Opening Speech by Mrs Tan Ching Yee, Permanent Secretary (Health) at the Singapore Healthcare Management Congress, 18 August 2015

Prof Ivy Ng, Group CEO of SingHealth

Prof Ang Chong Lye, Dy GCEO (Clinical Services & Informatices), SingHealth

Mr Tan Jack Thian, Organising Chairman of the Singapore Healthcare Management Congress and Group COO/CPO, SingHealth

Distinguished Guests and Colleagues

Ladies and Gentlemen

Opening

1.         It gives me great pleasure to join you this afternoon at the Healthcare Management Congress.

2.         I understand from the organisers that a key feature of the congress is a poster competition that encourages healthcare administrators in the various healthcare clusters to submit projects pertaining to supply chain innovation, service quality, human resource, risk management, finance and communications.  This competition was introduced as part of the congress in 2012.  It started on a small scale, with a total of 10 posters for one poster category in Supply Chain.  The number of congress participants, poster categories and posters received has since grown.  This year, a total of 220 posters have been submitted over 7 poster categories of Operations, Supply Chain, Finance, HR, Communications, Service Quality and Risk Management.  Kudos to our healthcare administrators!

3.         Among the 52,000 employees in public healthcare today, over 15,000  are in the “Admin and Ancillary” category.  Among them are nearly 3,500 who hold professional, managerial or technical roles.  Probe a bit more, and we have many interesting job titles – HR executive, financial controller, IT applications manager, business office executive, corporate communications officer, medical informatics executive, and many others. 

4.         This is a potent force. Healthcare administrators work alongside clinicians to ensure we maintain our high standards of care delivery in order to keep our population healthy.

5.         As the challenge we face is a common one, allow me to briefly re-cap the big forces sweeping Singapore healthcare.  And how healthcare administrators need to play your part in ensuring that we execute the transformation that is needed. 

Our World Today

6.         Many of you will be familiar with this narrative, but worthwhile to share and reiterate the key learning points for all of us. 

a.         First challenge is demographic. People are living longer. This translates to a higher demand for healthcare services. The number of older people is going to grow and the rate of growth will become even faster after 2013. Hospitalisation rates for the older people are four to five times that of a middle-aged person, and when they do come to hospital, they stay on average 1.6 times the average length of stay of a middle-aged person. If you double the number of old people, it does not just double the heathcare utilisation, but increases it by eight times.

b.         Many other societies are ageing, in Asia, Europe and even in lucky Australia.  For us (and some Asian societies), ageing is accompanied by another demographic trend which is worrying.  This is our falling birth rates. I hear that we may well have a bumper crop for SG50, but we need a trend, not the occasional blips! Falling birth rates mean a shrinking manpower supply across all sectors, not just in healthcare.  And keener competition all round for talent.

c.         So, we have a double whammy of an aging population, which means a higher demand and higher utilisation and falling birth rates, meaning fewer staff. So there will be a shrinking supply of workers joining us to help care for our fellow citizens. 

d.         Over the long term, our disease patterns have changed. We have shifted from a mode of curing diseases, which is episodic, to managing chronic diseases, which can be life-long.  Healthcare institutions now have lifelong relationships with patient AND caregivers.  No longer just a matter of patching them up, saying goodbye and never seeing them again for a very long time.  Think of hotels which remember the preferences of their guests.  We have EMR and National Electronic Health Records (NEHR), so we know about our patients.  And we also know they do not always seek treatment at the same institution or even cluster.

e.         Owing to changes in family structures, Government has made several changes to our social safety nets, including in the way we have chosen to share in the healthcare financing burden.  Many of our colleagues here helped us to deliver those changes.  What we know is that our clients and family members now demand more and better.  Not just a matter of giving better customer service, or having convenient e-payment systems, all of which are important.  Also, of empathy, taking perspectives, and being able to provide a first-line explanation of policy rationale. Not: “Don’t know leh. MOH policy!”

