charge, and work with community networks such as grassroots and People’s Association, Social Service Offices, and GPs, to address seniors’ health-social needs.
36. Another important move is to increase the supply of good quality end-of-life care at home, in centres and hospices. For a long time, end-of-life care was a taboo topic, but I am glad that we are more ready to openly talk about it now.
37. Most of us prefer to pass on in a familiar environment, surrounded by loved ones, instead of in hospitals. But few of us actually do so when the time comes. So we are not quite fulfilling the wishes of individuals, while stressing our health institutions.
38. Over the last few years, we have tested and integrated new models of care between hospital and home. We will have to do more for palliative care to be further anchored in the community.
39. NHs will be a key partner in this effort. NH residents will not want to go through multiple transitions to and fro hospitals towards the end of their lives, as it can be very distressing.
40. For NHs involved in the recent end-of-life pilot programme, I hope you would have seen the benefits of your efforts. AIC will work with more NHs to onboard this effort.
41. To do this, we will work with NHs to build up their skills and confidence in managing end-of-life journeys, including attending to the health symptoms, facilitating Advance Care Planning, and providing emotional support to residents and their family members.
42. I know this is a major shift for many NHs. But when I think about the resident-centric motivation behind how you quickly came on board Care@NH, I believe that you will rise to the occasion here too. AIC and MOH will support you as much as we can.
Building Up our People
43. Finally, let me talk about manpower, which is our most severe constraint in achieving what I just set out, and a major concern for community care providers.
44. We will need to continue to depend on the commitment of staff in the community care sector to deliver quality care and services for our seniors. We will need to retain as well as attract good staff. This requires a combination of measures.
45. First, salary competitiveness is a major factor. We have embarked on the Community Care Salary Enhancement exercise and have committed about $290 million to raise the salaries of Community Care Organisations (CCO) staff from 2020 to 2023. This will ensure that their salaries remain competitive against the public healthcare sector and the market. This will close the gap meaningfully.
46. Second, MOH and AIC will continue to invest in skills development of the sector’s workforce. AIC’s Learning Institutes have scaled up its offerings, with more than 18,000 training places offered annually.
47. Third, we are also working on transforming existing roles through job redesign for non-clinical manpower and digitalisation, to increase productivity and value of the jobs. We are embarking on a Community Care Digital Transformation Plan. It will help remove repetitive and administrative tasks, and will be a meaingful support structure for our partners and for Healthier SG.
48. Finally, we still need foreign healthcare manpower. I am a big believer in using technology and digital health to improve preventive care and adjust lifestyles, but community care is inherently a very high touch sector. There is a limit to replacing physical manpower with technology and digital solutions.
49. Hence, our manpower needs will continue to increase amidst an ageing population, even as our cohort sizes are falling. We will need to complement our local workforce, especially for nurses and support care staff, with foreign manpower. This is a difficult and sensitive topic, and I will be happy to hear your views and answer any queries during our panel discussion later.
50. The healthcare sector is undergoing a big transformation because of two massive challenges before us. In the short term – COVID-19, and in the long-term – ageing.
51. We need to do things differently, support each other to rise above these challenges. We will need resources, manpower, determination and hard work. But more importantly, we need to count on each other, and count on every Singaporean to do our part. We will be there to provide the key support. This is ultimately our most important success factor.