Accurate Diagnosis, Effective Treatment, Affordable Care

21 Sep 2007

By Khaw Boon Wan

Venue: Children Cancer Centre, KKH

Speech By Mr Khaw Boon Wan, Minister for Health

at the Official Opening of the Children’s Cancer Centre

on Friday, 21 September 2007 at 10.25 am

at KK Women’s and Children’s Hospital

Distinguished guests

Ladies and Gentlemen

At the recent President’s Challenge Charity Run, I briefly mentioned the decision to grow a second Heart Centre and a second Cancer Centre at the NUH.  Let me use this opportunity to explain why we took such a decision.

Finding Sweet Spot

The need for medical specialisation is obvious.  With new medical knowledge being added daily, it is humanly impossible for a doctor to know everything about his practice.  While most doctors will remain generalists with a good breadth of knowledge, some doctors will need to specialise in a particular field or even sub-specialise.  The main argument is over the pace and the extent of specialisation. 

There is an optimal level of medical specialisation.  Too many specialists will raise healthcare costs without corresponding improvements to people’s health.  Too few specialists may deprive patients with severe complications of viable treatment options.

Finding the optimal level requires political judgment to balance what is desirable with what is affordable.  This is because demand for esoteric medical care is unlimited but resources available will always be limited.  Consequently, the optimal level varies from country to country.  Within a country, the optimal point will also change in tandem with its economic health and healthcare needs. 

Medical Specialisation Version 1.0

The first attempt by MOH to formulate a strategy on medical specialisation was in the early 70’s.  A committee of senior consultants studied this subject and put up a report. 

They recommended that an Institute of Medical Research be put up in the SGH to concentrate the resources of a few key specialties under one roof and to push medical research forward.  This way, costly facilities could be shared and doctors could spend more time on their chosen specialties.  A building was duly put up but, because of limited budget, only one level was built with a foundation to support six levels.  But the building was never completed and used as planned.  For those who are too young to know, this was the former Radiotherapy Building which was subsequently converted into a Gamma Knife facility and eventually left vacant. 

This was medical specialisation version 1.0, relevant to a not-so-distant past when our resources were more limited and our ambitions more modest.

Medical Specialisation Version 2.0

Then in the 80’s, MOH embarked on a review of its medical specialisation strategy.   

The key recommendation was to be more ambitious and to set up several national specialty centres to cluster experts in the same specialty and concentrate our limited resources to improve the quality of care for more complex diseases.  We hoped that in doing so, we could push that specialty to international standards by leveraging our medical assets in the public and private sectors.

We decided to start with dermatology and ophthalmology as both were largely outpatient-based and hence less complicated to run.  In 1988, when the new National Skin Centre was ready to be commissioned as a replacement building for the old Middle Road Hospital, we took the opportunity to run it differently as an autonomous national specialty centre.  In ophthalmology, we roped in Prof Arthur Lim to help us push this specialty to a new height.  After a successful partnership at setting up a new Opthalmology Department at the NUH, we moved decisively to establish the Singapore National Eye Centre (SNEC) in 1990. 

In parallel, I was also tasked to restructure and rebuild the old KK Hospital.  We sent teams of doctors and staff to visit the best women’s and children’s hospitals around the world, including the Children’s Hospital Boston, the Toronto Hospital for Sick Children and the Sydney Children’s Hospital.  In planning the new KK Hospital, we sought to model ourselves against the best and adapted some of their ideas.  Our vision of a world-class women’s and children’s hospital as good as the best in the west has progressed as planned.  Now it is ready for the next phase.

These developments further paved the way for the establishment of the National Heart Centre in 1994, the National Cancer Centre and the National Dental Centre in 1997, and the National Neuroscience Institute in 1998.  The success of the medical specialisation strategy version 2.0 is clearly visible today.

Our national specialty centres have enriched significantly our medical landscape by raising the standards of medical excellence.  Several have achieved good international reputations.  A big reason is because they have been able to successfully integrate research, service and education to deliver medical breakthroughs that have enhanced our standing as a medical hub. 

Medical Specialisation Version 3.0

It is now time to prepare medical specialisation for its next lap, version 3.0.  Should the strategy be more of the same? What should the medical specialisation landscape be like by 2020?  How do we cope with rising demand for the services of the existing national specialty centres?  These are not trivial questions and how we decide will determine our medical landscape in 15 years’ time.  We should carefully reflect on them and contribute to the formulation of the strategy.

Let me share with you my take on these issues.

(a) Establish New National Specialty Centres

First, we have to decide what new national specialty centres will Singapore need, taking into account emerging disease trends, projected demand and clinical capabilities.    No doubt, there will be more proposals than we can adequately fund.

