Speech by Minister at Opening Ceremony of the JAMA-NUHS CME Conference

01 Aug 2008

By Khaw Boon Wan

“Changing Habits, Transforming Healthcare”

Good Morning Ladies and Gentlemen

Distinguished Guests

1. Let me join Prof John Wong in extending a very warm welcome to our overseas guests.  This is the first time that JAMA is organising a conference in collaboration with a foreign institution.  We are honoured that JAMA has chosen Singapore and NUHS to be its partners.   

MANAGING DILEMMA

2. The recent public debate over kidney trading is characteristic of many healthcare issues.  There are hard choices and people hold strong views on opposite sides of the camp.  Achieving consensus will require efforts to allow different views to be aired, sincere attempts to find common ground, and a willingness to accommodate different points of views.  Even though the issue is still divisive, I already see much common ground emerging. 

3. First, Singaporeans agree that we should try to reduce the incidence of End Stage Renal Disease.  We are not the best in the world on this score.  The top performers, like Norway, have ESRD incidence of about 100 per million population.  Ours is more than double, at 224 per million population.  Our high diabetes incidence is a major contributor to our poor performance.  We should strive to manage our diabetes better.  So this Conference has particular relevance to Singapore.

4. Second, all agree that cadaveric kidney transplants are the best option and we should maximise our yield from this route.  The top performers, like Spain, have cadaveric organ transplant rates of about 50 per million population.  Ours is at 12 per million population.  There is clearly scope to increase it.

5. Third, most agree that living-related kidney transplants are worthy of further promotion and we will encourage this.  We are now at 9 per million population and we will step up public education to push this up.

6. Fourth, all agree that altruistic donors and families of cadaveric donors should be reimbursed in a meaningful way.  Properly designed and implemented, such reimbursement, even in cash, need not be construed as kidney trading.  My Ministry will particularly look into how third parties in the charity and religious sectors may be able to play a role in this.

7. I believe the above provides a sufficiently broad common space for us to collectively build upon and push the process forward, even as we continue to mull over the possible expansion of living-unrelated kidney transplants to help supplement the supply.  I know the ethical arguments against the commoditisation of human parts.  I am equally aware of the misery of the patients and the outrageous exploitation of ignorant donors that continues to happen in many parts of the world.   This is the stark reality, the human dilemma that confronts many desperate people out there.  We cannot simply argue these problems away.   

8. As healthcare policy makers, we are used to managing such policy dilemma: to legalise euthanasia, or not?   To promote embryonic stem-cell research, or not?

9. We face such policy dilemma even in less ethically controversial areas.  As the National Health Service celebrates its 60th Anniversary, the UK is currently debating the issue of whether NHS should allow some of its patients to be prescribed more expensive drugs even if these patients are prepared to pay for them.  Singaporeans who are used to co-paying their medical expenses would find such a debate unusual.  But a 60-year old culture of equal treatment for all patients has forced the British government to consider it necessary to decline better treatment to some of its patients, unless the same treatment is extended to all.  Unfortunately, the latter approach would push up healthcare cost at the national level which may not be sustainable.

10. The UK is not alone in having to deal with this major challenge of how to keep healthcare cost low and quality high.  Healthcare reform is an issue in the current US Presidential Election.  To make matters worse, there is a looming global crisis in terms of managing chronic diseases, which threatens to weigh down all our healthcare systems if not handled properly.  In particular, obesity, a key risk factor for many chronic diseases, is reaching epidemic proportions, in both the First World and the Third World.

11. The good news is that the solutions are known, at least in theory.  We know, for example, that healthy lifestyles do reduce disease incidence.  We also know that early detection and intervention can reduce future complications.

12. The challenge is to bring about sustainable behavioural change, for example in adopting healthy diets and lifestyle habits.  Unfortunately, here we confront major obstacles.

13. First, we are the products of evolutionary biology.  The human sense of taste evolved when nutritious food was scarce and a positive response to sugar, fat or salt gave one a competitive advantage in survival.  But we have now entered a new era of abundance.  Until recently, many people struggled to secure enough calories for themselves.  Now, the opportunity to eat for pleasure has opened up to the masses.  Hence, most people take in significantly more sugar and more salt than is good for them.  That explains why most people prefer to eat junk food.  Only considerable self-discipline is preventing some of us from becoming addicted to it.

14. Second, we face the huge marketing and advertising budgets of global fast-food chains.  No Government health promotion boards have access to that kind of budget.  The creative talent has therefore tended to flow to the wrong side of the camp, exacerbating this struggle.

15. While the challenges are severe, our determination to overcome them is strong.  Governments know that more of the same is not sustainable.  The US already spends 16% of its GDP on healthcare and projections are pointing to 20% in a few years’ time.  Thinking people know that the current model has to be transformed, or the human race may all end up working in the healthcare sector(!)

16. In Singapore, we have a good standard of healthcare, achieved at 4% of GDP.  This is partly because Singaporeans are still young and healthy.  But it is also partly because we waste less in healthcare resources and we pace the adoption of new technology a lot more aggressively than others.

17. However, we know that our system is still far from perfect and there are many gaps which have to be plugged.  Let me highlight two areas.  

BUILDING A NATIONAL EHR SYSTEM

18. First, we will need to further exploit IT and put it to greater use to benefit the patients.  We were among the early adopters of healthcare informatics.  Our hospitals have had their Electronic Medical Records systems for many years now.  Three years ago, we took a major step forward, when we got our hospitals to integrate their EMR systems.  We now have in place the EMR Exchange or EMRX to allow cross-hospital exchange of patient information such as inpatient discharge summaries, laboratory and radiology reports, drug allergies and medical alerts, and recently, x-ray images.  Immunization and school health records of children are also available to the hospitals through EMRX.

