MOH 2012 Committee of Supply Speech Healthcare 2020: Improving Accessibility, Quality and Affordability for Tomorrow’s Challenges (Part 1 of 2)

1.Mr Speaker, before I address the specific issues raised by Members, I would like to take this opportunity to give an overview of our Healthcare System so as to provide the context to discuss these issues. Singapore’s healthcare has made good progress over the years. Our life expectancy has steadily increased from 78 years in 2001 to almost 82 years in 2010. Infant mortality rates have fallen from 2.5 to 2.0 per 1,000 live births over the same period. These achievements place us in the top quartile of OECD countries, on par with First World countries like France and Sweden. We have also shown steady improvement in other indicators, such as reducing premature mortality. For example, the death rate for heart disease among adult Singaporeans aged 35 to 64 fell from 76.2 per 100,000 in 2001, to 49.9 in 2010.

2.We have achieved these results on the back of a sound and sustainable healthcare financing system including a multi-layer safety net. Our strong economic growth in the past has provided us with resources to invest in our healthcare system to achieve good health outcomes.

3.However, there are areas where we can still do better, especially in preparing for the challenges ahead of us which I will now elaborate.

Challenges Ahead

4.My Ministry is committed to improving the healthcare system to achieve better outcomes, so that Singaporeans can live well and enjoy peace of mind. However, this will always be work-in-progress because we need to respond to the evolving needs of Singaporeans. At the same time, we have to keep healthcare affordable for our people and our society as a whole. I see a few challenges ahead.

5.The first challenge is the combined impact of a growing and ageing population on our capacity needs. Our population grew 25% over ten years and will continue to grow over the next decade. Healthcare services will need to grow in tandem. Our population is also ageing rapidly. By 2030, 1 in 5 Singaporean residents will be aged 65 and above. This is a threefold increase to 960,000 elderly, from about 350,000 today. The ageing population will be a strong driver for healthcare demand, as the elderly require a higher intensity of medical care. Studies have shown that they are about 4 times more likely to be hospitalised than younger Singaporeans. They are also likely to stay longer once hospitalised. This will have tremendous impact on overall healthcare demand in future. Already, we are seeing signs of capacity constraints across the system – from high bed occupancy rates to long waiting times for appointments.

6.Second, the ageing population also requires changes to how we organise and deliver healthcare. In the past, care was focused in the acute hospitals. This was not wrong, as our population was younger then, and our diseases were more episodic in nature. With increasing life expectancy and more sedentary lifestyles, we are faced with a growing burden of chronic diseases. We have therefore been shifting our focus from episodic care in the acute hospitals, to keeping people healthy and managing their chronic conditions in the community which is more effective and sustainable in the long-term.

7.Finally, we need to actively manage the rise in healthcare costs. Around the world, many governments are struggling to contain rising costs and Singapore too is not spared from the effects of global healthcare inflation. We thus need to constantly innovate to stay cost-effective in how we deliver care, to ensure that healthcare remains affordable for everyone.

8.Several members, such as Dr. Lam Pin Min, Dr. Teo Ho Pin and Dr. Lily Neo, asked how the Government plans to address these challenges. Let me now speak a little on the broader shifts that our healthcare system must make to prepare for the future.

Broad Shifts

9.The 1993 White Paper articulated the basic principles and objectives of our health policies. Many of these remain sound and relevant. The feature of co-payment, for example, continues to be a fundamental feature of our healthcare design, to encourage personal ownership of one’s health and to discourage over-consumption of healthcare services. Another design objective that remains relevant is to nurture a healthy nation by promoting good health, as a healthy population will reduce downstream healthcare costs.

10.As we look ahead, we will re-examine the role of the private sector. They are a part of Singapore’s healthcare landscape. As demand increases, we will need to consider how we can tap on their capacity and expertise, to serve our national healthcare needs, not just for the private patients, but also for subsidised patients.

11.Besides the private sector, we will also need to involve VWO as our integral partners. We want to tap on their drive and passion, and foster community ownership of the healthcare challenges and solutions, so that we can address these challenges together as a society.

