Professor Philip Choo
Group CEO, National Healthcare Group (NHG)
Assistant Professor Jerry Goo
Chairman, Organising Committee of the Singapore Health and Biomedical Congress 2022
Distinguished speakers and delegates,
Ladies and gentlemen
1. Beyond COVID-19, another pandemic which is silent, long-term and more challenging is our ageing population and the chronic illnesses that come with it. This is driven by two key trends.
Singapore’s Demographic Challenges
2. First, a rapidly ageing population and workforce. By 2030, one in four Singapore Citizens will be aged 65 and above, up from one in six today. We are not feeling the full brunt of ageing yet. This effect of ageing will lead to a concomitant increase in disease burden, as prevalence of chronic illnesses is higher amongst older people.
3. Layered upon it is the second trend, which exacerbates the first, which is the rising prevalence of chronic diseases. That is why when we came up with the name for this national programme, we chose Healthier SG and not Healthy SG because we are not really healthy. Our health is actually deteriorating. The National Population Health Survey 2020 showed an increase in the prevalence of high blood pressure and high blood cholesterol among Singaporean adults, alongside other worrying uptrends, like obesity. The only silver lining is that the prevalence rate for diabetes remained stable, probably due to the many initiatives that we are taking in our War on Diabetes.
4. It would seem that the disease burden dam has been released, and we cannot stop the water that is already gushing our way. We will try everything we can to stop this gush of water – value-based care initiatives in hospitals, Health Technology Assessment, removing the distortions caused by reckless insurance practices, bundled payments for hospital bills, co-payment for discretionary healthcare, better clinical practices. We will try them out but that is not enough. Reinventing healthcare is how we go upstream and shut the dam, or slow down the flow of water upstream at the dam.
5. The way to do this that is the most impactful and simplest to understand is to focus on preventive care. Clinicians all know that preventive steps in our daily lives can fob off severe illnesses later on in life. That is the genesis of our long-term, multi-year healthcare transformation plan, called Healthier SG.
Healthier SG and the Travellator
6. Healthier SG is a decisive shift in the focus towards preventive care to improve our population’s health, reduce disease burden for the long term, reduce suffering of people and their loved ones, and put our healthcare system on a more sustainable footing, whether it is in terms of manpower or financial resources needed to run them.
7. Today, I will borrow Professor Philip Choo’s often cited but less-known analogy of a travellator, which I will call the “Deadly Travellator of Life”. It is a bad travellator. It moves slowly and then it accelerates, and then it crashes. For some of us who are already on it, we actually may not know that because it moves very slowly at first and steadily, but is heading towards chronic illness, suffering and death. What is scariest is that most people are already on the travellator, yet are oblivious to the impending danger and not doing anything about it. Under Healthier SG, we want to save as many people as possible from this deadly travellator. There are a few things we can do.
Preventing the Onset of Chronic Diseases
8. First, let’s prevent people from getting on that travellator in the first place. We do that by warning everyone that there is such a travellator, and I think we may be having some success in doing so through all the publicity surrounding Healthier SG. I am very glad that the Health Promotion Board’s (HPB) effort to cut sodium salt has received so much publicity. People are talking about it, there are videos circulating, and people are starting to understand what kinds of food contain more salt. All these are making an impact.
9. Next, we need to empower residents of all ages to take charge of their own health and lead healthier lifestyles. A good example is the introduction of mandatory nutrition labelling and advertising prohibition for prepacked sugared beverages.
10. From end of this year, prepacked beverages with higher sugar and saturated fat must be labelled - Nutri-Grade ABCD. So far, we are encouraged by the positive response from manufacturers who have significantly reformulated and reduced the sugar levels in their beverages even ahead of the effective date of implementation. Sales of beverages with less than 5% sugar content have also gone up from 37% in 2017, to 60% in 2021. We are planning to extend the initiative to outlets selling freshly prepared beverages.
11. Physical exercise needs to become habitual. If you make it a habit, you prevent yourself from stepping on the travellator. We promote it through various avenues, in schools, during National Service, and in the community. Singapore has a wonderful network of public parks and park connectors, plus the Green Corridor, for joggers, walkers and cyclists. You can visibly see more and more people participating in exercise.
12. We also help residents make healthy living more attractive through gamification. One programme that has received strong traction is the National Steps Challenge by HPB. Participants download an app, which counts the steps you take every day, and grants small awards to those who can achieve their health goals. Our experience is that with gamification, you have a constant companion next to you, which is your smart phone, and the App will constantly nudge you to do the right thing, to exercise and not get onto the travellator.
Assessing Risk Factors Upstream
13. Second, for those in the initial part of the travellator which is still moving slowly, such as pre-diabetics, we will help them get off it while they can, through lifestyle modifications, and then they can return to good health.
