Speech by MS Yong Ying-I, Permanent Secretary (Health), at the opening of the 8th NHG Annual Scientific Congress

16 Oct 2009

By Ms Yong Ying-I

1. Thank you for inviting me here today. I am very glad to see not just a good turnout from NHG but also strong support and continued participation by NUHS and AHPL in organising this Scientific Congress.  I’m also glad to see participation by SingHealth, Duke-NUS GMS, Jurong Health Services and IHIS.  This is important, as we are all working towards the same ends of improving care to patients, and we can all benefit and learn more if we share our knowledge and insights.  MOH would encourage the public sector healthcare groups to continue to be inclusive and collaborative.

2. The topic of this scientific congress is a timely one. Tackling healthcare is clearly a major challenge everywhere.  The tough debates in the US on affordability of care has ensured the publication of an enormous number of opinions about how to improve medical coverage, improve care and somehow cut costs.  As the long-established western models are shown to be challenging to sustain, politicians and opinion leaders are looking for other models that appear to work, including those in Asia.  We in Asia are likewise looking for answers. While Singapore appears to have a very good model of healthcare, we too have much further to go.  Some of our solutions are also not applicable to other countries.  I hope that my sharing today will be helpful to my Singaporean colleagues as we work on improving Singapore’s own healthcare system.  And I hope that some of our experiences may be insightful to our overseas friends present today.

3. Healthcare is bedeviled by the cost vs quality vs access conundrum.  Countries cannot afford all the healthcare that its people might “desire”.  It is often said that healthcare system designers can achieve 2 of the 3 points of the triangle, but it is very hard to optimise the 3rd leg, whichever leg it is.  Trying to optimize the triangle is striking a fine balance. Singapore has done very well generally, where we have achieved universal coverage and excellent outcomes with only 4% of GDP spent on healthcare historically.  We believe Singapore’s is due to a few key features, namely (i) our 3M framework to ensure that care is affordable and accessible to all, (ii) our co-payment framework to contain over-consumption, (iii) sustained investment in training our doctors to high standards, and (iv) a public-private mix that offers choice, yet some exercise of control over quality and price.

4. I am prepared to say that in the past decade, we didn’t quite hit the balance in this triangle, due to underfunding by government.  We don’t want to overspend on healthcare due to waste and inefficiency.  But spending too little is also no good.  As many people working within the public sector know, the public sector system was under great stress in recent years.  As the population grew faster than the growth in beds and staffing, waiting times for appointments lengthened, and both doctors and their patients complained of less and less time available for each patient consultation.  Our hospitals were running at full occupancy, and when there were spikes in load, we experienced ballooning wait times at our EMDs.

5. In recent years, Government has significantly increased funding to help the system catch up with investments in new infrastructure and more manpower.  We are opening KTPH next year, and the Jurong GH team will keep AH running when the original AH team moves north until they open Jurong GH in 2014.  We have also expanded the number of beds in existing hospitals. We have increased the staffing numbers in the public sector by some 36% in the last few years.   This is a significant increase by any measure.  However, we remain highly productive as our bed and manpower ratios are comparatively very good compared to other countries.  The investments have eased the strain significantly, so that the system is coping better.  Waiting times for appointments have dropped somewhat and wait times for beds in the EMD are under better control.  Very importantly, we increased ICU capacity to cope with possible surges during emergency – thankfully just in time for the H1N1 pandemic in the middle of this year. The ability to cope with a surge cannot be taken for granted, as many other healthcare systems around the world were overwhelmed.  I think we can congratulate ourselves that we did well.  Yes, we were lucky the virus was mild.  But a big part of our good performance was due to your preparation and practice over the years, and the commitment and hard work of your staff during the pandemic.

