Dr Gerard Ee, Chairman, Agency for Integrated Care (AIC)
Friends and partners
Ladies and gentlemen
1. I am happy to join you today at AIC’s Community Care Workplan Seminar.
2. Last week, I presented all the key work streams for the healthcare sector at the MOH Workplan Seminar. I covered a range of health issues, including expansion of acute care capacity, manpower expansion, Healthier SG, supporting palliative care, ageing in communities and precision medicine.
3. Today, I will elaborate on one work stream that concerns the community care sector the most, which is ageing in communities.
4. Given that this is the first time I am addressing all of you since we transited to DORSCON green, let me start by expressing my appreciation to everyone.
5. It has been a trying few years. The community care sector bore a heavy burden during the pandemic crisis because the virus exposed our seniors to the most risk.
6. Many succumbed to the virus. Our hearts go out to them. I speak for everyone in this sector. We did what we could to protect our seniors and treat those who were sick. Singapore registered one of the lowest COVID-19 death rates in the world.
7. I would like to offer my deep appreciation to every one of you for your tireless dedication and energy throughout this period. We have weathered this crisis together as one healthcare family.
8. We are going through another COVID-19 wave, and probably at its tail end. This time, there were no additional safe management measures, which means the healthcare system, including you, bore the brunt of the impact.
9. We registered over 50 deaths in April, quite similar to what we go through during an influenza season. Hospitalisations went up by about 340 more beds at one point, which contributed to the already very heavy workload in hospitals. As the infection wave continues on its downtrend, and we expect this week to be better than last week, hospital beds are being freed up and this will somewhat help relieve the capacity constraints on our hospitals.
10. We have just demonstrated what it is like to be living with COVID-19. While hospitals became busier, we protected the normal social and economic lives of Singaporeans.
11. We must remember that COVID-19, with its different strains, is not a mild disease, and we can live with it because our resilience has stayed strong due to vaccination and natural recovery from COVID-19 infections.
12. So it is important that we, as community care health providers, continue to urge our patients to update their vaccinations typically once a year, for those who are vulnerable, such as those who are 60 and above or those who have underlying illnesses. Only then, can we continue to live with the virus as an endemic disease.
13. Having more or less settled COVID-19 for now, we now have to deal with a much bigger wave coming our way – which is ageing. We all know the story, that by 2026, Singapore will be a “super-aged” society with 21% of our population aged 65 and above. By 2030, about 25% or one in four Singaporeans will be a senior aged 65 and above.
Ageing in Communities
14. In anticipation of that, we are adjusting many policies – raising the retirement age and re-employment age, transforming our economic model to a more innovation and productivity-driven one, rather than a manpower-intensive model, and building more ageing-friendly assets and living environment. We are upgrading estates so that it is easier for our seniors to live in the community. We started doing these many years ago.
15. We are also increasing nursing home capacity, with the number of beds doubling from 16,000 in 2020 to 31,000 in 2030.
16. I recently met the Health Ministers of Sweden and Finland and we exchanged views on ageing. They shared that in their countries, the approach is to keep seniors healthy as much as possible and should they be sick or frail, they support them to live at home for as long as possible.
17. Health services are layered upon social support activities to help seniors live in their own communities and homes. A community nurse can visit a senior at his or her home about three times a day. They know that this model requires more manpower, but this is their care model. They want to do this to keep seniors at home and transfer them to nursing homes only as a last resort. Typically, their average stay in a nursing home is about one year, at most two years. Our average stay in a nursing home is three years.
18. These countries have aged before us, and they have learnt from experience. There is much we can learn from them. We have now come to the same conclusion, that it is very important for us to expand our nursing homes capacity, but we cannot expand it forever, in order to address our ageing challenge.
19. Nursing homes are not as scalable as we think, as they require land and manpower. More importantly, it is much better for seniors, medically and emotionally, to age in their current communities where there is a sense of purpose, there is agency, they have friends, they have relationships and they are more likely to stay active.
20. This is the best way to prevent them from being socially isolated. Social isolation is a growing issue, with an increasing number of seniors living alone. The New York Times published an article last December on the rise of kinless seniors in the United States. They are called “solo agers”, who present worse mental and physical health, and tend to pass on earlier. They describe social isolation as the new epidemic.
