SPEECH BY DR JANIL PUTHUCHEARY, SENIOR MINISTER OF STATE, MINISTRY OF HEALTH, AT THE ASIA-PACIFIC INTENSIVE CARE SYMPOSIUM 2024, 17 AUGUST 2024

1. Thank you for inviting me to speak at the 11th Asia-Pacific Intensive Care Symposium. I’m very happy to be here. 

2. I am a lifetime member of the Society of Intensive Care Medicine, and also benefitted from a fellowship in Sydney in some of your intensive care units. There are a number of colleagues, trainees, students, professors, mentors and teachers in the room here – so what then can I offer to such a distinguished gathering?

Singapore’s Intensive Care Landscape 

3. I thought I would explain a little bit about how intensive care in Singapore is organised, delivered, and supported in our larger healthcare system. We currently have nine public acute hospitals, operating a total of 365 intensive care beds. That makes up about 4% of our total acute beds. Together, across the ecosystem, these nine centres provide a comprehensive suite of critical care services. We have a common national intensive care training curriculum and a common examination. This approach has allowed a cross-deployment of staff between our ICUs, balanced against the opportunity to pursue further training and a greater degree of specialisation.

4. Our tertiary hospitals, like in many cities, have separate specialised ICUs – medical, surgical, neonatal, coronary care, neurosurgical, and paediatric. Like many other cities, our secondary acute hospitals have combined ICUs covering a wider range of disciplines, and also moved to further combine their ICUs with high dependency or intermediate care beds, allowing for more efficient use of space, easing the use of a larger pool of physicians to contribute to part-time ICU work around a common core of acute care and critical care services. This has improved the allocation of manpower resources, maintains the competency of the larger pool of physicians, and provides sufficient personnel, we hope, to be able to deal with the fluctuations in ICU workload as well as the very real risks of burnout in this profession. 

5. We have centralised selected sub-specialised ICU services in certain public healthcare institutions. Given, as you well understand, the need to sometimes concentrate workload and develop the skills and competencies of dedicated teams of clinicians in all disciplines with these advanced competencies, and ultimately then to optimise clinical outcomes. Examples include the provision of Extra-Corporeal Membrane Oxygenation services, coupling that with a dedicated cardiothoracic service, as well as the Molecular Adsorbent Recirculating System therapy for liver failure together with specialised liver failure services and liver transplant programmes. Both of these examples are provided at the Singapore General Hospital and the National University Hospital for a national need. There are further examples , such as specialised teams providing treatment for major burns, and hyperbaric oxygen for dive injuries. 

6. I also want to specially point out two of our teams. One is at Alexandra Hospital, and the other at KK Women’s and Children’s Hospital. They provide a medical transport palliative care service for compassionate, or in some jurisdictions, termed terminal discharge, for patients who prefer not to pass on in a hospital. They provide a service for the withdrawal of ICU care within one’s home, accompanied by family members and loved ones in a familiar setting. We have a variety of these services, and I hope, as comprehensive as they can be, to serve every anticipated critical care need.

Access to ICU Care in Singapore

7. I can detail a very comprehensive service delivery model, but I’m sure colleagues in this room will be far more concerned with quality of care and clinical outcomes. 

8. We watch closely the standardised mortality rates, the incidence of nosocomial infections, rates of ventilator-associated pneumonias, and we look to benchmark against international comparisons. I’m sure many of the presentations over the next couple of days will dive into those details, provide the data and comparisons, and I hope it will show that these outcomes demonstrate the excellent work that our clinical teams here do. So instead, I’m going to make a slightly adjacent point around outcomes.

9. In government, one of the markers we watch closely is access to care across our system. This includes access to critical care services at the point of need. Given the size of our city and with ICUs located in all public hospitals across the island, patients are literally a few minutes away from intensive care should they require it. But how does this work in practice?

10. Well, the bottom line is that our city has never had to deny critical care because of a lack capacity, or the inability to pay, even at the height of the pandemic. In the years of practice that I had at KK Women’s and Children’s Hospital before joining politics, we’ve never had a situation where there was not a paediatric ICU bed available for a patient. Care has not been withheld as a result of capacity or affordability.

11. This speaks to the coordination that exists within our hospitals, between the various centres that we have, and the presence of national mechanisms to divert patients where necessary, balance workloads, and coordinate our responses to crisis. Ultimately, it speaks to the good work of our critical care teams to do two things which sometimes appear to be in conflict – to serve the patient at the bedside as best they can, and at the same time, make the national healthcare system work.

The COVID-19 Test - Singapore's Approach to Pandemic Preparedness and Resilience

12. We are able to deliver ICU services in this way because of deliberate planning and investments in people and infrastructure, and this is backed by an appropriate financing framework. This was evident during the COVID-19 pandemic. Looking at the news, we saw stories and vivid pictures of hospitals and ICUs in other countries that were overstretched and overwhelmed. We knew that it would eventually place unprecedented demands on our healthcare system. 

Personnel

13. In the face of this global crisis, our intensive care professionals demonstrated remarkable resilience, adaptability and dedication to patient care. For our intensive care personnel, we had established the formal recognition and accreditation of intensive care as a sub-specialty in 2012 with an inaugural 158 sub-specialists, and in 2017, established paediatric intensive care with a further 10 sub-specialists. By 2020 when COVID-19 struck, we had 256 intensivists and 20 paediatric intensivists. This group went on to develop processes to quickly train additional staff and doctors which allowed us to rapidly increase our capacity.

14. Senior physicians who were non-intensivists but had done a previous ICU rotation, as well as junior doctors from various specialties, were activated and re-deployed to get ICUs ready for the surge in the number of patients requiring intensive care management. We were able to ramp up quickly as critical care rotations are mandatory for most medical and surgical specialty training programmes. As a paediatric intensivist, visiting some of these ICUs at the time, it sent a little flutter in your heart when an orthopedic surgeon introduced himself as being in-charge of respiratory care. But this was a testament to the fundamental training that our specialists had and their ability then to retrain and redeploy to look after patients. 

