Speech By PS (Health) At AIC's Inaugural Asian Conference On Integrated Care

25 Feb 2011

By Ms Yong Ying-I, Permanent Secretary (Health)

Venue: Grand Copthorne Waterfront Hotel

1. Good morning and thank you for inviting me to be here with you today.

2. It is truly a joy to see AIC grow from strength to strength since it was restructured from a tiny entity in 2008. AIC is not only the national care coordinator, helping patients navigate the healthcare eco-system. It has an industry development role for the primary care, long-term and aged care sectors. It has added on the challenge of developing and coordinating mental health care delivery in the community. The size of the audience at this conference and the quality of speakers, local and international, is testimony to what it has achieved in a short period of time.

Integrated care landscape will change rapidly

3. Dr Jason Cheah asked me if I could share my thoughts on integrated care to kick-start this conference. I thought the theme “Taking Stock and Pressing On” a useful and timely one. I’m told that I do not need to preach the “whys” of integrated care to this converted audience. You want to learn about “how” from the various speakers. However, I had dinner last night with many of the international speakers who made the observation that we focus on “doing things”, but we may not take enough time to think and reflect on what we are doing. So I will share Government’s philosophy behind its support for integrated care, which I hope will help you as we go on this multi-year journey together.

4. The landscape for integrated care is changing rapidly in Singapore. In last week’s Budget, the Government made its support for long term, aged care and the voluntary welfare sector clear. Sizeable top-ups were announced for Medisave, Eldercare Fund and Medifund. A $10m fund to support functional mobility of seniors was announced. Training and development of medical social workers came in for special mention, with their having a significant share of a $20m development fund. A huge $1bn Community Silver Trust fund to enable matching grants for donations to the healthcare and social care charity sector was announced. Last weekend, my Minister mentioned publicly the secondment of professional staff from the public sector for deployment stints in healthcare entities in the VWO sector to ensure that they are staffed up adequately with quality manpower. My Minister will elaborate on these in the coming Budget debate.

5. The development of the non-acute sectors is crucial to greatly enable integrated care to happen. We have all gradually come to the realisation that acute-centric, hospital-based systems are not sustainable solutions to cope with rapidly ageing populations and the increasing prevalence of chronic diseases. Having strengthened the entities in the non-acute sector, the focus of our efforts and of this conference is to discuss how the providers can come together to provide coordinated, coherent, high quality care. The end-goal is to create an environment where Singaporeans can move seamlessly across providers, without repeated testing, duplicative care or falling through the cracks. This will allow chronically-ill patients, frail elderly and even the well to receive the care and attention they need, where they need it the most, at a price that they can afford.

6. In learning from each others’ experiences, an international conference is valuable. Integrated care is a common thread that runs through the healthcare reform efforts of developed countries around the world. Each country’s approach differs due to their different starting points and sociopolitical context. But the underlying objectives are similar – balancing quality, accessibility and cost. So are the challenges in trading off multiple objectives that can be in conflict. For example, the UK is in the midst of a reform effort aimed at strengthening the gatekeeping role played by general practitioners. Sweden, which is often regarded as a model healthcare system, is increasing market competition among healthcare providers and pharmacies to keep costs down and improve accessibility. In Asia, Hong Kong and Australia have developed systems of integrated care, but are actively undertaking healthcare reforms – Hong Kong is working on private healthcare and insurance coverage. Australia has challenges at the interface between social care and healthcare as well as between Federal and state supported services. I gained many insights from my dinner last night with the international speakers, and I know that you will find their views stimulating and thought-provoking.