21. I think the same trend is happening in Singapore. During my home visits, I came across many such seniors. Many are single. Others married, but their spouse may have passed away, and their children visit them once in a while because they are busy.
22. They still look relatively healthy, but are reluctant to get out of their homes. Many of them will cite COVID-19, or leg injuries. I worry for them because they are at risk of becoming socially isolated. When they are isolated, it is very bad for their health.
23. We need to and can do more to help and support our seniors to age in communities healthily and happily, with a social circle, surrounded by friends and engaged in activities.
24. Our Active Ageing Centres (AACs) are established in residential estates to directly support our seniors. To better support them, we have announced that we will significantly expand the network of AACs. We have 119 now, and we aim to increase to almost double to around 220 by 2025.
25. More importantly, we need a qualitative change in the way we operate AACs. This will be a key priority of the community care sector in the coming years.
Reboot our Operating Model
26. What do we need to change in order to reboot the AAC operating model? There will be detailed discussions at the breakout sessions this afternoon, but let me outline the broad changes that we need to bring about.
27. First, we need to significantly, and proactively extend our outreach to seniors. Each AAC has about 1,000 to 4,000 seniors living in the area under its charge, and we need to be able to engage most of them. A lot of our seniors are still at home, and are not willing to leave their houses. To do so, the few staff of the AACs is not enough, and we need a large community volunteer force, by tapping on the good work and capabilities of our Silver Generation Ambassadors, People’s Association (PA) volunteers as well as other community volunteers.
28. We need to work together, quickly reach out to seniors all over Singapore, and identity those who are at risk of social isolation. We must do our best to limit the number of seniors who are unknown to the system, living alone with no support, or worse, dying alone at home.
29. Second, we need to strengthen our befriending efforts. Once we identify who are socially isolated, befriending starts. This will require sustained effort by volunteers. Over time, by building up our relationships with the seniors, we should be able to engage them to participate in more community activities.
30. AACs have organised many activities and I encourage you to continue to do so. Having spoken to many AAC operators, what is commonly cited by you as the most effective engagement method is communal dining. I am convinced too, and I think we should do this as a starting point to build communities.
31. Third, we need to connect seniors to other activities and spaces in the community. AACs need not feel that you must do everything. You are the staging ground. AACs need to leverage all existing community assets like coffee shops, hawker centres, parks, libraries, and community centres, and connect seniors to all activities in the community, whether they are organised by PA, the Health Promotion Board, SportSG or any other organisations.
32. Fourth, promote senior volunteerism through the AACs. Senior volunteerism provides seniors the opportunity to meaningfully contribute to the community and help others. It will benefit them tremendously. Further, senior volunteers are a very strong ground asset given their passion and connection with other members of their own age group.
33. Finally, we need to expand and extend the scope of AAC’s work. We would like to evolve the operating model of AACs from ‘ABC’ to ‘ABC+2Ss’. I know MOH has been explaining as ‘ABC+2Cs’, but we are adjusting the ‘Cs’ to ‘Ss’, with no change in substance.
34. As you are familiar, “ABC” stands for organising Activities, Befriending and referral to Care services. The two “Ss” are building social circles by being Social Connectors, and performing Community Screening.
35. In particular, we can explore how functional and health screening, over and above regular vitals monitoring, could be introduced in AAC premises. This could involve partners such as health clusters, who can work with selected AACs to see how such screening services could be made available at the AACs on specific days of the month. Over time, more residents will be aware of these and the numbers attending will grow. The idea is for health screening to be as simple and accessible as getting your haircut.
Supporting the community care sector
36. A lot of effort and resources are needed to make these changes. The community care sector will need stronger support and I fully appreciate this.
37. Some of the support is within the ability of MOH to deliver. The first is manpower. Recruitment and retention are perennial challenges in the community care sector. There is a limit to how much digitalisation and productivity improvements can help to moderate demand in such a high touch sector.
38. We will continue with our community care salary enhancement exercise to provide funding support to keep salaries as competitive as possible. AIC also has ongoing efforts on sectoral job redesign, to transform the workforce through better task allocation across support care, nursing and therapy manpower.
