Priorities and Challenges for Women’s and Children's Health In Singapore

08 Jul 2007

By Ms Yong Ying-I, Permanent Secretary

Venue: Meritus Mandarin Hotel

Good evening, friends and colleagues

Thank you for inviting me for the 3rd KKH Formal Lecture and Dinner. I have big shoes to fill after my Minister and former DPM Dr Tony Tan spoke at the previous 2 occasions. With some trepidation, I accepted Ivy Ng’s kind invitation to speak tonight.  I then thought it wise for me to read up what my Minister and Dr Tan had said in their speeches.

In 2005, Minister Khaw Boon Wan had encouraged KKWCH to expand its role beyond O&G and delivering babies.  Bearing in mind the declining birth rates and the growth of the private sector O&G capabilities, he challenged KK to be the best hospital in Asia for women’s health.  He thought a good model for this development was Boston’s Brigham and Women’s Hospital.  He also encouraged the Children’s Hospital to benchmark itself against Boston’s Children’s hospital.  I also read KKH’s 2005 more detailed strategy paper.  A month ago, Dr Tay Eng Hseon, your CMB, briefed me on what KKH had done in the last 24 months to implement this “Brighams of the East” strategy.  You have moved rapidly and effectively to build up capabilities in a large number of new areas.  This is most impressive and I encourage you to keep up the momentum.

I asked Ivy what she thought I should speak about.  She suggested that I speak on “a larger budget for KK”; “KK expanding into Asia and the World” (just kidding).  After listening to me at the MOH Workplan seminar, she suggested I speak on “Priorities and Challenges for Women’s and Children’s healthcare in Singapore”.  This is a larger topic than I can do justice to tonight, but I will try to earn my dinner by sharing my thoughts on some of the challenges ahead for Singapore healthcare, how MOH plans to respond to these, and the role that KKH can play in that landscape.

THE CHALLENGES AHEAD & MOH’s PRIORITIES

The first challenge is the rapidly ageing population.  You know this.  You have heard this ad nauseum in ministerial speeches.  But I think that we are now beginning to see its implications on healthcare.  First, it is appearing in higher length of stays (that’s obvious), but also in the utilization of hospital facilities.  The elderly may be well but they visit the hospitals frequently for continuing care.  So our patient loads are rising at all our general hospitals.  Second, the elderly have different sets of problems that we may not have built capabilities for, especially outside the tertiary hospitals.  Chronic diseases is one; rehabilitation and recovery assistance is another; mental deterioration is yet another.  Third, women live longer than men, and they are the majority of the “old-old”.  They have a different social profile from men of the same generation – less well-educated; many with very little Medisave and perhaps no insurance coverage. Affordability, understanding, home support are non-clinical problems but as all of you at the frontline know, they have important implications for healthcare delivery.

The second challenge is a healthcare delivery system under pressure because of very tight resources.  For decades, we have been trying to deliver excellent care while containing costs.  To all intents and purposes, we have succeeded brilliantly.  We have outstanding healthcare outcomes and high medical standards, at a level of expenditure that is the envy of many other countries.  Many Government delegations come to study the secret behind our success.  But to me, it’s like riding a bicycle: we need to find that optimum balance between not over-spending and not under-spending.  I think today that we are somewhat off-balance, where we have swung overly much to the under-supply side.  We are very tight on beds and manpower.  We face great pressure to contain waiting times to reasonable levels, and sometimes we don’t succeed.  The current dengue epidemic is a good example.  The system today is really being held together by the outstanding dedication and very hard work of healthcare professionals like yourselves. But we cannot carry on sustainably this way. 

Government has recognized this and is taking action.  The Treasury has accepted the need for increased healthcare spending by the Government. MOH has received more than 10% increase in our healthcare budget this year over FY06. These additional funds are being channeled primarily to developing infrastructure capacity and funding manpower.  We are expanding beds in existing hospitals and are accelerating our infrastructure plans. We hope to get the new hospital at Yishun open as early as we can.  We are also starting serious planning for the next hospital after Yishun.  More important than that is funding for manpower.  Last year, the Treasury agreed to fund significantly more nurses as well as pay them more.  Our nurses across the public sector have already felt the fruits of this change.  This year, we will be seeking funding for doctors and for allied health professionals.  Chief amongst my budget objectives is to get higher manpower norms approved.  We have expanded our local training pipelines and are also looking to recruit manpower from overseas.

