Speech by Minister for Health

14 Nov 2006

By Mr Khaw Boon Wan, Minister for Health

Venue: Parliament

"The Journey Itself Is Home"

Last month, my wife and I explored the northern Honshu region of Japan. We went from Sendai to Matsushima on the Pacific coast. In between, we crossed the mountain range to the western side of Honshu, spending some time in the mountains, hiking and visiting ancient temples.

We re-traced a section of a long journey made by Matsuo Basho over 300 years ago. Basho was a zen practitioner and one of the most popular poets in Japan. He left behind many poems or haiku, and is well loved by the Japanese. He is the Japanese equivalent of Li Bai.

At Yamadera (a village in Yamagata Prefecture), among the temples and mountains, we paused at where Basho wrote his famous haiku, in English translation:

"Silence

Penetrates the rocks -

The cry of the cicada"

I was grateful for the opportunity to savour that wonderful moment when Basho, the rocks and the cicada all melted into one. Mr Speaker, after 50 speeches, you must have wished for such a moment of tranquility in this Chamber.

The Japanese villages and towns that we explored are no longer like what Basho experienced. Their population has grown and, in particular, it has aged considerably. In the villages, the old visibly outnumber the young. Conversation topics are distinctly elderly: "How is your knee? Does it still hurt?"; "Isn't that mochi too sticky for your dentures?"

Active Ageing

During those few days, I had a glimpse of what Singapore may be like in the future when our population would be as elderly as Japan is today. Though on holiday, I asked my Japanese friends to arrange for us to visit a nursing home. The home was top-of-the-range, providing a high standard of care, with happy residents. It was buzzing with activities, both indoors and outdoors, day and night. It comes with a high price tag, and residents pay about 10% of cost, with the rest picked up by long-term insurance.

I asked the home for the admission criteria since the residents did not look sickly or frail. They said that all applicants were interviewed. The main criterion is that their children were unable to care for them at home. But I said that would surely qualify most people. In typical Japanese way, they replied "no" when they meant "yes". There is therefore a long waiting list. But all this while, demand was still manageable because most Japanese consider it shameful to put their parents in nursing homes. But that attitude is eroding.

I commented that the long-term funding prospects for such a model must be poor. They confirmed that this is their biggest challenge going forward. Meanwhile, Japan's shrinking birth rate does not help. The Japanese attitude against immigration further compounds their problem. But the Japanese are actively thinking out solutions to this demographic trend, and trying out various models. They have not got all the answers but some of their approaches offer useful reference for us.

First, the elderly in Japan work longer years. You see them, in their late 60s, manning counters, sweeping floors, cleaning spas, directing traffic, ushering tourists. They work, keep busy, stay active both physically and economically.

Second, their elderly are well-represented among the self-employed, running small businesses, like mom-and-pop shops, ramen stalls. They keep the cost of living low for consumers, while allowing the elderly themselves to make a living.

Third, shops and businesses are responsive to the needs of the elderly clientele. The mini-marts' items reflect elderly needs, while the stores have wide corridors for wheel-chairs and the price tags are large in font size.

Fourth, there is an active programme to develop devices and systems to allow the elderly to be home alone, while giving peace of mind to the children working outside. They have bracelets or wrist watches which monitor heart beats, blood pressures, body temperatures and transmit the readings wirelessly via the internet to a central monitoring centre. This way, if an elderly appears to be motionless or has abnormal readings, an alarm will sound and the operation centre can alert the neighbours to pop in quickly to take a look.

Fifth, the community builds on the traditional Japanese sense of neighbourliness to help support each other as a system. They help to check on one another, cook or buy groceries for the frail, clean the house. I help you while I am OK; you reciprocate when I am frail. The community self-help spirit is strong.

Stronger 3Ms

I went to Japan not to study how they cope with ageing. I went there to enjoy the autumn leaves with my wife and to be inspired by Basho's poems. I return reminded that we too should prepare early for a future when ageing will be more pronounced.

Today, Singaporeans above 65 are less than 8% of our population. By 2015, it will be 11%, still not yet like Japan's 21% today. But one day, we will be. By 2030, one in five (18%) will be above 65. And there will be a significant number of the "old-old", people living beyond 90.