6. So we have shifted the balance in the triangle.  Cost has gone up but access has been enhanced. We must now continue to innovate and improve, to take the healthcare system forward. An important focus will be quality.  Not surprisingly, as funding goes up, government wants greater clarity on what the money is being spent on and what is being achieved.  Recently, MOH was criticized in the Auditor-General’s report to Parliament for the inadequacy of the healthcare targets published in the national Budget.  Actually, we have been doing a lot of work on this, and have now produced clearer scorecards nationally and for the public sector institutions for a range of key goals. These goals include measures for access such as waiting times; for clinical quality such as adherence to protocols, patient safety and clinical outcomes; for affordability such as proportion of bill sizes covered by Medisave and Medishield; and for customer satisfaction, patient-centredness and organisational excellence.  Clinical leaders have been asking MOH in recent years “what is the realistic standard of care we commit to deliver to subsidized patients”, that we can be proud of and yet bears in mind the resource constraints we have to manage within?” We have attempted to answer this through the national standards of care complemented by the national and public hospital scorecards to measure our progress towards these standards.  Your CEOs and CMBs and their staff are working with us on finalizing the detailed measures.

7. We also hope to use the tracking of clinical outcomes to enable improvements in care outcomes. We want to encourage an evidence-based approach to care, supported by good accurate data.  One good example is the Singapore National Asthma Programme, led by KKWCH, which relies on database and tracking outcomes. First, analysis of data from specific treatments in institutions like our hospitals can support more informed discussions about the efficacy of various clinical treatment protocols.  Or for that matter, the importance of complying with protocols as simple as washing hands before and after patient contact. Second, being able to analyse where the big costs are being incurred in treatments compared against the clinical benefits of those treatments can help us contain or reduce costs by cutting back on expensive treatments that aren’t really beneficial and shift funding to treatments that produce good outcomes. 

8. Third, we will benchmark this type of data not only across our institutions but try to do meaningful comparisons against OECD data and also against comparable regions with high quality healthcare in various parts of the world.  Some of the initial data comparisons we have made are yielding insights that while our episodic treatment in our hospitals is very good, our care as a whole for some conditions can be considerably improved.  This is because other OECD countries tend to do better than us in integrated approaches to treating chronic conditions, including in the primary care sector.  This is part of the reason for our push to restructure the healthcare delivery landscape in Singapore.  Fourth, clinical outcome data will help greatly in focusing our translational and clinical research efforts on the questions that matter or us and help us with analyzing whether the research is bringing us closer to the solutions we are seeking.

9. For this, IT is key and we are investing in a national electronic health record system linked to hospitals’ key operating systems. The national EHR, the first phase of which should go live Nov 2010, will cover our public sector institutions, community hospitals, the long-term care sector, GPs, and eventually even pharmacies.   Healthcare informatics is complex, but I am confident that we have a good team working on its design and implementation, including hundreds of clinicians, and we will be able to deliver the EHR as planned.   

10. Technology can be a major lever for breakthroughs in design of delivery and we will exploit this.  For example, Alexandra Hospital asks their surgical patients to take a photo of their surgical wounds and send it via MMS to them.  The medical team then makes a visual assessment and those whose wounds are healing normally need not make extra trips back to the hospital.  In TTSH, where previously patients may need to be disturbed or even awakened at night to have their temperatures taken, 80% of them now wear a 50-cent coin sized SmartSense temperature sensor-cum-RFID transmitter, that is able to take regular (up to the minute) temperature readings unobtrusively and transmit these wirelessly directly into their electronic clinical charts.  It can also track their exact locations in the hospital.  Infectious disease physicians can track fever spikes and understand patients’ conditions better. The whole hospital has been enabled with this, and this is a first in the world.

11. There are many dimensions to excellence in quality of care. A major dimension is delivering care in the right setting, and integrating care across these settings so that the patient is cared for holistically.  So beyond each institution’s role in improving the care it provides, we also want to redesign care delivery across institutions by improving the linkages and coordination between them. PM spoke at the National Day Rally about the importance of this to our strategy of caring for the elderly and the long term management of chronic diseases.  Quite clearly, this will involve building up of the capability of these entities in intermediate and long-term care as well as in primary care and preventive health.  Government and the public sector healthcare institutions will help where we can with capability building.