19. The strategic intent is to put in place an IT backbone, as a critical enabler in healthcare transformation.  This will allow sharing of patient health records among healthcare providers, and enable the seamless movement of patients across the whole healthcare spectrum, receiving care at the most appropriate setting, without duplication of tests and scans. 

20. At the heart of the challenge  is ensuring inter-operability across diverse systems.  This will require the setting of data and systems standards and ensuring that they are widely adopted.  Beyond technical issues, there are many other issues that need to be addressed, including system security, data protection, privacy, regulation and audit.  That all these are issues of hot international debate reflects the complexities involved and the work required to take them forward.  

21. We are proceeding to set national data and IT standards and putting in place the legislative framework for data protection.  These will provide the foundation on which we will build a national Electronic Health Records system containing critical health records of every Singaporean.   The ultimate goal will be to have all healthcare institutions – public and private hospitals, primary healthcare clinics, step-down care institutions – linked to this national EHR, accessing and providing real-time clinical information of the patients they are treating.   

22. This is an ambitious, national-level undertaking that will take years to achieve.  But we are gearing up to take on the various tasks, organising our work and resources for better focus and accountability.  This includes having a core group focussing on broad strategy and policy setting, guiding the process of standards setting, defining the overall enterprise architecture and requirements of a national EHR system.  We are also aggregating our IT resources, currently residing in the hospital clusters, under a new IT company.  The company’s primary focus is to provide IT support services and execute our national strategy, not only for the public healthcare institutions, but eventually for step-down and primary care providers. 

INTEGRATING HOSPITAL AND LONG TERM CARE

23. Second, we must address the current fragmentation and poor coordination of care between hospitals and the long term care sector.  The strategic intent is to achieve seamless and integrated care for patients across the whole healthcare eco-system.  This will particularly benefit the chronically-ill patients who have to move to-and-fro from hospitals to nursing homes and community hospitals but more often than not, get treated in the wrong place.  Right-siting these patients will save them money and reduce much inconvenience, not to mention rendering better health outcomes.  To realise this ambition, we need the diverse healthcare providers to treat the patients as a team, share information about the patients, and partner one another to bring care to the patients, without duplicating efforts and replicating tests.   

24. Earlier this year, I challenged our hospitals to think in terms of geographically distributed, vertically integrated healthcare systems, with each hospital at the apex of such regional clusters, seamlessly integrated with step-down care institutions including community hospitals and nursing homes, and GPs.  Each regional cluster’s focus is on delivering integrated care particularly for the chronic sick, and will be given autonomy in deciding how it wants to do so.

25. Changi General Hospital has volunteered to blaze this trail as the eastern cluster.  The team there has taken on the challenge seriously.  Over the months, they have studied the experience of France and its regional community-based specialty systems for patients with chronic diseases.  They have looked at the University of Michigan in the US and the Canadian Chronic Care Network in Calgary, which have piloted models of care where coordinating physicians and health navigators from so-called “Advance Medical Homes” educate, plan, provide and coordinate care for patients, supported by standardised care paths and health risk appraisals, and an integrated IT system that captures information about visits both to the Home and other healthcare facilities in the cluster, including admissions. 

26. The CGH team tells me that they are preparing concrete proposals to experiment with restructuring care around specific medical conditions over the full cycle of care.  Central to this model would be multi-disciplinary Disease Management Units for different medical conditions or chronic diseases.  Each unit will be responsible for integrating care with other healthcare providers and accountable for care transitions, so that patients can receive appropriate, timely, cost efficient care at an appropriate institution. To minimise variations in care standards, all providers in the cluster will work together on a standard protocol based on current best practices.

27. There are many details to be sorted out.  And as with all pioneering work, we must accept that some aspects may not work.  But I support the broad thrust that the CGH team has come up with, and cheer them on in their exploration and experimentation.  I hope they succeed in transforming the way healthcare is being delivered to Singaporeans living in the eastern side of Singapore. 

28. I know that the Khoo Teck Puat Hospital team is also busily thinking through this problem to help better serve the Singaporeans living in the northern part of Singapore.  The friendly rivalry and competition between these two teams will benefit all Singaporeans, I am sure.

CONCLUSION

29. While Governments and healthcare providers will do their best to transform healthcare, true transformation can only come about when patients take responsibility for their own health, be it living healthily or managing their risk factors.  We will empower them, providing them with necessary information and knowledge so that they can make informed choices of care settings most appropriate to their needs.  But they must act on the information.

30. Paradoxically, the better a healthcare delivery system is, the harder it becomes to convince patients to take charge.  Part of patient apathy may well be due to easy access to good and affordable healthcare, which then leads to the “you are the doctor, you take care of me” mindset.

31. To be sure, patient behaviour is driven by economics.  Under normal conditions, a rational patient would choose the most effective and cheapest treatment option for a given medical condition.  But government subsidies and, at times, ill-conceived insurance plans have distorted the economics and skewed patient choice and behaviour.  Patients therefore seek care under more expensive tertiary settings, because they are not faced with the true cost of such a choice at the point of consumption.

32. Getting the economics right is therefore an important part of any healthcare transformation strategy.  Given the politicised nature of healthcare, putting things right, whether for patient subsidies, insurance plans or hospital subvention formulae, requires adroit but sensitive political management.  Conferences like the JAMA-NUHS CME Conference are important platforms where science can be summarised and explained to the layperson clearly and accurately, so that policy-makers can use the evidence to implement effective and appropriate policies.  I have therefore have a personal interest in your conference, and wish you all a most fruitful conference.