Singapore’s approach to integrated care

7. I thought I might usefully frame Singapore’s philosophy towards integrated care in the following way:

Key thrust 1: “From disease to wellness”

8. We want to keep Singaporeans healthy so that they do not come into the healthcare system in the first place, especially the high cost acute sector. Other than Health Promotion Board’s prevention and education efforts, we are helping Singaporeans detect and treat diseases early through health screening, in GP clinics and in the community such as at NTUC’s Wellness Centres. Our Restructured Hospitals are helping the frail elderly and patients with chronic diseases manage their medical conditions better so that they stay well. In recent months, Changi General Hospital launched its chronic disease prevention programme called Eastern Community Health Outreach (ECHO) to help families in the Eastern part of Singapore access low cost screening and healthy lifestyle activities. It is also running a nurse-led call centre that supports discharged chronic disease patients on an ongoing basis to manage their condition at home, so as to avoid unnecessary visits to the hospital. When my Minister visited the Disease Management Unit operation at CGH, he coined an additional term to “from disease to wellness”. He said we should also think “from programme to population”. He challenged CGH and our other regional health systems to look at how to scale their excellent programmes serving small groups so that they can support their regional constituents as a whole.

Key thrust 2: “From provider to patient”

9. We must also plan the delivery of healthcare services with the patient in mind. This sounds obvious but all of you know that implementing a hassle-free, patient-centric system of care is challenging. Seamless care within the acute hospital is hard enough. Seamless care beyond the hospital across a network of primary care and ILTC providers requires the various parties to look beyond organisational boundaries, professional cultures and business models to structure care based on what is best for patients and the system. This patient-centric ethos extends to clinical leadership, coordination of treatment plans, quality evaluation, sharing of medical information and daily operations.

10. The Government’s restructured acute hospitals are leading the efforts in their respective Regional Health Systems (RHS). The logic behind the RHS is that each of these should be anchored by an acute hospital, with a network of community hospitals, nursing homes and community services to support the frail elderly, mentally ill and other vulnerable patients. The collaborations have started, all over the island. The best known ones are those between the restructured hospitals and their partner community hospitals – CGH and St Andrews’ Hospital; NUH and St Luke’s Hospital; Tan Tock Seng Hospital and Ren Ci; SGH and Bright Vision Hospital. Our hospitals are also working with other entities in their regional systems. For example, TTSH has worked with a few nursing homes on fall-risk assessments and coaching of high-risk seniors to improve balance. Khoo Teck Puat Hospital is working with St Joseph’s Home on tele-consultation. This has helped the nursing homes avoiding costly admissions to the hospital.

11. Patient-centric care would not be possible without AIC playing its role as national care coordinator. Its Aged Care TransitION (ACTION) teams within the acute and community hospitals help patients with complex medical and social needs transit smoothly from the hospitals back to their homes and communities. To date, AIC has helped over 15,000 patients receive good quality intermediate and long-term care after discharge from the acute hospitals.

12. Good patient-centric care is also about empowering patients and their families to make informed choices about the care services they should access. I am very happy that AIC is making this process easier by rolling out the Singapore Silver Pages, the first of its kind ILTC portal here. The Silver Pages features a Self-Assessment Tool to help patients and their families estimate their care needs, an Eldercare Service Locator, a product directory of medical consummables and assistive devices, an online helpdesk and other useful resources.

Key thrust 3: “From institution to home”

13. Third, we are taking a home-centric approach to care. The priority of our healthcare institutions should be to get patients well again so that they can go home. To make this happen, acute hospitals, community hospitals and nursing homes are thinking hard about helping patients maintain contact with their families by explaining the patient’s care plans and goals, facilitating family visitations and home leave arrangements.

14. These institutions are also addressing gaps in service planning, capabilities and resources that currently hinder patients from returning home. We are supporting home care providers such as the Home Nursing Foundation (HNF) and Touch Community Services to expand their capabilities and staffing. HNF is now working on a pilot with TTSH where a HNF nurse joins some ward rounds in TTSH. This allows her to speak to and better understand the needs of patients who require HNF services post-discharge. This way, patients, families, home care nurses and other personnel like physiotherapists and medical social workers, are all better prepared for the patients’ eventual transition home. We have also set up an Expert Panel on Nursing Homes to advise us on improving the rehabilitative capabilities of nursing homes, so that patients can benefit from effective rehabilitation and are able to return home eventually.