12.On the issue of affordability, while personal responsibility and family support remain important, we need to pay greater attention to the concerns of vulnerable groups in our society such as the elderly and chronically ill. While we have always focussed more assistance on the lower-income, and rightly so, as healthcare costs rise, some middle-income Singaporeans too may find it difficult to pay for their bills, especially when it involves intermediate and long term care. We will thus need to find ways to also help the middle-income group, while keeping our eye on the lower-income. Singaporeans should have the assurance that they will be able to afford quality care appropriate to their needs, and come forward to seek the necessary care. We will do more to strengthen safety nets to build this peace of mind.

13.It is also critical that we strengthen our feedback and engagement mechanisms with the public and our stakeholders, so that we can benefit from their inputs and co-create the solutions together.

13.1.We have organised two major stakeholder engagement sessions to date, first for private sector GPs in October last year, and then for the leaders of aged care organisations in January this year.

13.2.As we seek to provide more services in the community, we will also need to engage the residents more closely. Singaporeans may find themselves living beside a new healthcare facility, be it an eldercare centre or a community health centre. Some may have concerns, and we will try to engage them and address their concerns as best as we can. I am confident that at the end of the day, as a society, we can find the right balance to address the different needs.

Healthcare 2020

14.Our review and consultations over the last few months have enabled my Ministry to put together a “Healthcare 2020” Masterplan to improve healthcare services for Singaporeans. Healthcare 2020 is more than a vision; it is a set of strategies that will guide us in building an inclusive healthcare system for the future.

15.Healthcare 2020 will focus on three strategic objectives: enhancing accessibility, quality and affordability of healthcare for our people. This means that:

15.1.Singaporeans will receive healthcare when we need it;
15.2.Our healthcare services will be of good quality and effective; and
15.3.Singaporeans will be able to afford such services.
16.Today, I will focus on these 3 key themes of Accessibility, Quality and Affordability as I address Members’ questions about future-proofing our healthcare system.

16.1.First, I will touch on our plans to expand capacity in the healthcare system, and growing and retaining our pool of healthcare professionals in tandem, to improve accessibility of healthcare services.

16.2.Second, I will then speak about how we intend to improve the effectiveness and quality of care for patients. I will talk about our efforts to integrate care through the Regional Health Systems and how we intend to improve primary care so that patients receive better care in the community.

16.3.Third, I will touch on our plans to improve healthcare financing to make healthcare more affordable.

17.I will then round off by sharing our holistic plans for the aged care sector, under the Ministerial Committee on Ageing.

Building Capacity

18.First on capacity building. We have made investments to build up our infrastructure and manpower over the last 5 years to keep healthcare accessible for patients.

19.Over the period 2001-2011, our public sector acute beds increased by 700 beds to around 6,900 at the end of last year from various expansions, including the new Khoo Teck Puat Hospital. Over the last 10 years, our Community Hospital beds have increased from 420 to 800. We also expanded nursing home capacity, from about 6,300 to 9,400 beds over the last 10 years.

20.We have also invested significantly in manpower development. Over the last 5 years, we have increased the number of our doctors, nurses and allied health professionals in the public sector by 53%, 72% and 86% respectively.

21.Nonetheless, we continue to see a tightening of capacity across the hospitals.

Infrastructure

22.Associate Professor Muhammad Faishal, Ms. Lina Chiam and Mr. Gerald Giam highlighted the shortage of hospital beds and asked how we are going to address it.
23.Let me share with this House our long- and short-term plans to expand capacity across the healthcare sector.

24.To tackle short term demand, our hospitals have over the years improved their processes to reduce admissions and facilitate discharges. For instance, innovative initiatives such as discharge lounges have been introduced for discharged patients to wait for their family members to pick them up, enabling beds to be turned over more quickly for incoming patients. Where possible, our hospitals have also added more beds in an incremental way, by optimising space and converting administrative areas into medical facilities and bed space. For instance, SGH moved more than 800 non-frontline staff offsite to commercial buildings over the years, and converted the administrative and office space to add over 50 beds and 20 outpatient consultation rooms. We will continue to explore ways to optimise the available bed capacity and space wherever possible. We also make use of private wards for subsidised patients when necessary.