14. This is the main impetus for us to mobilise our family doctors in the community to participate in preventive care and embarking on a national enrolment programme for our population under Healthier SG. We are starting with residents aged 60 and above next year, followed by those in the 40 to 59 age group in the next few years.
15. The physical act of enrolment when it happens next year in the middle of next year, is to commit to build a long-lasting patient-doctor relationship, receiving a health plan with diet adjustments and exercise as your ‘social prescriptions’. We want the individual to realise that it is important that you can do something to step off the travellator. We will support you to take the initiative.
16. The support for the individuals will come in a few forms. Most individuals will exercise by themselves, or with their families and close friends. Others may appreciate community support. We are working with a network of health, social and community partners, plus our healthcare clusters, to organise more physical and social activities in the community.
17. Our healthcare clusters have been building up Communities of Care in neighbourhoods, to specially support the seniors. These communities bring together health and social partners, General Practitioners and the healthcare clusters.
18. I visited one recently which is called “Wellness Kampung”. It is a community space which facilitates residents to form their own interest groups, such as social dance, language lessons and qigong. Through these peer-led sessions, they will be able to keep themselves physically and socially active. For a senior, having a social network is a very important prerequisite to stepping off the travellator. We want to expand the network of such centres and make them ubiquitous throughout the housing estates.
Improving Chronic Care
19. Third, there are residents and individuals who are on the travellator and are past the slow-moving part. It is now moving faster and it is too late to get off. We will help them and try our best to walk in the opposite direction, and not unwittingly move into the crash zone. At this stage, the priority is to manage their conditions well, to delay or prevent rapid disease progression and complications. Under Healthier SG, we will strengthen care coordination and leverage technology to improve chronic care management so as to achieve this.
20. Our healthcare providers have been working on integrated care models to provide a seamless healthcare journey for residents. This includes care transition programmes like Hospital to Home, and the Community Hospital Aged Care Transition Programmes.
21. Upon discharge, patients with more complex needs are managed by a care team, including a care coordinator, who will make referrals based on their psychosocial and healthcare needs, even though they are at home. That way, the stepping down of healthcare from hospital to home is not drastic. Patients can get continual care, anchored in the community and in their home, and probably supported by infrastructure such as “Wellness Kampung”. This is a more sustainable path in managing the disease.
22. We can also leverage technology to help patients monitor their health regularly and for healthcare providers to provide continuity of care. Wearable technologies are improving in accuracy and sophistication. In time, we believe they can play a bigger role in managing chronic diseases. For example, algorithms could already identify anomalous readings specific to an individual and prompt him to take follow-up actions. I think in time to come, it could potentially measure other things like blood pressure or sugar levels easily, thus complementing chronic care management.
Boosting Support for Palliative Care
23. Finally, at some point, all of us will reach the end of the travellator one day, and at that point, we hope to step off it comfortably and with dignity at the end of our life journey. We want our residents to spend their final days with loved ones, in a familiar environment. This is the preference of most people, and we should do our best in our healthcare system to fulfil their wish.
24. Therefore, we aim lower the proportion of those who spend their final moments in a hospital bed, from about 60% to 50% within the next five years. We are working towards this aspiration by increasing the adoption of advance care planning, and making more timely referrals to palliative care. My sense is this is not so much an issue about hospital protocols, which are important, but more of an issue of mindset and culture, and whether each of us and our family accept that for many people, their final wish is not to die in a hospital, but at home, or at least at a hospice, somewhere familiar, somewhere where they can be surrounded by their loved ones. To do so, our medical personnel need to have early and tactful conversations with the patients and their loved ones about death. Matters concerning the last wish cannot be treated as a taboo subject.
25. There are ongoing close consultations with experts and stakeholders on this topic. We also need to progressively engage our primary care providers, including family doctors, to provide basic end-of-life care. With strong patient-doctor relationships developed under the Healthier SG enrolment programme, family doctors are also well-positioned to discuss the wishes and concerns of residents, at the earliest possible stage of a disease trajectory.
Closing
26. As we continue to learn to live with COVID-19, we are also reimagining and reinventing our healthcare system and our care delivery models, to prepare ourselves for a much older population. Many countries have experienced this demographic change before Singapore, and we have much to learn from your experiences.
27. If I were to put it in one simple sentence, what is Healthier SG? What is reinventing healthcare about? I think it means this. We need to go beyond doing things right, doing things well, but also doing the right things. The things that prevent people from stepping onto the travellator, things that help people to step off the travellator, things that help them walk in the opposite direction, and things to help them step off with dignity, and comfortably eventually. These are the right things to do, beyond just doing things right. MOH can set the direction, make the policy changes, and make resources available to some extent. But we really look towards hospital and cluster leadership to operationalise them, to make sense on the ground, so that we can create an impact.
28. Let us continue to come together to share, discuss and exchange ideas to create a Healthier Singapore, and a healthier world. I wish all of you an enriching Congress ahead. Thank you very much.