Mr Tan Tee How
Chairman, National Healthcare Group (NHG)
Professor Philip Choo
Group CEO, NHG
Our valued partners, friends and colleagues
Ladies and gentlemen
1. I am happy to join you again at the Population Health Collective (POPCollect) workplan seminar for Community Partners and General Practitioners (GPs). A lot has happened in the past year.
Endemic COVID-19
2. The first is on COVID-19. We have transited to DORSCON Green, stood down practically all our social restrictions, and are treating the disease as endemic.
3. But we continue to watch the situation closely. We sample patients who display acute respiratory symptoms for testing and genetic sequencing, testing for viral fragments in wastewater samples throughout the island, monitoring occupancy of hospital wards and Intensive Care Units (ICU) by COVID-19 patients. We do this on a daily basis.
4. By all indications, for the past month, we have been in the middle of another COVID-19 infection wave. However, like all endemic diseases, we no longer have very granular data on COVID-19 infections.
5. This is no different from the Ministry of Health (MOH) or any hospital being hard put to report the number of Influenza infections on a particular day or over a week. We can say that it is either going up, down or stable, but we do not know the actual number because most people choose to recover at home on their own, and many do not get tested too.
6. Through our sampling techniques, we did however notice that the percentage of patients with acute respiratory symptoms and who tested COVID-19 positive, as well as the viral load in waste water samples, have gone up. This indicates that we are in the middle of a wave for the past one month. From there, we estimate the daily infections have probably gone up from 1,400 a month ago to about 4,000 daily cases last week.
7. This is a small fraction of the 20,000 or more daily cases we used to experience at the peak of the crisis. Our assessment is that the case numbers have likely stabilised this week.
8. I read some comments by people who attributed the rise in local infections mostly to travellers bringing in the virus. Indeed if it is a new variant, chances are it came in from travellers. But the understanding that this causes a rise in infections is incorrect. The virus is endemic, which means it is always circulating within our community. In such a situation, what drives our local waves is not imported infections, but re-infections of existing individuals in the community.
9. When the protection against infection from past infections or vaccinations wanes over time, people get re-infected and that causes the number of cases to rise and a new wave will emerge. MOH estimates that about 30% of current infections are re-infections, higher than the observed 20% to 25% during the last infection wave.
10. We continue to do genetic sequencing of the viral samples. There are now multiple variants circulating – XBB, XBB.1.5, XBB.1.9, XBB.1.16, XBB.2.3, BN.1, CH.1.1 – without a clear dominant strain. Of particular interest now is XBB.1.16, also called Arcturus. Of all the various strains now, there is really not a single one that we notice is particularly dominant, and there is no evidence showing that any one of them causes more severe illness.
11. The most important aspect of any infection wave is the severity of symptoms and whether patients become hospitalised. There has been no evidence showing that any of the current XBB strains cause more severe illnesses.
12. The number of hospitalised COVID-19 patients has gone up, from 80 to 220 over the past month – but far below the peak of the pandemic. It is also much lower than the number of patients hospitalised due to non-COVID-19 infections.
13. ICU admissions remain stable and low, with less than ten COVID-19 patients at any one time over the past month.
14. What is happening is a clear demonstration of how far we have come in living with COVID-19. Even during a COVID-19 infection wave like now, we continue to live life normally, not pre-occupied over infection numbers, and not constantly talking about it. This is what endemicity looks like.
15. While it is not a severe wave, the additional caseloads do add to the very heavy workload of the hospitals. So please help educate your patients, friends and family to stay healthy and hydrate, stay home and wear a mask if unwell, and get vaccinated annually if they are vulnerable or aged 60 and above. Our Joint Testing and Vaccination Centres continue to be open and vaccinations continue to be free.
Healthier SG
16. My second update today is on Healthier SG. Over the past year, the MOH family has been hard at work to prepare for the roll out.
17. A key pillar of our public healthcare system all these years has always been our acute hospitals. They are very important as they look after the sickest patients. It is probably the costliest part of the entire ecosystem and they work with various partners.
18. Our policies and processes tend to focus on ensuring acute hospitals deliver quality and affordable care, and we are able to transfer patients to other parts of the system so that acute hospitals are not overloaded. That has been our focus because it is the key pillar.
19. As the healthcare system grows and matures, we need more than a strong pillar, but a broader foundation. Healthier SG aims to do this, by broadening the healthcare foundation through primary care, i.e. polyclinics and GPs who serve in the community and maintain valuable, personal patient-doctor relationships. This provides the broad foundation of care.
20. That is why MOH, together with the clusters and the Agency for Integrated Care (AIC), has been engaging the GPs and developing Healthier SG with them. It is a co-creating process because we need to get this foundation right.
21. Roping in GPs to contribute to public health is not new, as many countries have done it. We are in a way learning from them. But how we are doing it under Healthier SG is quite different.
22. In many countries, it is compulsory for GPs to join such Government schemes. After joining, GPs earn mostly a fee income from the Government, and their main role is to triage patients and gatekeep the most expensive hospital system.
23. In our case, we did not design Healthier SG for GPs to become gatekeepers, but we want GPs to deliver preventive care to residents. We also consciously decided that GPs should continue their current business and operating models. Instead, GPs can choose to join Healthier SG, and if they do, they earn an additional fee income from MOH, to deliver preventive care to residents enrolled with their clinics.
24. We have gone through a few iterations on the design of the scheme, and I think we have something very workable before us. With Healthier SG, the revenue composition of GPs will shift – towards more fee-based income from the Government for delivering preventive care, and also more services such as nationally recommended vaccinations and health screenings, which the Government will fund fully for enrolled patients.