25.For the longer term, DPM Tharman announced in his Budget Speech that we will be making major investments in healthcare infrastructure in the coming years. By as soon as next year, we will be adding some 170 acute and Community Hospital beds.

26.By 2020, we will increase the number of acute hospital beds by more than 30%, or 1,900 beds, and Community Hospital beds by around 1,800, which is a tripling of the 800 Community Hospital beds we have today. Altogether, we will provide 3,700 more hospital beds over the next 8 years.

27.Let me take you through some details of our key plans.
27.1.In the west of Singapore, the new Ng Teng Fong General Hospital in Jurong is scheduled to open in 2014, followed by the Jurong Community Hospital in 2015. Taken together, these hospitals will add more than 1,000 beds in total in the west.

27.2.In the northeast, we will advance the opening of the new Sengkang General Hospital from 2020 to 2018. Not only are we bringing Sengkang General earlier, we are also planning a higher than usual capacity for the hospital and its sister community hospital, of 1,400 beds in total. We intend to integrate acute and community hospital beds to provide greater flexibility and to better cater to the needs of patients. This is in fact contrary to Ms. Lina Chiam’s earlier suggestion during the budget debate that we should segregate the acute and non-acute facilities, which will result in less flexibility and therefore higher cost.

27.3.In the east, we will increase the capacity of both Changi General Hospital and St Andrew’s Community Hospital through the construction of a new Integrated Building, which will yield around 250 acute and community hospital beds. This will be ready by 2014 and increase the combined bed capacity of Changi General and St Andrew’s by more than 25%.

27.4.In the north, the new Yishun Community Hospital next to Khoo Teck Puat Hospital will be ready by 2015.

27.5.In the central region, we will build a new community hospital in the Outram campus, where Singapore General Hospital is. Together, Yishun and Outram will add another 800 CH beds.

27.6.The increase in Community Hospital beds will allow the more stable patients to receive the appropriate level of care at a less costly setting. At the same time, it will relieve our general hospitals and allow them to focus on the more acutely ill patients. This will also reduce the demand for acute hospital beds. Nonetheless, we will continue to monitor the growth in demand, and if necessary, we will also start work on another acute hospital before 2020, so that it will be ready soon after 2020.

28.We are also ramping up specialist outpatient capacity. The new NUH Medical Centre will be ready in 2013. This will house the National University Cancer Institute and increase capacity for day surgery and specialist outpatient clinics. The new National Heart Centre building at Outram is also expected to be ready by 2013, with a more than threefold increase in capacity.

29.We will significantly increase the capacity of long-term care services, such as nursing homes, home care, day care and rehabilitation facilities – more than doubling by 2020. In the short-term, we will be adding almost 560 nursing home beds every year on average from 2013 to 2015. I will elaborate on our plans when I speak on the aged care masterplan later.

30.Primary care is also an important sector that we need to develop to prepare for emerging needs. Working together with our private sector partners, we will introduce new models of care to tap on the capacity of private GPs to provide Singaporeans with accessible, affordable and high quality care. At the same time, we will also explore how we can increase access to polyclinics where necessary.

Private Sector Engagement

31.Similarly, there is an opportunity for us to tap on existing spare capacity in private hospitals to add capacity to our public system. The private hospitals’ bed occupancy rate averages about 55% currently.

32.Tapping on private sector capacity is not entirely new to us. For instance, NUH has been renting 30 beds at Westpoint Hospital since 2009. We have reached an in-principle agreement with Parkway to lease some of their beds at Parkway East Hospital, which will ease the load at Changi General Hospital. Patients using these leased beds will continue to be managed by CGH’s doctors and pay subsidised fees, if they were subsidised patients in CGH. My Ministry will also be entering into an MOU with Raffles Hospital for them to take on some subsidised patient-load. We will continue to explore ways to tap on private sector capacity. This can be a win-win situation for the private sector too as their capacity can be better utilised.

Building a World-Class Public Healthcare Workforce

33.As we invest in hardware by building new hospitals and adding more beds, we also have to invest in people, which is equally, if not more, important.