MOH will set up a committee of senior doctors to study this issue objectively and make the appropriate trade-off.  They will consult closely with the medical community, so that all views are heard.  Please share your thoughts with us.  But do not just argue for your own specialty.  Take a broader view of Singapore’s needs and an objective view of our capabilities and affordability.

(b) Expand Existing National Specialty Centres

Second, we need to review our existing specialty centres and prepare them for 2020.  Patient load is expanding and will continue to expand as our population ages.  At some stage, we will have to decide if we simply continue to expand the existing centre on site or to set up an additional centre.  Views will differ: incumbents will prefer to retain their monopoly or near monopoly status while newcomers will favour a competitive outcome.

My Ministry prefers a competitive model so long as there is sufficient critical mass to support it.  A competitive model will offer more choices for both the patients and the doctors.  This is why we decided to support a second Heart Centre and a second Cancer Centre. 

The details are being worked out.  The plan is to evolve the current Cancer Institute and Heart Institute at NUH to take on more tertiary cases, do more research and improve the standards of care.  They will integrate clinical service, education, and research between NUH and the NUS School of Medicine.  They are starting from a strong platform. 

(c) Set Higher Ambition

Third, our established national specialty centres, like the SNEC, should now raise their ambition and aspire to be the best in the region.  They should strive to be the standard-bearers for professional and ethical standards, well known for their clinical outcomes benchmarked against the leading centres around the world.  Being a regional leader means that clinicians from the region should think highly of us and choose to refer their complex cases to us.  Clinical trainees from the region should also see us as the place of choice for them to do their training.  This is within our grasp.

Setting higher ambitions is not about mindlessly chasing foreign patients.  This is not a numbers game, but a quality game.  Our mission remains to serve Singaporeans well, but if we succeed along the measures that I described – benchmarked clinical outcomes, referral of complex cases, being the regional training centre of choice – then we will naturally attract foreign patients.  As I have stressed to you before, attracting foreign patients should be a natural result of our achievements, not a goal to pursue in itself. 

Setting higher ambitions is also not about mindlessly chasing esoteric treatments to benefit a tiny group of rare complications.  Our focus should remain on the common illnesses that impact large number of Singaporeans.  Our top specialists should use their talent and expertise to look for more accurate diagnoses, more effective treatments and at lower cost.  And when we have enough expertise, experience and volume of patients, they should actively push out proven services beyond the national centres into the hospitals and clinics.  For instance, cataract surgeries are now routinely and safely done in all hospitals.  This way, as we build higher peaks, we also build stronger and broader foundations for the common services which can then be provided better, faster, cheaper and safer. This will be the specialists’ greatest contribution to medicine and to the world.  Our translational and clinical research priority should be firmly set in this direction.

Developing our medical capabilities and specialty centres would also depend on the quality of people we are able to attract and retain.  This is a virtuous cycle, as we will attract even more top talent as our medical capabilities improve.  Our local medical schools will continue to expand but we can never have enough if we solely rely on local trainees.  Since 2005, we have been expanding our list of approved foreign medical degrees to bring in the best doctors from the rest of the world to Singapore.  Nineteen more foreign medical degrees will be added to our list with immediate effect    .

Conclusion

In 2005, I challenged KKH to go beyond O&G and strive to become the best hospital in Asia for women's health, besides its mission to be the Children’s Hospital for Singapore.  Two years on, I am pleased that KKH has made substantial progress.  You have obtained JCI accreditation and expanded your medical capabilities for women’s health, including services such as Breast, Orthopaedic and Plastic Surgery, as well as psychological and adolescent medicine. 

The Children’s Cancer Centre is another major step forward for KKH.  From its humble beginnings, the Centre has developed steadily and today is one of the biggest paediatric cancer centres in Southeast Asia.  It treats 70% of childhood cancers in Singapore, as well as a growing number of children with cancer from the region, with good results.  It is well equipped, with bone marrow transplant rooms, day therapy beds, and practices holistic childhood cancer management.  The Centre has achieved 80% cure rate for common cancers such as leukaemia, lymphoma, germ cell tumour and kidney tumours, and a 70% success rate in Hematopoietic Stem Cell Transplants (HSCT).  I congratulate the dedicated staff at KKH for this outstanding achievement. 

In Singapore, we have outstanding clinicians and researchers.  We have passionate clinical leaders.  I am confident that the KK Children’s Cancer Centre, together with the other healthcare institutions will help to better medical care for all Singaporeans.  On this note, I declare the Children’s Cancer Centre at the KK Women’s and Children’s Hospital open.  Thank you. 

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