SPEECH BY MR ONG YE KUNG, MINISTER FOR HEALTH AND COORDINATING MINISTER FOR SOCIAL POLICIES, AT THE IHI-BMJ INTERNATIONAL FORUM ON QUALITY AND SAFETY

Distinguished guests

Ladies and gentlemen

1.            I am happy to join you today at this International Forum on Quality & Safety in Healthcare. To our overseas guests visiting our garden city – a special welcome to Singapore.

2.            We have more than 1,700 healthcare leaders and practitioners from across the world here today. This Forum has brought together over 80 speakers, 40 workshops and lectures, and 400 quality improvement poster presentations from 28 countries. I thank everyone for your generosity in sharing your knowledge.

The Quality Chasm and the Healthcare Trilemma

3.            In 1999, the Institute of Medicine’s landmark report “To Err is Human” highlighted the problem of medical errors. The report pointed out that while human error is inevitable, good system processes and designs ensure reliability and minimise mistakes. This report had a profound impact in the way we think about healthcare. If six sigma principles can apply in manufacturing and so many sectors, it can also apply in healthcare.

4.            Two years later, systems thinking in healthcare was further developed in the “Crossing the Quality Chasm” report. The report went beyond advocating for a reduction of medical errors, but also to improving effectiveness, efficacy, patient-centredness, timeliness and equity.

5.            In the following two decades, remarkable progress has been made in the quality of healthcare. However, the quality chasm continues to persist. Sub-optimal care continues to cause 64 million Disability-Adjusted Life Years of disease burden every year, on par with major infectious diseases or traffic injuries.

6.            The OECD estimates that managing patient harm from diagnostic error and curative care accounts for over 28% of healthcare expenditure, which translates to trillions of dollars globally every year, actually more than the GDP of many countries.

7.            The emphasis on quality and safety can help shape the way we tackle the broader healthcare challenge that confronts Governments. Let me explain.

8.            All Governments want to develop a healthcare system that fulfils three objectives. One, quality; two, accessibility; and three, affordability. But these three objectives often present themselves as a trilemma, because improvement in one aspect is usually at the expense of the other two. For example, better quality healthcare costs more, and that affects patient affordability. And if Governments raise subsidies to maintain affordability, more people will queue up for cheap and quality care, which increases waiting times and reduces accessibility. Some things have to give.

9.            As a healthcare policy practitioner, I know that the healthcare trilemma is real and biting. But I would also argue that the choices need not be as stark as they are made out to be. This is because healthcare systems around the world are not operating at a Pareto optimum.

10.         Improving safety and reducing medical errors illustrate an example. Medical errors consume unnecessary time and resources and cause unnecessary patient suffering. In Singapore, for every dollar invested in safety improvements, we get back four dollars, because of fewer complications, fewer re-admissions and fewer adverse events. Quality, accessibility, and affordability, the so-called trilemma, can all improve if we reduce medical errors. The trilemma is not always a zero-sum game.

11.         There are still many aspects of healthcare where similar calculus exists. At a time when populations are ageing and patient load is rising, healthcare capacity is becoming increasingly under pressure, these are the areas governments would need to prioritise, because they will be most impactful, and the return on our effort and investment will be the highest, and benefit on patients and the population will be the highest too.

12.         Today, let me talk about three areas that Singapore is working on, to optimise achieving the healthcare trilemma.

Three Singapore Responses

13.         First, implement Appropriate and Value-Based Care, or AVBC, for healthcare delivery.

14.         At its heart, AVBC is about delivering ‘appropriate’ care, that is, the right care, at the right time, at the right setting, guided by evidence and focused on what truly matters to patients. There must be 'value’ in the care, which means adopting practices that are grounded in evidence, implemented in a well-coordinated way, and able to produce good patient outcomes.

15.         AVBC is therefore a consciousness, or a culture, that needs to run through the veins of the entire healthcare system. It needs to be embedded in the governance and management of hospitals, in professional education and training, and in clinical operations.

16.         Over time, it fosters a value-conscious, as opposed to just a cost-conscious culture or mindset. The former wants to do the best for patients, but in a cost effective and financially sustainable way, while the latter is just penny-pinching. Over time, and if possible, the culture should spread to patients and their families.

17.         One of the key enablers of AVBC in Singapore is our value-driven care. Value-driven care in Singapore was first adopted by the National University Hospital in 2015. With encouraging results, the system was adopted at the national level two years later, through the National Value-Driven Care programme. Today, 19 medical and surgical conditions are subjected to the Value-Driven Care methodology. It has produced good results.

