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09 Feb 2009
By Khaw Boon Wan
1. Last year, the American Geriatrics Society coined the term“silver tsunami” to sound the alarm on the enormous healthcare challenges facing the United States as their post-war baby boomer generation enters retirement. The ageing of their baby boomers,combined with a rise in life expectancy and a drop in birth rate, will place tremendous strain on the US healthcare system, which is already under a lot of pressure. They concluded that the US is ill-prepared tomeet the “silver tsunami”.
2. Singapore will face a “silver tsunami” of our own as the elderly are more likely to be hospitalised and consume more healthcare resources. In fact, our hospitals are already facing the first wave, a relatively small wave, as our baby boomers turn 60. In 10 or 15 years time, when the baby boomers turn 70 or 75, we will feel the pressure of the second and the larger wave of the silver tsunami. We have been served notice; we must protect Singapore against it and we have started the preparation.
3. We are expanding our healthcare capacity, adding hospital beds,training more staff. But preparing for the silver tsunami goes beyond simply expanding the hospital sector. Most of the elderly will have health conditions that require long-term chronic care, rather than short-term acute hospital care. GPs and polyclinics will play important roles in the care of the elderly sick. The long-term care sector will have to grow quantitatively and qualitatively to meet the expanding demand. We need many more doctors, nurses and allied health professionals. Failure to strengthen the long-term care sector will end up in the elderly patients seeking treatment in the more costly hospital sector, often with worse health outcomes, less satisfactory service level and larger bills. I believe one reason for the US spending 16% of their GDP on healthcare is that many of their elderly patients get treated in the wrong place when lower cost and in fact better care should be rendered in the long-term care sector. We must avoid this.
4. We have 10 to 15 years to put the policies, systems and infrastructure in place, so that we can face the silver tsunami with confidence. I highlighted this issue last year. After a year of analysis, I now have a better sense of what we need to do. There are gaps in several important areas and we need to fix them.
More Money
5. First, we need to have enough funds to support the long-term care sector, of a quality which Singaporeans will demand. Unlike our parents and grandparents, the elderly baby-boomers of 2020 will demand and expect a higher level of care. Many will not be satisfied with the current level of care rendered in some of the nursing homes. I think many will expect, and will be able to afford if we help them save up while they are young, a higher standard of care run by professionals and better trained staff. This is the future which we must prepare for.
6. To help Singaporeans prepare for this future, we can take a leaf from how we prepare Singaporeans for their anticipated hospital care in old age. Over 25 years, we have carefully constructed a comprehensive 3Ms framework to ensure its adequate funding:Singaporeans save regularly in Medisave, MediShield ensures efficient risk pooling and Medifund provides the ultimate safety net.
7. As wisely noted in this House by PMO Minister Lim Boon Henglast week, we need to construct the equivalent of the 3Ms for the long-term care sector. He called it the 3Es: Eldersave,ElderShield and ElderFund. I support his call. I was part of the MOH team led by SM Goh, which 30 years ago carefully thought through and constructed the 3Ms framework for acute hospital care. It took us many years to finalise the various 3Ms components, explain them to Singaporeans and progressively get them implemented. We now have a robust 3M system, it is not perfect but we continue to make improvements to it. Sound long-term planning and effective implementation have enabled Singaporeans to afford The 3Ms way to financing hospital care is now part of Singaporean life, and the envy of many countries.
8. We need to do the same for the long-term care sector. The work has actually already begun. Former Health Minister Lim Hng Kiang drove in a key piling, ElderShield, in 2002. Minister Lim Boon Heng’s Elderfund is what we call Medifund Silver and was introduced in 2007. I am now able to build on these elements.
9. We need Singaporeans to regularly save for their anticipated long-term care, while they are young and working. We can either create an Eldersave or save more in Medisave so that it can also be used to fund long-term care. The question is how much will be needed for long-term care. We are studying the experience in the more mature societies, such as the US, UK, Europe and Japan. Preliminary analysis suggests that they spend less than 2% of their GDPon long-term care. An outlier is Sweden which spends more, buteven this is below 3% of their GDP. This gives me comfort that thefunding problem may not be insurmountable, but there must be a conscious effort to ensure that Singaporeans save regularly for their long-term needs, just as they do for their hospitalisation needs.
10. This is of course not the time to talk about raising the CPF contribution rate, and we have no plans to do so. But when the economy eventually fully recovers, we should revisit this issue ofsaving for our long-term care. Meanwhile, we have allowed Medisave to be used for some aspects of long-term care: in community hospitals, chronic sick hospitals and hospices, and also to pay for ElderShield premiums. But we must remember that the current Medisave contribution rate is based on the projected needs of hospitalisation; it has not priced in the additional needs forlong-term care. We need to compute how much Medisave should be enhanced to finance this expenditure going forward.