Integrated care – leveraging resources beyond the tertiary hospitals

My Ministry believes strongly however that just adding more beds and manpower to cope with rising patient loads in the tertiary hospitals is not the solution.  We believe that for many aspects of healthcare management, patients would be best treated in non-tertiary settings. For instance, in managing chronic diseases over the long-term, private GPs can play a valuable role in guiding a large bulk of such patient in a holistic way.  The GP can partner the appropriate specialists to manage the patient long-term, not just episodically.  For the elderly recovering from an operation, step-down care institutions like community hospitals may be more cost-effective places for them to stay for the latter part of their convalescence.  This requires the tertiary hospital and the step-down hospital to have a close linkage and collaborate on discharge protocols and patient management.  For elderly patients who need rehabilitation or other therapy, day-treatment facilities in the community may be best.  We lack some of these components in our system today, and we certainly lack the working processes to link these together to provide seamless care to the patient.  A critical supporting infrastructure would be shared electronic medical records.   So the top priority of the ministry this year is to begin to build this network for shared integrated care. 

This has implications for the way our public sector tertiary institutions deliver care.  The hospitals have started seriously to look at closer links with step-down institutions and how to build networks with the GPs and VWOs in the community that can help them to discharge patients more safely and effectively. 

IMPLICATIONS FOR KKWCH

Where does KKH fit into this landscape?  First, I believe that the new and expanded services you have launched since the push to build “Brigham of the East” are moves in the right direction. I understand that you have developed 8 new services in the last 24 months: Breast Centre & Colorectal service, Women’s Wellness and a 24 hour clinic, Mental Wellness and Ambulatory Geriatrics, Aesthetic, Plastic Surgery and Sports.  You have also expanded your paediatric departments to care for adult women in ENT, orthopaedic surgery and ophthalmology. 

I think that these set you up to be better able to deliver a comprehensive service for women.  The emphasis is on integrated and holistic care.  The Breast service is a logical extension of your core O&G strengths and I gather that it has already become very popular, handling more than 250 cases of breast cancer in just 18 months.  Also, many women develop a very good relationship with their obstetricians, and this allows you to offer a more holistic care including preventive care such as encouraging regular PAP smears and mammograms, eating well with adequate calcium intake and doing weight-bearing exercises from a younger age to guard against developing osteoporosis later.  (And this matters as I gather that fractures and injuries are a key reason for admission to our acute hospitals for over-65s).

Now, I realize that your expansion into other areas of adult care like cancer, ENT and orthopaedic can generate debate as it overlaps with these services offered elsewhere on a non-gender basis.  As the Minister explained in his Brigham vision speech 2 years ago, your offering some of these capabilities well can relieve the heavy workload and overcrowding in other hospitals.  A segment of women patients may value the more comprehensive care they can get from you.  There is a balance to be struck. My analogy about finding the balance on the bicycle applies here. It would not be sensible to expand the overlaps to many other areas of cancer or try to do cardiac surgery, for instance, where there is no gender difference and where the patient loads would make it wiser for us to centralize limited specialist manpower.  So what services to offer or not offer is a judgement call, and hinges to a great extent on whether we can sustain a high quality team in those areas.

I am glad to learn about the new capabilities you are building in mental wellness and geriatrics because these will be areas of growing demand in the landscape that I painted.  I gather that the driving force for your mental wellness service was the perinatal depression that afflicts some 10% of women and the psychological symptoms in the perimenopausal stage that can hit up to 30% of women.  Beyond these, however, mental health will be a necessary priority area to develop with a growing elderly population.  I visited Australia recently to study their elderly care capabilities and was struck by the scale of resources devoted to mental health.  Dementia and Alzheimer are major afflictions that the elderly will suffer from, and as I noted just now, the majority of our “old-old” will be female.  The Singapore Government has recently adopted a coordinated whole-of-Government approach to look at mental health issues that can affect Singaporeans.  At one of our recent strategy meetings, I suggested that we promote mahjong parlours in the housing estates as keeping one’s mind active can slow down the slide into dementia.  Unfortunately, my medical colleagues told me this is not evidence-based and my civil service colleagues said that we must not promote gambling!

Integrated holistic care must go beyond the walls of the institution and it is in this direction that I would like to guide KKH.  I was told of your efforts to treat asthma in children.  Prior to 2001, poor management of this condition led to acute attacks requiring unscheduled visits to EDs and specialist clinics, not to mention hospitalization.  KKH launched a holistic programme in 2001 for asthma that entailed counseling, telephone consultations and an asthma resource nurses, coaching and empowerment of care-givers.  The statistics show the results – before entering the programme, 70% of the children needed acute care and 60% needed some hospitalization.  After entering the programme, the need for acute care was dramatically reduced to 20% and hospitalization to 10%.  The indirect benefits were sharp reductions in the number of missed school days by the children and missed workdays by parents.  I mention asthma because we are presently wondering if this should be one of the conditions to include in the next phase of our chronic disease management programme where patients can draw on Medisave for outpatient treatment.  KKH’s efforts show how a holistic approach can reduce acute episodes.