What does ageing mean in our context? How can we make ageing a smooth and graceful process in our society? We cannot wait until it hits us. We need to intensify our planning efforts and begin the process today.

In the Health Ministry, we are acutely aware of this demographic trend as most of our patients are elderly. Our 3Ms framework was put in years ago, precisely to address ageing. Medisave is growing at about $1 billion a year. MediShield, after last year's reform, is building up its reserves again. And we are steadily topping up Medifund and Eldercare Fund as and when we have budget surpluses. All these efforts are in anticipation of a future when we will be drawing down Medisave, MediShield, Medifund and Eldercare Fund faster than we add to them. Hence, I worry each time I hear requests to spend Medisave for this condition or for that illness. I have to be the gate-keeper to say no. But I don't say "no" all the time. Where appropriate, I have said yes.

Several Members have commented on the 3Ms' enhancements which we have made over the last 3 years. I am glad that you appreciate the efforts. I am not through yet. There are still some more enhancements that I want to do.

First, Medisave will cover 3 more chronic illnesses (stroke, high blood pressure and high cholesterol) from next January. The pilot for diabetes has gone well. Last month, over 7,000 diabetic patients have benefited from this Medisave enhancement. But my interest in this scheme goes beyond funding. I hope the scheme will raise the level of care for these common chronic illnesses so that the patients can avoid severe complications in the future. Today's medical science offers no cure for diabetes, so we cannot hope to eliminate diabetes. But my ambition is to make Singapore the best in the world for diabetic patients, where there is early detection of the disease and effective long-term care of the disease in the community. The science for this is well-known but turning it to reality requires full co-operation and compliance from the patients.

Second, I am planning a sequel to last year's MediShield Reform. If there is public support, I hope to further increase the MediShield payout for patients with large hospital bills. Preliminary sounding suggests that patients are prepared for such an enhancement if the premiums do not go up by too much.

Third, at each budget cycle, I will apply to MOF for top-ups to Medifund and Eldercare Fund. So far, I am grateful for MOF's understanding and have been successful. I will continue to try, but I know that this assumes healthy budget surpluses.

Fourth, I will press on with greater information sharing so that patients can make informed choices and hospitals can learn best practices from one another. We have published hospital bill sizes for the common illnesses. The public hospitals do so systematically because I require them to, but the private hospitals less consistently. I am thinking of making it a requirement for all hospitals to disclose bill sizes for their claims to Medisave. This way, patients to private hospitals will also benefit from greater transparency.

Fifth, I plan to publish service standards of our hospitals and how well they are being met, to help our hospital CEOs focus on the key concerns of our patients. How long do patients have to wait for their new clinic appointments? On the day of an appointment, how long do they have to wait before they get to see the doctor? Standards vary between specialties and between hospitals. We do not have comprehensive data yet, but I will publish what we have compiled so far and improve on the data collection as we progress.

Sixth, we have implemented in polyclinics the policy of differential subsidies among citizens, PRs and foreigners. This way, we keep heavy health subsidy as a citizen's privilege while requiring foreigners to pay for their own cost. PRs continue to be subsidised although slightly less than citizens. We will look into extending this policy to hospitals. The Government will work with employers of foreign workers and require them to buy medical insurance for their foreign workers. As the workers are generally young and healthy, their health insurance premiums will be affordable. We will announce details when available.

Focusing on the Unglamorous

These enhancements are largely for the acute care sector, where patients receive treatment in hospitals and specialist clinics. The enhancements will ensure that Singaporeans continue to have access to high-quality care, without causing severe financial strain to themselves or to society.

But with the continuing ageing of the population, I will now focus greater attention on primary healthcare and step-down care. Unlike tertiary care, this is an unglamorous cousin. But for the elderly, this is an important sector. The better a sick elderly patient is cared for by his Family Physician or in the step-down care sector, the better off the patient will be. We will study how best to strengthen and grow this sector. This sector ranges from care at home, to care at day centres, to GPs, to nursing homes, hospices and community hospitals.

We do not yet have all the solutions, but some of the problems are known. First, the care is not well-integrated. When patients move from one care provider to another, they often encounter obstacles. Patient flow across facilities and institutions is certainly not seamless. To make proper chronic disease management happen, our doctors, nurses and other professionals need to work together, in a different, improved manner across inpatient, outpatient and step-down care. We need to have public sector specialists collaborate with private sector GPs. We need VWOs running community hospitals and nursing homes to work with acute care institutions and Family Physicians, to deliver better patient care. Ideally, all care providers should regularly share information and consult each other, but the reality is not quite there yet.