11. As for ElderShield, I have restructured the industry to incorporate ElderShield supplements in their product offerings. But we need to do more. Half of Singaporeans above age 40 are now enrolled in basic ElderShield. Not bad. But we must persuade the other half to join in, and everyone to also top up with ElderShield supplements as basic ElderShield only pays $400 per month for 6 years to its successful claimants. This falls short of the monthly cost of about $1,800 in a private nursing home, and wouldrequire a sizeable out of pocket monthly payment by the elderly or thefamily. Singaporeans’ understanding of this insurance product remains poor and we have to work harder to raise awareness of the ElderShield supplements and their benefits.
12. As for Medifund Silver, we will continue to top it up whenever the budget position allows it. This year, despite the pressure on the Government budget, I am grateful to the Finance Minister fortopping up Medifund with $100m, of which a portion will be allocated to Medifund Silver. We will definitely put it to good use.
13. Dr Lily Neo highlighted the larger proportion of female among the elderly population. Due to their longer life expectancies and higher incidence of chronic diseases such as arthritis and osteoporosis, women will have greater need for long-term care,incurring higher medical expenditures. That is why it is so important that all working females should stay within 3Ms and eventually the 3Es:contribute regularly to Medisave and subscribe to both MediShield andElderShield. For housewives, husbands should do their duty by contributing to their wives’ Medisave accounts.
14. A/P Mehta asked if current community-based long-term careservices are affordable. For the vast majority of Singaporeans, theyare. The lower-income patients are assisted by MOH subvention,ElderCare Fund and donations raised by VWOs. Medifund Silver provides a safety net. Subsidised services include home medical,home nursing, home rehabilitation, dementia day care services, andrenal dialysis. But as the population further ages, we expect to do more.
15. Ms Sylvia Lim asked about the means-testing framework for long-term care. We provide subsidies for half of the Singaporean population, thus including the lower middle-income group. This model based on per capita household income is a better gauge of financial means. However, for means-testing in acute hospitals, we hadto simplify it to rely merely on personal income. This is for practical reasons, given the large volume of admissions and short stays in public hospitals. However, we will continue to refine the means-testing framework and the assessment process so that they remain fair and relevant for Singaporeans.
More Capacity
16. Second, we need to build up capacity, including new communityhospitals (CH), nursing homes and train more skilled manpower.Community hospitals play an important role in helping some patients transit from their acute hospital stay to their return home. Timely and appropriate CH care – results in lower re-admission rates and improved quality of life for patients, especially our elderly. With an ageing population, demand for CH services will increase further. We now have 6 CHs with more than 800 beds in total. This includes the new Ren Ci CH near TTSH. I visited them last month. It was quite empty but I expect it to fill up eventually. Over the next 10 years, we will add more community hospital beds, by an estimated 60%. Our immediate plan is to build 2 new CHs with 200 beds each: one next to KTPH by 2013, and another next to JGH by 2016. Our targetis to raise the current ratio of 1 CH bed per 8 acute beds to 1 CH bed per 5 acute beds by 2020.
17. Similarly, we are expanding the nursing home (NH) capacity by50% over the next decade from 9,200 to 14,000 beds. This will be in both the private and VWO sectors. We are working with several existing NHs to increase their bed capacity and help those with expiring land leases relocate to larger facilities. Over the next 2years, we will help the private and VWO sector to set up 5 new NHs. We will also work with URA to reserve more sites for NH development, to meet longer term demand.
18. Where appropriate, we are blurring the line between VWO and private NHs by allowing means-tested patients access to private NHs through the portable subsidy scheme. This is one way to help raise professional standard across the industry. Last year, 750 beds in private NHs came under this scheme. We are ready to do more. In addition, from this year, MOH will extend MedifundSilver to needy subsidised patients in private nursing homes on the portable subsidy scheme. Separately, I agree with Mdm Cynthia Phua that we need to increase the number of community rehabilitation and dementia day care centres and we will.
More Capabilities
19. Third, we need to upgrade the capabilities of the long-term care sector. For example, they need to raise nursing standards in the nursing homes, to deal with increasingly complex needs of the elderly, including caring for elderly with dementia. For community hospitals, they need to develop stronger medical capabilities to manage more complex sub-acute cases, so that we can discharge patients from there helping patients to save, and to help free up more beds.
20. Similarly, the public will expect a greater degree of accountability from the healthcare VWOs as they receive more government subsidies and public donations. Beyond delivering good long-term care to patients, sound corporate governance and financial account ability will have to be established in the VWOs.
21. We have extended the Health Manpower Development Programme to the Intermediate and Long-Term Care sector. Many healthcare professionals from the sector have benefitted from both local and overseas training. We have further revamped the programme to provide higher level of support.
22. I agree with Dr Lam Pin Min and Mdm Cynthia Phua that we should also enhance the home care sector. My Ministry currently supports several home care services, including home medical, home nursing, rehabilitation, and dementia day care services. As the next step, we are working with the stakeholders to develop viable models to deliver more coordinated and integrated healthcare services to the home. We recognise that the caregiver is the key to successful home care. Nevertheless, we need to recognise that there are limitations of home care, brought about by smaller family sizes and frailty from increasing life expectancy. We will have to be realistic and recognise that home care may not be for everyone, given that the home care model can be relatively expensive and skills-intensive.