18.         From 2017 to 2023, we estimated 320 more lives saved; 1,753 re-operations averted; 589 re-admissions avoided; and almost 22,000 bed days saved. Notably, the rate of Serious Reportable Events has been trending down and stands at 0.44 per 10,000 patient days in 2024. We will continue to strive for improvement. This is Value-Based Care at the healthcare delivery level.

19.         Second, a sustainable financing model.

20.         We all want universal healthcare for our people. In many countries, this is achieved by making healthcare free or very cheap through tax-funded subsidies. However, because healthcare is almost free and paid for by others, excess demand builds up, waiting times will be long and accessibility is compromised.

21.         Another commonly adopted model internationally is to rely on national insurance and let premiums fund healthcare. There is greater discipline for healthcare demand, but insurance premiums can be expensive and out of reach for the low income. In these systems, healthcare is accessible but may not be affordable.

22.         We can strike a more optimal balance between accessibility and affordability, through a financing system that is part insurance, part subsidy. Like in the US, where it started off with heavy reliance on private healthcare insurance, but later introduced subsidy programmes like Medicaid and Medicare. I believe most Governments came to that conclusion, but the transition is not easy.

23.         Fortunately for Singapore, we started with such a blended system from the outset. Ours is described as a S+2M system – S for subsidies, the 2Ms for MediShield Life (or the national health insurance scheme) and MediSave, a mandatory personal healthcare savings scheme. They work hand in hand to finance healthcare.

24.         Another aspect of healthcare financing is how we fund public healthcare institutions. Singapore’s public healthcare clusters – we have three – operate a range of healthcare services across multiple settings, from intensive care, acute care to rehabilitative care, outpatient primary care and community preventive care. Two years ago, we shifted away from funding them through the equivalent of the fee-for-service model and adopted a capitation model, where public healthcare clusters are provided fixed payments per resident living in the geographical area assigned to the clusters.

25.         The capitation model incentivises these clusters to right-site patients to the most appropriate settings under their charge. It encourages healthcare providers to invest in the health of the population, instead of just focusing on the treatment of diseases.

26.         But remember this: however we choose to fund healthcare, the people ultimately pay, whether in taxes, premiums, or waiting times. Healthcare is a national invoice billed to the population. But the size of the bill is not pre-determined, it also depends on how we decide to pay. Governments need to adopt a healthcare financing system that optimises quality, accessibility and affordability and curbs wastage, unnecessary treatments and over-servicing, and hence minimise the bill for the nation. This is AVBC applied not just at the institutional level, but at the systemic level.

27.         Third area, and perhaps the most transformative, is to invest in preventive care and population health.

28.         In Singapore and many developed economies, the gap between lifespan and health span is about 10 years. That means the average senior will spend about 10 years in not so good health, probably coming in and out of hospitals, needing treatments and medication, some of which may be expensive.

29.         The most impactful outcome a healthcare system can deliver is to narrow the gap between lifespan and health span, by making the population healthier. Then healthcare capacity is freed up, healthcare professionals can better focus on severe cases more promptly, healthcare becomes affordable not just because cost is lower, but because people are less sick generally. Preventive care and population health is the ultimate tool to resolving the healthcare trilemma.

30.         There are many levels of preventive care. At one level it is about personal health-seeking habits, such as developing a long-term and trusted relationship with a family doctor, timely health screenings and vaccinations. It involves inculcating good life habits such as sleep, exercise, diet and hobbies. But the largest determinant of good health is social, such as the living environment, pollution, education and work, which ironically all fall outside the ambit of health ministries.

31.         Preventive care is therefore all encompassing. It is delivered in our homes and in our community, not in clinics, not in hospitals. The future of healthcare must therefore involve a decisive shift of the centre of gravity of care delivery upstream, away from hospitals, and into the community. We can leverage technology to do this much better now. Patient data can now be shared securely across settings, including those in the community. Telemedicine and home medication delivery reduce the need to visit clinics. AI tools can help high-risk groups predict onset of severe diseases, with an appropriate follow-up intervention, to reduce or delay the need for complex and costly treatments later.

32.         The Ministry of Health in Singapore is driving these changes. It is a fundamental reorientation of how we approach health in Singapore. An ambitious transformation. A population health strategy is the ultimate AVBC, at the societal and population levels.

Closing and Appreciation

33.         So I have talked about Value-Based Care and shared the importance of safety and quality, how these are salient in Value-Based Care, which are applicable at the institutional, systemic and population levels.

34.         I thank the Institute for Healthcare Improvement, the British Medical Journal, and the Local Programme Advisory Committee – co-chaired by Professor Lee Chien Earn and Dr Albert Ty, for putting together this Forum.

35.         I wish you a productive and inspiring forum ahead. Thank you.