Second, the care quality varies over the range of providers. While some providers do provide good care and service within their facilities, there are places which do not do as well.

Third, information on this sector is incomplete and hazy. Patients do not know the full range of step-down care choices that are available to them. Some feel that they are stuck with no option other than their current provider. Last month, we published the key data on nursing homes and community hospitals. It is a first step and we will refine the publication further.

Fourth, we do not know if our range of step-down care services is comprehensive enough. Are there gaps? Are there niche services which are absent today but can usefully meet a real need? Some of these services go beyond my Ministry's portfolio, and we will work with other Ministries to ensure that genuine needs are adequately met.

Mr Speaker, Sir.

Our population will continue to age. We will try to slow it down by raising births and stepping up immigration, but we cannot avoid it. The better prepared we are for this inevitable demographic change, the better we can ensure that elderly Singaporeans face old age with confidence, calm and peace of mind. My Ministry will do its part to anticipate rising demand for healthcare services, both at the acute and step-down sectors, and marshal resources to ensure that there will be sufficient beds, manpower and expertise.

Today, we spend about 4% of our GDP on healthcare services. Considering the high standard of our care and Singaporeans' health status, this is quite an achievement. But to meet the future needs of our population, it is not possible to keep healthcare expenditure in this region of 4% indefinitely. It is bound to increase. This increase will have to come from all stakeholders: Government, employers, insurers, patients and their families. This is part of the reason why GST has to go up. But I will recommend to the MOF to fully offset any GST increase on medical costs incurred by subsidised patients, as we did in the previous GST offset package.

Happy Ageing

Last week, inspired by what I saw in Japan, I decided to visit two elderly day care centres even though they do not come under my Ministry's portfolio: one in Tampines run by Tampines PCF, another one in Marsiling run by NTUC Eldercare. They are doing good work, caring for the elderly whose option is otherwise home alone in front of the television, counting the hours and minutes. I know of a group of bank managers who do voluntary work, visiting the old folks at nursing homes and checking out what they need. It turned out that the single biggest issue with old age is loneliness at home and loss of dignity when they feel that they are no longer useful and sometimes unable to control their bodily functions. There is a lot that the Japanese are doing that we can learn from.

Basho certainly had much to teach us about ageing and living. As his health deteriorated, he continued to work, composing poems. In Osaka, he penned this famous haiku:

"This autumn

Why am I ageing so?

Flying towards the clouds - a bird" 

He was ageing but his spirits were free. He knew he was dying but he remained calm in his last days. Before he drew his last breath, he wrote his final haiku:

"On a journey, ailing

My dreams roam about

Over a withered moor"

I asked my Japanese friend for his favourite haiku from Basho. Without hesitation, he rattled it off: "kono michi ya; yuku hito nashi ni; aki no kure". In English:

"All along this road

Not a single soul - only

Autumn evening"

It appears, in spirit, to be similar to the Chinese poem "the beauty of sunset, unfortunately it is fleeting". But it is not. He was a zen practitioner and had realized the road of poetry, the road of zen and the road of life itself. He was not lamenting his impending death. He was sharing his insight when he was confronted with the solitude of an autumn evening. We came to this world alone and we will leave it alone, whether we are rich or poor, strong or weak. When he undertook his journey over the mountains, the journey itself was the destination, as he wrote "in old age leading a tired horse into the years, every day is a journey, and the journey itself is home".

Basho was not rich, in fact far from it. He was a wandering poet, with merely "a traveller's hat on my head; straw sandals on my feet". But he left behind a rich legacy of wonderful haiku which immortalize him. He lived a full life doing what he loved, and taught us how to live.

Few of us have the talent and the spiritual strength to live and achieve as Basho did. But all of us can strive to be a good person, a responsible spouse, a caring parent, a good child, a helpful neighbour. Different people play different roles in society; some achieve more than others; some have greater responsibilities than others. But all can do their best to be kind and helpful to all fellow human beings and make this world a better place. I will do my part.