23. Mdm Cynthia Phua highlighted the major challenge posed by dementia. We need to do more on prevention, early detection and treatment. HPB will expand its programme to help improve the mental wellbeing of elderly, and will scale up targeted public education on the signs and symptoms of dementia.
24. We certainly need to train more geriatricians. But I would like to emphasize that it is neither sufficient nor sustainable to rely on geriatricians alone to take care of the sick elderly. There needs to be a general leveling up of capabilities of our healthcare professionals in caring for the elderly.
More Integration
25. Fourth, we need to achieve greater integration among the various healthcare providers. So far, our “many-helping-hands” approach to community care has served us well to deliver affordable services.Going forward, the Government may need to play a more active role inthe design of services and the integration of care. Our objective is to enable our patients to move seamlessly across different institutions. Integration of care is critical so that we can care for patients in the most appropriate setting at lowest cost.
26. To facilitate smooth patient transitions, we need to strengthen collaborative partnerships between primary care, hospitals and the long-term care sector. For the frail elderly in particular, a multi disciplinary approach with close collaboration between doctors, nurses, allied health professionals and social workersis essential, given their multi-faceted needs
27. Last month, TTSH signed a clinical governance agreement with the new Ren Ci Community Hospital. We will continue to encourage such win-win collaborations.
28. We are also building up various support services and mechanisms to integrate care. The Agency for Integrated Care(AIC) was set up last year to strengthen discharge planning and facilitate the movement of patients from hospitals to the variousl ong-term care services.
29. Affordable drugs are another important means to integration,as this lowers the financial barrier to right-siting. In reply to Dr Fatimah Lateef, many of our restructured hospitals and polyclinics have already established drug supply partnerships with some of the VWOs running community hospitals and nursing homes. We support these partnerships. Our hospitals and polyclinics are working towards expanding the partnership to more VWOs.
More Use of IT
30. Finally, we need to tap technology more smartly to help us fight the silver tsunami. IT is an important infrastructure. President Obama’s stimulus package includes a programme to digitalise medical records nationwide. We are ahead of the US. All hospitals here have already digitalised their medical records. In the last few years, we worked on getting these individual hospitals to link up their medical records electronically. Today, public hospitals are able to share electronically relevant clinical information of their patients, regardless of which public hospital the patient is seeking treatment at. This is quite a milestone.
31. In parallel, MOH has begun reaching out to the GPs and exchanging electronic medical records with the community hospitals.These building blocks have provided basic capabilities in health information exchange amongst public hospitals, polyclinics, GPs and step-down facilities.
32. As the Finance Minister has mentioned, Singapore is in the unique position to be one of the first in the world to implement Electronic Health Records nationwide, across the primary, acute and step-down care settings. This is made possible through the strong foundations built in our public hospitals. MOH will see this initiative through to benefit our patients. We will be spending $176m for the next two years to complete this project. Healthcare providers no longer need to shuttle individual paper records to and fro, reducing unnecessary repeat tests and ensure improved safety and continuity of care for the patients. We will not disappoint the Finance Minister. Singapore will be among the first in the world with a nation wide system of EHRs, bringing real benefits to our patients.
End-of-life Issues
Advance Care Planning
33. Mr Chairman, confronting the silver tsunami cannot avoid a discussion on death and end-of-life issues. This used to be quite a taboo subject. But I am glad that after many months of public discussion on this morbid subject, Singaporeans are now able to discuss this subject openly with less emotions and more logic. I thank all Singaporeans who have offered their views and insights on this difficult subject. Some of the discussion focused on euthanasia, which was not MOH’s intention. What we wanted to do was to get Singaporeans thinking about the necessity to prepare for a good death.
34. One concrete way of doing so is to introduce broader Advance Care Planning among healthcare professionals. We are really trying tofind a middle ground between a scenario where families insist on treatment at all cost contrary to clinical opinion and the situation where families opt for non-action due to ignorance on the option of palliative care. There was a recent article in the New England Journal of Medicine (“Fighting On” by Jeffrey Drazen, Nihar Desai and Philip Green) by 3 American ICU doctors on their experience with the terminally-ill. It was a moving article, on how the dying suffered unnecessary pain as their children insisted on “fighting on” and refusing to let go. The authors ended their article with this rhetoric: “Those of us on the front lines can’t but wonder: for whom do we “fight on”, and why do we do it?”
Amending AMD legislation
35. An important part of end-of-life care is the Advance Medical Directive (AMD). The directive provides an avenue for people to think about and make a choice about their end of life care in advance.
Conclusion
36. Mr Chairman, the silver tsunami is definitely coming and we must gear up so that we do not end up overwhelmed by it. We still have some time to fix the gaps in the current system. Many countries are trying out various ideas and solutions and we must learn from them. Which schemes are effective and where are the pitfalls? We must also have the confidence to innovate and evolve schemes that best work for Singapore, given our special circumstances,with a unique 3Ms financing framework and a practical Government with a supportive population.
37. There will be fundamental changes which we will take care to implement progressively. Change is necessary for the long-term sustainability of our healthcare system, and we should not shy away from these changes, even as we cope with the short-term challenges of the current economic tsunami.