34.In my meetings with doctors, nurses and other healthcare professionals in our public sector, I was struck by their passion, dedication and professionalism in caring for Singaporeans who are ill. They shared about the challenges they faced, from the physical and mental stress of working in a fast pace and highly demanding environment, to the emotional stress of caring for the very ill and managing the occasional difficult patients or their family members. Yet, despite these challenges, they remain dedicated and committed to their mission. Ever eager to contribute ideas to bring even better care to patients.

35.Our healthcare infrastructural expansions will require many more such dedicated healthcare professionals. We estimate that we will need to grow the healthcare professional workforce such as doctors, nurses, dentists, pharmacists and allied health professionals by 50%, or about 20,000 more, by 2020.

36.Mr. Patrick Tay, Associate Professor Muhammad Faishal and Mr. Gerald Giam asked how we were going to address our healthcare manpower needs.

37.First, we will train more healthcare professionals locally by expanding the intake of our schools. The Lee Kong Chian School of Medicine will open next year with an initial intake of 50 students and this will grow to 150 eventually. With the third medical school, we expect to boost our locally-trained supply of doctors to 500, across the three medical schools. We will also be expanding the dentistry intake from 48 to 80. To train more nurses and pharmacists, we intend to expand the annual intakes for nursing from 1700 to 2700 as well as for pharmacy from 160 to 240.

38.Second, even with the increase in local training pipelines, we will still need to supplement our workforce with foreign-trained professionals, both Singaporeans and foreigners. We have stepped up efforts to attract back overseas-trained Singaporeans through the pre-employment grant for medical students studying overseas. The response has been encouraging thus far, with 89 grants given out since 2010.

39.Ms Wong Shimin is one such recipient of the pre-employment grant. Currently studying in the University of Glasgow, Shimin grew up aspiring to be a doctor because of her mother’s experiences as a nurse and ex-paramedic. PEG will give her an opportunity to return and work in a public hospital and be closer to her parents. Shimin’s aspiration is to be an A&E specialist so that she can be at the frontline of saving lives. Shimin will return later this year to start her housemanship.

40.I am heartened that Shimin and others like her have decided to return and contribute to public healthcare. To attract back more Singaporeans, we will now extend the pre-employment grant to those studying dentistry overseas in recognised universities. Through these efforts, we hope to build on our current success, and attract back even more Singaporean medical and dental students from overseas, moving forward.

41.We will continue to recruit qualified foreign healthcare professionals to supplement our local healthcare workforce. Our foreign doctors, nurses and allied health professionals have worked alongside our local professionals and contributed towards quality patient care in the public sector, and they will continue to be an important supplement to our local healthcare workforce.

42.Aside from growing in numbers, we have also made strides in growing capabilities, by enabling more of our healthcare professionals to undergo more advanced training, and undertake more complex tasks in patient care.

43.Let me illustrate with an example from nursing. Over the years, nursing has developed peaks of excellence in nursing clinical practice, leadership and education. In the area of clinical practice, our Masters-level trained Advanced Practice Nurses work as independent partners to the doctors in their respective areas of expertise performing work of high complexity.

44.Ms Tan Siok Bee is an Advanced Practice Nurse and an Assistant Director of Nursing at the Singapore General Hospital (SGH). With her advanced nursing training in Neurology, Siok Bee is able to conduct care clinics for people with Parkinson’s disease. In addition, she facilitates workshops to empower and support caregivers in looking after their loved ones. There are more than 100 APNs in the public sector today. Together with nursing leaders in the management and education tracks, they are pushing the boundaries of the practice of nursing and changing how healthcare is delivered.

45.Our pharmacists and allied health professionals are similarly charting new frontiers in their respective areas.

46.As a Principal Clinical Pharmacist at the Communicable Disease Centre (CDC) in Tan Tock Seng Hospital, Ms Law Hwa Lin is part of a multidisciplinary team that provides holistic care to HIV patients. As a pre-registration pharmacist volunteer with the CDC, she saw that there was no pharmacist involvement despite the complex management required for HIV patients. This motivated her to pursue a specialisation in clinical pharmacy and pharmacotherapy. Today, Hwa Lin conducts medication adherence clinics for patients, conducts research and teaches medical and nursing colleagues about HIV medications.