15. As part of the team, we also had wound care nurses redeployed to our ICUs, and midwives coming in to help with respiratory care. In 2020, we had 34 Advanced Practice Nurses working in our ICUs. And every year, we send about 80 to 110 post-basic registered nurses for an Advanced Diploma in Critical Care. But still, there was a shortfall of nurses with ICU training. So the nursing profession adapted and developed a focused approach to training and team structure, and over eight weeks, almost doubled the number of ICU-capable nurses to 2,600. Post-COVID-19, we sent more nurses for formal Advanced Diplomas, as well as training in the fundamentals of critical care because we see that these are important things to do to maintain the resilience of our system. 

Infrastructure

16. This approach to manpower augmentation, together with flexible multi-use bedspaces and clinical locations, as well as stockpiled equipment, consumables, and medication, provided us with the ability to double our ICU capacity in response to the pandemic. 

17. Major infrastructure works had to continue during the crisis. Evidence emerged that patients on high-flow nasal cannulas had better outcomes, and so we had to engage major mechanical engineering infrastructural changes within the hospitals to accommodate the large number of patients who needed to access high flow cannula oxygen treatment.

18. In some instances, our approach to infrastructure had to extend beyond the ICUs. For instance, Ng Teng Fong General Hospital has in its design, provisioned for transforming its basement car park into additional wards during emergencies, while Khoo Teck Puat Hospital is able to use the white space around its atrium to serve the same purpose. This intentional design and implementation for resilience in personnel and infrastructure have continued post-COVID-19, with plans to increase the proportion of intensive care services and isolation bed capacity.

Financing Framework 

19. In the background, being able to think about ICU services in this way would not have been possible without a financing approach which has to cater to both access and quality while also being sustainable in the long term. Our healthcare financing framework is designed to ensure that all Singaporeans have access to high quality affordable healthcare, including critical care. It comprises government subsidies; MediSave, our national medical compulsory universal savings scheme; MediShield Life, which is our national health insurance scheme; as well as MediFund, which acts as a safety net for those who face financial difficulties. 

20. Patients in need of ICU care are eligible for government subsidies of up to 80%. The insurance protection of MediShield Life, the limits are sized to cover nine in 10 subsidised bills. MediSave can also fully cover the co-payment for most bills, which results in the majority of patients having no out-of-pocket costs. Taking all these policies and services together, we benefit from an integrated robust framework that ensures access to high quality medical care, including vital ICU services, and we hope doing so in a way that maintains the fiscal responsibility for the future of our healthcare system.

Managing Demand

21. But all is not rosy. We have a rapidly ageing population, and with an increasing burden of chronic diseases, we need major interventions to have our healthcare system be sustainable for the future. We are moving upstream and investing heavily in strategies for population health.

22. Healthier SG is an initiative that drives individual enrolment with a designated primary care physician, and supports regular health screening, lifestyle and social prescriptions and robust chronic disease management. Age Well SG is a plan for public sector investments, interventions and strategies for ageing in place, to reduce isolation and delay the onset of dementia. In the long term, we hope that all this will moderate the demand for acute hospital care, and ensure the effectiveness, efficiency and the viability of our healthcare system.

23. Even as we develop these population-wide strategies for the long term, we continue to implement interventions that address issues that are of immediate concern.

24. We have a proposed Health Information Bill, which will provide for the contribution, access and sharing of health information, with cybersecurity and data security requirements put in place for healthcare providers. This will allow providers continued access to an up-to-date and accurate centralised national repository of key healthcare information, regardless of where care is provided, enabling better collaboration across teams, better research and better coordination of care delivery.

25. We’ve learnt from the pandemic and set up the Communicable Diseases Agency to ensure that we are ready for the next crisis. It will oversee a comprehensive range of activities, including policy and system development, disease prevention, control, surveillance, and enable the government to swiftly and effectively respond to disease outbreaks through a unified public healthcare initiative. 

26. Turning to research, we have a Programme for Research in Epidemic Preparedness and Response (PREPARE) set up as a national effort to support and strengthen our key essential research capabilities, translational platforms and expertise to prepare for future infectious disease threats.

Collaborations Across Borders

27. Research in our specialty, in critical care, is challenging. There is the varied nature of the diseases that we treat, the very varied nature of patients that come to us, and the settings in which we discharge our duties. A culture of collaboration, of knowledge sharing, of communities of practice internationally, are essential for driving the scientific basis for improvements within our discipline. 

28. The Asia-Pacific Intensive Care Symposium serves as one such platform to exchange ideas and forge new collaborations. We extend a very warm welcome to all the leaders of the Intensive Care Societies from countries representing more than 60% of the world’s population around the world. We hope to have the opportunity to learn from you and put our collective expertise and experience together. 

29. The theme of this year’s conference – Best Care Beyond Borders – highlights our dedication to deliver exceptional care, transcending geographical boundaries and pursuing excellence within critical care.

Closing

30. I would like to take this opportunity to acknowledge the exceptional work of the SICM and the members of the intensive care fraternity in Singapore who have coordinated and participated in much of our pandemic response.

31. I extend my deepest appreciation to every one of you for your commitment to the field of intensive care medicine, including our committed nurses, pharmacists, dietitians, respiratory therapists and physiotherapists, and doctors. I would especially extend a welcome and appreciation to the trainees and students who have chosen to walk down this path of critical care medicine; I know I am biased but I think you have chosen a most fascinating and rewarding career.  

32. I wish all of you a great conference. Thank you very much.