Key thrust 4: “From isolation to integration”

15. This covers a broad range of concepts, such as structuring of services so that each provider does not deliver care in an isolated way. Beyond the obvious patient flows across institutions that I have talked about, I also hope that institutions within each Regional Health System can share staffing and capabilities more effectively. Shared group procurement is an obvious area to work on together on; another area is pharmacy where smaller community institutions and nursing homes may not need nor be able to afford a full-time pharmacist on-site. With part-time deployment possibilities, as well as tele-pharmacy, it should be possible to use scarce manpower more effectively. Guardian Pharmacy has been using tele-pharmacy for some time now, and has shown that it can work.

MOH and AIC as enablers

16. As our healthcare providers continue to take meaningful steps forward, MOH and AIC will support you in your efforts. MOH and AIC will invest in long term capacity and capabilities, including infrastructure, professional manpower and information systems.

17. In infrastructure, you will have already read about our plans to build more third-generation community hospitals like Yishun and Jurong Community Hospitals next to our restructured hospitals. We also plan to augment primary care, nursing home, hospice, home care and community care capacity to facilitate right-siting. Recognising that fund raising to build physical infrastructure is challenging for VWOs to do, we will fund the development of new infrastructure like nursing homes (subject to availability of funds). We had announced earlier the building of six new nursing homes for the VWOs to run.

18. We are also stepping up efforts to train and recruit quality healthcare professionals for the acute and ILTC sectors. We are expanding local training pipelines in all major healthcare professions, not just for public sector needs, but for national needs in the private and VWO sectors as well. For example, more local undergraduate programmes are being developed in medicine, nursing and allied health.We are giving out significant numbers of scholarships in professions where we are short, including pharmacy, physiotherapy, clinical psychologists, medical social workers, and even health economists etc. We have already begun helping VWOs in the ILTC sector recruit professional manpower and are considering seconding public sector professionals to them. AIC’s Learning Institute is also rolling out several training programmes to raise the capabilities of the ILTC sector. AIC will develop a national care assessment tool and it is also guiding VWOs on quality assurance frameworks. MOHH with IHIS (Integrated Health Information System) will take on the challenge to develop the various IT projects.

19. MOH will also develop the key information systems for institutions outside the public sector. We are working with community hospitals on their electronic medical records needs and administration support IT infrastructure. Likewise, IT for primary care GP clinics and community care providers. These will all need to ride on top of the National Electronic Health Records system rolling out in the next few months. We are also very keen on trying out teleheath options where patients can consult their providers on the phone, via the TV or over the internet.

Frail and recovering patients can be monitored by sensors and equipment that can send data to healthcare providers remotely.

20. The national healthcare financing framework is also being progressively redesigned to support the structural changes we are proposing. For instance, last year, we raised Medisave withdrawal limits for patients at community hospitals and day rehabilitation centres. We allowed Medisave for health screening, outpatient treatment of chronic diseases, and for home palliative care. My Minister will share more of his thoughts in the coming Budget debate. We recognise that healthcare financing influences institutional business models, and these in turn will have a huge impact on whether care is effectively integrated.

Closing

21. In closing, I would say that we can certainly do more to make our system better. But I think we can be very proud of what we have already achieved. I am confident that we can realise our vision of integrated care, taking the next 5-10 years to scale up our ideas. Singapore’s size is often a disadvantage, but in this case, it can be an advantage as we can get everyone involved together in the same hall to brainstorm. Our fundamentals are right, giving us room to gear up and restructure our financing to support our goals. And most importantly, we have the right people – dedicated professionals and volunteers with the values, commitment and passion, anchored by the Singapore ability to get organised and get things done well. The number of people here today for this inaugural conference is testament to that.

22. I look forward to benefitting from your sharing at this conference. May I wish all attendees a fruitful and enjoyable experience. Thank you.