25. But the overall primary and preventive care pie will be enlarged, because the Government is investing a lot more into it.
26. We started recruiting GPs into Healthier SG in mid-March. I have been very encouraged by the response and the momentum of participation. 90% of the clinics in our Primary Care Networks have applied to join. As of yesterday, out of 1,200 CHAS clinics which are eligible to join, about 800 have been onboarded to Healthier SG.
27. There will bound to be some teething issues, like IT for example, but we will work through them with the GPs. I am sure in a few months, things will stabilise. I am very sure that this is a much better way of taking care of people. With this development, we are on track to launch the programme in July 2023. A pre-enrolment exercise will start in May 2023 to ensure that GPs can retain their existing patients aged 40 and above with chronic disease.
Discipline and Empowerment
28. With a broader foundation, comprising acute hospitals and Healthier SG and primary care, the next pertinent question is – where do we go from here?
29. I think the vision shared by us all, is to continue to deliver high quality and affordable healthcare, and at the same time, create health in homes and in our communities. We should live up to our name as the Ministry of Health and not the Ministry of Sickness.
30. This must naturally involve all healthcare providers that are in our homes and communities. Beyond the GPs, they include community hospitals, nursing homes, hospices, Active Ageing Centres, and entities that organise fitness, exercise and other health activities.
31. Therein also lies the formidable challenge before us. With so many providers, each well-intentioned, capable and passionate, opinionated – how do we orchestrate our work in harmony and make healthcare integrated and seamless from the perspective of the patient?
32. In the US, the role of the orchestrator falls on Accountable Care Organizations, often centring around an acute hospital or insurance company . The UK has Integrated Care Systems.
33. These countries use various funding methods to encourage the right behaviour on the part of healthcare providers so that they can work together – fund by disease episodes or by capitation – to optimise care and eliminate wastages at various levels. Sometimes it works but sometimes it does not work as well.
34. When it does not work, countries like New Zealand recently went the other direction, removing District Health Boards and decentralising healthcare planning and decision-making. So what should we do since there are many international experiences and references?
35. We have concluded that there is no magic in any particular organisational structure or funding formula that is universally superior and applicable to every country. Ultimately, we need to figure out which structure works best in Singapore’s context.
36. We have decided that the role of the orchestrator falls on our three healthcare clusters. The key reason is that our three-clusters structure is many years in the making, and each has the size and range of capabilities needed to right site and integrate care across settings, making them best placed to play the role. Imagine if you deliver only one service, you cannot orchestrate much, whereas if you run a range of services within your capability you can orchestrate a big part of the pie and therefore the clusters are best placed to do this.
37. Another key consideration is that acute hospitals under the clusters are the costliest part of the healthcare system, so relatively small improvements in care optimisation at that level, right-siting or disease prevention can have an outsized impact. We will continue to evolve the clusters’ structure and capabilities, so that the clusters are ready to assume the role of Regional Health Managers (RHM).
38. From this financial year, the clusters started to receive their budget based on a capitation formula for the 1.5 to 2 million residents under their charge. For each resident, depending on their age, they get a fee and they aggregate to a budget which is no less than what they have been getting. MOH too, we will receive a budget from the Ministry of Finance aligned to the growth of this capitated budget.
39. In other words, MOH and health clusters are now in this together. Our budgets can grow in tandem with the number and age bands of residents under our care. But it cannot grow simply because we perform more surgeries and complex treatments. We now have a strong motivation to deliver preventive care and make people healthier to ensure that costs do not escalate unsustainably.
40. Between MOH and the clusters, our partnership cannot be defined purely by KPIs, reporting structures, processes and protocols. Instead, the greater emphasis must be on discipline, empowerment and shared motivation.
41. In particular, discipline and empowerment must go hand in hand. To illustrate, the discipline we now place on health clusters, through capitation funding, must come with greater empowerment. Clusters will need to have the mandate, flexibility and support to work with other partners, or start new services, in order to deliver preventive care and enhance health or make care transitions seamless.
42. Likewise, I encourage clusters, as RHMs, to take the same philosophical approach when working with your partners. So as you flow your budgets to them, be it a hospice, a community hospital or other healthcare providers in the future, do consider doing three things.
43. First, bundle up services and simplify the funding formula as much as possible. Don’t fund by specific procedures and processes, but bundle by patient episodes.
44. Second, empower your partners to exercise discretion and judgment to deliver the most appropriate care to their patients, guided by clinical procedures and within the discipline of their fiscal envelope.
45. Third, let MOH know of any existing rules and policies that inhibit the exercising of good judgment, so that we can review them.
46. It is in this context that we need more premises-neutral healthcare financing policies that I announced earlier in Parliament this year. If home care is best for the patient, or direct admission to a community hospital is better than routing a patient to an acute hospital first, we must make support from MediSave and MediShield Life available to such patients. The broader foundation we have laid and funding discipline we have put in place justify a review of existing rules which are restrictive for good reasons. Otherwise, there is no empowerment to speak of.
Motivation
47. Ultimately, no rules and funding formula can substitute our motivation to create health and deliver the most appropriate care.
48. On the contrary, replacing some existing policies and rules with the appropriate combination of discipline and empowerment will create the space for the best motivations to surface and guide us in the right direction.
49. The next one to two years will be crucial, as they will be the pivotal years of our healthcare transformation journey. Healthier SG will hit the road running, the support system for ageing in communities will start to take shape, and we need to work out how our orchestra will play, by putting in place the right system of discipline and empowerment.
50. I seek all your patience, support, passion and wisdom, and may we continue to uphold our shared motivation to promote health in our homes and communities.