7.         What about money?

a.         MOH’s budget has more than doubled between FY2011 and FY2015.  This represents Compound Annual Growth Rate (CAGR) of 24% per annum. These figures exclude other forms of Government spending, like top-ups to Singaporeans’ Medisave accounts, or the $8 billion Pioneer Generation Package. 

b.         What is the upside for MOH?  Limitless, if experience of other countries is anything to guide us.  This figure shows National Healthcare Expenditure (NHE) as a per centage of GDP. NHE includes all forms of healthcare expenditure, including spending by individuals and in private hospitals and clinics, health products and supplements.  In the latest year (2013), we were at 4.2% of GDP, compared with the highest in the world – the US at 17%.  For comparison, the total Singapore government expenditure in FY2015 is estimated to be at 18% of GDP.  Healthcare spending can surely grow, until there is no room for anything else, if we follow the ways of the US healthcare system. 

8.         Rather depressing –talent no enough, money also no enough? 

9.         But I did not come here to deliver bad news, but good news.  We need a burning platform, to launch the next phase of disruptive innovation in healthcare. And we need YOU, our healthcare administrators to be part of the journey. 

10.      I am not pessimistic. Looking around us and beyond Singapore, many interesting innovations, including mature ones.  Like new technologies that promise blood tests that use very little blood and can return results in the doctors’ office. One such example is Theranos, which is the world’s first Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory running its tests on micro-samples. Or new marketplaces for healthcare products, and even services of healthcare professionals on alibaba.com. Google has gotten into the act with Google Health. Machines and robots that can help with eldercare. 

Re-inventing Our World

11.      Fundamentally re-designing the way we organise our healthcare system is the game-changer.  This is not the work of clinicians alone, but requires all hands on deck.  Not an impossible task, but would certainly feel like changing the tyres on an F-1 car on the move. Others have done it, including examples from around the world.

12.      One is the Canterbury Health System from New Zealand, which MOH and the Agency for Integrated Care visited a couple of years back. Canterbury is one of twenty District Health Boards in New Zealand, and is the 2^nd largest DHB by population and geographical size. Each DHB focuses on operating hospital facilities, and funds provision of services, including primary care, much like our Regional Health Systems. Over several years, Canterbury DHB has pulled together disparate players and re-formed them into a coherent system with a common identity. The system has allowed the DHB to form effective networks with other community healthcare providers including primary care organisations to provide integrated care to patients. There are multiple partners in the back-end, but this is transparent to patients, who only see a single, reliable service.

13.      Another is Geisinger Health System, based in Pennsylvania, which many of us have visited in the past few years.  Geisinger serves more than 2.6 million residents in Pennsylvania as a not-for-profit, fully integrated health services.  Like Canterbury, within the GHS is a network of acute hospitals, speciality hospitals and ambulatory surgery campuses.  Clinical services and programmes range from prenatal outreach to community-based care for the frail elderly.  Intent of the system is to provide a full suite of services along the care continuum at different care settings.

a.         One of Geisinger’s key successes is its integrated IT infrastructure, EHR (Electronic Health Record), which is accompanied by processes to change clinical and professional practices. They use clinical, financial and operational data to draw insights on clinical care and organisational performance, and provide real-time visibility of clinical operations. They relay this data back to clinicians and administrators so that they can look at where they have diverged and can bring their practices back to best practices of other people. This collaboration between clinicians and administrators – something we can take a leaf from, to engender doctor ownership and collective buy-in, is important if we want to bring about changes.

14.      Before you book your air-tickets to NZ or Philadelphia, neither of these systems is perfect or should be emulated to the smallest detail. The key for Singapore is to distil the principles, and to apply them in a bold yet practical manner.

15.      Allow me to suggest three approaches for administrators to be part of this transformation. Think systems, think lean, join hands.  Cannot just think, must have action!