I believe you can take the innovation to the next level, by not trying to deliver all the aspects of this integrated care yourselves.  I would like to suggest that your approach to asthma, mental wellness and geriatric care can be modified so that KKH plays a leadership role in reaching out to and drawing in healthcare providers in the community who can be part of our integrated network.  This can reduce the pressure on specialist resources without compromising the quality of care. GPs may know less than you do about the treatment of asthma, and they do not presently have the other resources to approach the problem that you have used.  But we can together, at the national level (or even regional level), pull together resources in community nurses, counsellors and case managers that can support a network of GPs. They would be in a good position to drive prevention and education. One benefit to KKH would be containing the uptrend of cases at your Children’s Emergency Department. GPs will partner your specialists who still have co-responsibility for the patient, but the partnership enables you to impact more lives with the same specialist resources. VWOs in the community can provide some of the actual care for the elderly, but they too will gain much from the professional guidance and leadership that you can provide.   Your particular expert knowledge in women and children’s conditions puts you in the best position nationally to reach out to the VWOs which are gender-specific or care heavily for women or children.

Let me suggest 3 leadership roles you can play.  One of these is in taking the lead to set clinical standards of care across the integrated care package offered by the network.  A second leadership role is in patient education.  Patients are not going to be able to navigate the network of suppliers even if you organize the network of supply relationships.   KKH’s guidance can help them get connected to the right care at an affordable cost.  A third leadership role is in helping to train staff from some of these partners so that they are better equipped to play their roles.  I understand that you have been training GPs for a number of years to do PAP smears in their clinics in conjunction with the cervical screening effort.

I think KKH has the clinical and organizational capability to do this, but some of you may ask whether it is your role to lead this network of community resources and VWOs. My view is that you should precisely because you can and no one else is in a position to do this other than you.  You are a public sector institution, and this is a strategic role that can make a difference to healthcare outcomes in Singapore.

MOH is prepared to work closely with you and help make some of these ideas happen.  We are, for instance, ready and willing to roll out suitable IT software to the relevant VWOs, step-down institutions and community care providers so that electronic medical records can be seamlessly shared.  We are open to working with you on studying clinical treatment protocols and standards of care which leverage the skills of multi-disciplinary teams and cut across institutions.  It will be challenging, but I think it will be exciting to try.  We are also willing to relook our funding approach so that it support integrated care across institutions.

Building Manpower capabilities

Of all the things that you can and might do, the foundation of all these is a focus on manpower development.  I urge you to focus on this.  Healthcare is a talent business.  Soon after coming to MOH, I was taught this phrase by cluster administrators, “no money, no healthcare mission”; this was the phrase used to explain that while healthcare is a social mission, keeping it going is still a business operation that has to watch the bottomline.  That’s true.  But in this context, I would modify the phrase to “No people, no mission”.  To deliver the various initiatives and ideas that we hope to going forward, we need to recruit, develop and retain people with the requisite skills and commitment.

We are short of people in many areas.  Obviously, we are short of geriatricians and general internists. But we are also short of people to staff our Child Development Unit.  And while we are on the subject of shortage of skilled personnel, let me also mention some non-patient-facing staff that we need to build – health services researchers; discharge case coordinators and medical social workers, physiotherapists, speech therapists, and clinician scientists and investigators.  I mention health services research because a deeper understanding of women’s health issues and patterns of disease evolution are necessary if KKH is to be a strong thought leader.   To address our shortages, we have to fill gaps by recruiting from overseas or bringing people back from the private sector, and we have to aggressively and systematically grow our local training pipelines. 

Towards “Brigham of the East”

In conclusion, I commend you for moving rapidly in implementing your strategy to become a comprehensive women’s and children’s hospital of international standing. You are doing well and I encourage you to continue your efforts.   In going forward, do benchmark yourselves against the best in the world, in your quest to be the best in Asia.  Your international reputation in your core areas of strength is obviously strong – I was told that the daughter of the Maldives President chose to give birth to her baby in KK, and there are many others like her.  I encourage you to continue to expand the set of clinical outcomes that you publish.  The next step towards thought leadership is in participation in international learning networks such as the Vermont Oxford network, (which allows you to compare yourselves against more than 600 Neonatal Intensive Care Units around the world) and collaborations in clinical research projects, locally and internationally.

At the heart of greatness will be what you can do to keep all Singaporean children and women healthy. Since we are shooting for greatness, a stretch vision is “no sick children and women in Singapore”!  I wish you all well in your efforts.  Thank you very much for inviting me to speak.