39. There has been much discussion, including in Parliament, about the conversion of foreign healthcare staff, who have become an integral part of our team, to PRs in order to retain them. With heightened international competition for healthcare talent, experienced healthcare staff can easily be poached by other countries. Offering PRs will help anchor them in Singapore.
40. All these efforts have produced some results. Our out-of-sector attrition rate in the community care sector has improved from 14.3% in 2021 to 12.5% in 2022. In terms of recruitment, over the past three years the number of local staff in the community care sector has increased by 12% from 7,100 to over 7,900.
41. Second, clinical care support from our three healthcare clusters. With Healthier SG, there is a strong push by the clusters to deliver preventive care to the community. So in revamping the operations of AACs, do work closely with the health clusters.
42. We need to make it easier for you to escalate cases to secondary or tertiary care. Likewise, when clusters need to discharge a patient for home care or palliative care, they also need to be assured that you are able to receive those patients. It works both ways.
43. Third, – but this comes in the form of a somewhat bitter medicine – is to structure the care industry for better effectiveness. While each community provider does good work at its own facilities and settings, at a system level the varied services can be seen as fragmented. Care journeys for seniors can be disrupted with multiple assessments and administrative procedures. This in turn affects accessibility and impedes our effort to right site patients when the time is right.
44. We need to work together to address this. A large part of the issue is really of no fault of the community care sector, but how the system is designed, or in fact not designed. Hence, MOH is reviewing the way services can be more seamlessly delivered for seniors to age well in community.
45. However, there is also a structural issue. We must acknowledge that if a provider can deliver multiple services, say nursing home, home personal care plus AAC for the same patient, the overall care journey will surely be more seamless and integrated .
46. To move in this direction, MOH and AIC will facilitate providers to gain scope and scale within a geographical area, wherever possible. If this is not practical in a locality, then at least form tighter networks between providers within the same area.
47. We will do this gradually and in a practical way and AIC will follow up with detailed discussions with you.
48. I mentioned that MOH is reviewing how we ensure better coordinated care across settings. One key determinant is the consistency of financial support. A fourth area is therefore to enable seamless access to healthcare financing across settings. Here, we are working on two specific initiatives, which I have announced in Parliament earlier this year, during the Committee of Supply debate.
49. Today, many homebound patients are eligible for subsidies but due to limited mobility, are unable to make the trip to the polyclinics or hospitals. They opt for home care instead and are unable to tap on their MediSave.
50. From 1 October 2023, MOH will allow subvented home medical and nursing providers to submit MediSave claims for your patients who are homebound. With this change, if you provide home medical and nursing services like Home Nursing Foundation, your clients will be able to tap on MediSave, similar to how they are able to do so for medical services in clinics.
51. Our providers may however need a bit of time to get operationally ready to submit the claims, and will progressively come into the new arrangement, from 1 October 2023. But I urge everyone to put some priority into this to get the system set up. Our policy change is with effect from 1 October, so come on as quickly as you can to give your homebound patients that peace of mind. When the scheme stabilises, we will extend this to other non-subvented home medical and nursing providers.
52. Another change is financing support for telehealth, which is a very useful tool for community care providers. We intend to progressively extend healthcare financing to support more telehealth services.
53. For a start, we will extend subsidies and MediSave for video-consultations for their home palliative care services, from 1 July 2023. Later this year, we will further extend subsidies and MediSave for tele-consultations for chronic disease management.
54. Finally, the sector will need more resources, whether it is to recruit more manpower, expand the scope of AACs’ work, or promote volunteerism or integrated services. This goes beyond what MOH is able to do, and is an issue currently under deliberation by the inter-ministry Forward SG exercise.
55. We recognise that to decisively address our demographic change, and to pre-empt the rapid rise of frailty and other age-related diseases, the Government will need to prioritise spending in this area and develop a major national programme probably as significant as Healthier SG. So give us some time to work on this.
56. We are at the cusp of a major change in the community care sector. It will fundamentally revamp the way we look at aged care. The refreshed system will be more effective, focusing on prevention of diseases, preservation of health, and giving purpose and agency to seniors to age in their communities and homes. It will require all our contribution and help, and our support in realising this vision. AIC, MOH and the Government will in turn do whatever we can to support you.
57. I look forward to working closely with everyone to bring about this very important change. Thank you.