16.      First, think systems.  The healthcare system is a complex network of many parts.  Unless we think systems, we are likely to miss out on something important.  Four years ago, our current Director of Medical Services, Associate Professor Benjamin Ong, who was then CE of National University Health System, was interested in the pattern of patient flows between polyclinics and hospitals.  As the old National Healthcare Group family shared a common database, the HSOR team from NHG was asked to piece together a picture, but not complete, of how each hospital had a dominant referral polyclinic. But there were a few puzzling patterns they could not explain. When Prof Ong moved to MOH, he was able to share the findings with colleagues from across public healthcare. An important missing chunk of the puzzle was added back – data about patients who were using services at SingHealth institutions, particularly its national specialty centres.  Now, the picture is more complete.  

17.      I said “more complete”, because the picture is still incomplete.  Many patients do make use of services in the private sector. Which is why MOH Holdings (MOHH) has been working hard to sign up General Practitioners to join NEHR.  And why we intend to gather our analytics resources and talent into network, so that we do not have individual small teams analysing things, when the bigger picture is yet to be discovered.

18.      Second, think lean. Not what I can do if only I had 100 more headcounts or millions of dollars more in resources.  Who and what do we have now, which if organised differently, can yield better outcomes?

19.      Share an interesting example of flexible working arrangements piloted in 10 wards in Changi General Hospital, KK Women's and Children's Hospital, Singapore General Hospital and Tan Tock Seng Hospital, and which will be progressively rolled out to more wards and hospitals.  What they did was to make some small tweaks to the shift hours.  Afternoon shifts ended earlier, and night shifts lengthened[1].  Nurses could go home on time, and had more time in the evenings with their families.  Before the pilots, married nurses with young families never got to see their children as they were already asleep by the time they returned home.  The result?  More satisfied staff, happier patients, and in one ward, 5 pregnancies!  Not only are we using our existing resources better, we are adding to our future talent pool!  The next challenge for us?  To ask the Sengkang and the Woodlands teams to imagine and build wards that can provide good care with 30% fewer nurses.

20.      Third, work together, for more sustainable outcomes.  The SingHealth Group Procurement Office is a misnomer.  Since its birth in 2000, it was meant to be a secret weapon for the entire public healthcare system.  Based on the latest year figures, over 90% of drugs by volume and about two-thirds of drugs by value were purchased through GPO.  MOH has given GPO its renewed mandate, to procure drugs and supplies at the most competitive prices, and help drive cost effectiveness.  Every dollar saved is an additional dollar that can be used for patient care or staff development or to stave off fee increases.  MOH will also expect all public healthcare institutions to buy through GPO, with few exceptions. The rules for exceptions will be very tightly policed.

21.      Let me cite another example.  In FY2008, all the public healthcare clusters agreed to pool their long-term reserves which they need only to use in the medium to long term into a common pool and have the funds managed through MOHH.  I am pleased to share that the returns since then have been better than if each institution had invested on its own.  I am not at liberty to disclose more.   Our money guys want some privacy. 

Looking to Our Future

22.      I hope that I have given you a few ideas to chew on and, more importantly, to turn into actionable items in the not too-distant future.  And while I still have the stage, I would like to suggest for our senior healthcare administrators to take a lead in mentoring your juniors. 

23.      When I first joined MOH, I met many of our leaders, both clinicians and administrators.  All spoke of mentors who gave them opportunities, and guided them in their careers.  Not all leadership roles in healthcare will be filled by doctors or healthcare professionals.  There is room for our administrators to take your place among the senior leadership.

24.      MOH, MOHH and the Healthcare Leadership College will be very keen to support any ground-up effort by our healthcare administrators to come together, join hands, and mentor our juniors.

25.      On this optimistic note, let me wish all of you a fulfilling time at the Congress

[1] PM shift: Original timing from 1pm to 9.30pm/10.00pm. Under the pilot, revised timing from 12.00pm to 8.30pm (ends 1.5 hours earlier).

Night Duty: Original timing from 9pm to 7.30am/8.00am. Under the pilot, revised timing from 7.45pm – 7.45am (ND lengthened to 12 hours).