47.Another example is Mr Abdul Rashid Jailani. A physiotherapist by training, Rashid headed the Department of Physiotherapy at the Singapore General Hospital. He specialised in cardiopulmonary physiotherapy and intensive care when he was at the hospital, and was also an avid clinical educator. Rashid is now with Nanyang Polytechnic as a manager and lecturer for the Diploma in Physiotherapy programme, where he is able to impart his knowledge to budding physiotherapy students.

48.Siok Bee, Hwa Lin and Rashid are examples of healthcare leaders who constantly seek to advance patient care and groom the next generation of professionals. We will continue to raise the capability of our public healthcare workforce by opening new pathways for upgrading and investing in professional development and growth. This will also help to retain good staff by making their career more rewarding and fulfilling,

49.As we build greater capabilities, we have to ensure that the recognition and rewards are commensurate. While pay is not everything, it is an important factor to retain and attract high calibre individuals to pursue careers in the public healthcare sector. For this reason, my Ministry embarked on a joint review with the public healthcare clusters of healthcare professionals’ pay.

50.Over the past year, we gathered feedback from public sector doctors on how we could improve recognition and rewards. Besides more competitive pay, many told us that they wanted a pay system that reinforced a greater sense of public sector ethos and values and that recognised and rewarded doctors for looking after all patients, regardless of whether they are subsidised or full-paying. Individual doctors also wanted greater clarity around their diverse roles – in clinical service, education, leadership and research – and wanted recognition for excellence in these areas.

51.We will therefore introduce a new and more competitive pay framework for doctors that is aligned with our public healthcare ethos and values. The framework will better recognise public sector doctors for the complexity of their clinical work, quality outcomes and workload regardless of patient class. It will also strengthen the recognition for doctors who play crucial roles in education, administration, leadership and research.

52.The new pay framework, together with enhancements to the performance management system for public sector doctors, will take time to implement, and will be rolled out in phases over the next two years. On average, doctors will see an increase in total compensation of around 20% by 2014. Under Phase 1 which will start from Apr 2012, doctors will receive increases depending on their job levels. For example, most Associate Consultants in hospitals will get an increase equivalent to 20% of base salary while Consultant Family Physicians in the polyclinics will get an increase equivalent to 10% of base salary. House Officers and Medical Officers will see an increase of 20%. When the new pay framework is fully implemented in 2014, doctors will receive further increases. We will similarly adjust dentists’ pay.

53.We must also recognise the important contributions of our public sector nurses, pharmacists and AHPs who form the core of our healthcare workforce. They will also see one-time base pay increases of 4% – 17% from April 2012. In particular, senior nurses, pharmacists and AHPs will be recognised for their experience, leadership and role in training the next generation. As an example, a nurse manager will expect to receive between 8% and 13% of increase in base pay.

54.These salary enhancements will cost about $200 million in FY 2012 which is fully funded by Government.

55.These salary enhancements are part of our continuous efforts to make healthcare careers more attractive and better recognise the critical role that our public sector healthcare professionals play. We will continue to review pay regularly to ensure that public sector salaries remain competitive including healthcare support staff who are important members of the healthcare team, as Mr. Patrick Tay highlighted. We will also enhance the value proposition of public sector work and make it more fulfilling and challenging.

56.Beyond issues of pay, the well-being of public healthcare staff will continue to be a key priority of the Ministry. We will enhance their work life harmony by recruiting more manpower and through initiatives such as 5-day work weeks, family care leave and part-time work arrangements. We will also protect our frontline healthcare workers against abuse. In fact, many of our workers gave us the feedback that what will make their day is simple words of appreciation from the people they serve. I would therefore like to encourage patients and their loved ones to continue to show your appreciation to our public healthcare staff for their care, professionalism and commitment– your simple words and gestures motivate them greatly.

Conclusion for Speech 1-1

57.Mr. Speaker, I have laid out MOH’s plans to address Singapore’s healthcare challenges. Healthcare 2020 sets out the strategy to ensure that Singaporeans can access care good quality and affordable healthcare. I have covered the issue of increasing accessibility – how and where we are increasing capacity; and how we are going to address our manpower needs. Tomorrow I will discuss how we will raise the quality of our healthcare sector and still keep our services affordable.