12. One of the partnerships that PM mentioned in his Rally speech was the Tan Tock Seng Hospital (TTSH) and Ren Ci Community Hospital (RCCH).  Since he spoke, they have set up a Joint Clinical Governance Committee as well as a Senior Management Coordination Meeting to oversee the integration of care for patients moving from one setting to the next.  They are now working out integrated care pathways that not only cover treatment of patients in the two hospitals but also the care to be continued in the community and at home if appropriate.  The shared electronic medical records I mentioned just now will allow the multi-disciplinary and cross-institutional teams to be precisely that – one team. 

13. The idea of regional health services involves a different mindset to our work.  When the focus is on care of the patient regardless of setting, it follows that workflow conversations about subsequent community treatment options and alternatives will take place earlier during the patient’s stay in the hospital, to facilitate smooth and timely discharge.  Patients and their families can seek advice from care coordinators over the phone and these care coordinators can help to link them up with a family physician and other community services for follow-up care.   We will do this by pulling many of the care coordinators into an entity called Agency for Integrated Care.  Dr Jason Cheah has been seconded from NHG to lead AIC’s expansion and development.

14. Excellence in quality also includes timely anticipation and response to emerging challenges. A growing challenge for Singapore is mental health.  With the growing number of elderly, we will see more people suffering from dementia, depression and other mental health challenges.  I was tasked by a group of Ministers to lead a cross-ministry team to look into building the capabilities nationwide to do prevention, early identification and treatment in the community.  This is because acting early to build mental resilience or arrest emerging problems can prevent the onslaught of mental illness or improve chances of recovery. The Government has provided tranches of funding that have allowed IMH to set up mobile Community Action Teams to respond to cases and to teach frontline parties such as our schools, the universities, the military, employers and the grassroots how to build awareness, encourage early detection and treatment. Interested GPs are also being trained to manage appropriate cases in the primary care setting.  Community response teams are labour intensive, and it is still early days in terms of having adequate resources on the ground.  But we have made a good start and we will continue to grow the capabilities. 

15. I would consider the mental health supply network as a critical subset of the regional integrated care capabilities we are building.  While it is an area that many in the broader regional system do not feel adequate to deal with, it is nevertheless important that we work in integrating the community level mental health efforts into the mainstream healthcare delivery network.  After all, people with mental health problems also suffer from other medical problems, all the more so when they are elderly.  

16. Quality care does not just depend on innovations and initiatives by suppliers.  What patients know and how they behave as patients is half the story.  The population is becoming better educated and wants to be engaged both in managing their own health and in managing the healthcare they receive.  We should welcome this – indeed it fits the theme of transforming healthcare, empowering lives.  The internet and new media is now a way of life, whether each of us are comfortable with it or not. My Ministry has decided that we will learn how to engage patients and the population better using new media.  Minister Khaw Boon Wan has started a daily blog that comments on healthcare policies and healthcare developments. He has acquired quite a following.  If you’ve not checked it out, I encourage you to do so.  You can offer comments via MOH’s Facebook page. We are also trying out tweeting and Flickr. 

17. The idea is to build an engaged online community that shares ideas, and engages in valuable discussion which will hopefully improve understanding of our policies and the nature of those policies.  He has encouraged our public sector healthcare leaders and my colleagues to contribute to the MOH blog.  For instance, Prof Chee Yam Cheng recently contributed a blog on our proposed residency training and this appears to have helped us explain our plans to the younger medical professionals.  HPB too has recently revamped its website, to look at health and wellness issues from the customer’s point of view.  This sounds obvious but not often done, and HPB recently won an innovation award from the Singapore IT Federation for its efforts.

18. I have mentioned quite a range of thrusts that I believe will contribute to transforming healthcare and empowering lives in Singapore.  If we do well, others might emulate us.  We might then indeed have an impact on transforming global healthcare and in a meaningful way too.  But as the saying goes, big cathedrals are built brick by brick and oceans are made up of many droplets of water.   The transformation of care in Singapore, never mind the world, will come about because of the immense hard work, dedication and commitment from the legions of healthcare professionals to improve the quality of care for the people they serve.  I salute our hardworking professionals, from the specialists and nurses in our acute hospitals and tertiary centres, to the many staff in the step-down care and community care institutions, our allied health professionals, our ancilliary and support staff.  I am privileged to have the opportunity to work with you to improve and empower the lives of the people we serve.