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06 Jun 2009
By Khaw Boon Wan
Ladies and Gentlemen
I started working in the Ministry of Health 30 years ago, in the Finance Department. My job included assessing applications from patients with financial difficulties who ask for fee remissions and waivers. Those were the days before the 3Ms: no Medisave, MediShield nor Medifund. All major cases of financial hardship would end up on my desk for a decision to either reduce the charges or waive the bills completely. I was exposed, very early in my career, to the problem of large hospital bills and their impact on low-income Singaporeans.
Tutored by MSW
2. Through assessing such requests for waivers and fee remissions, I got to know about the Medical Social Worker, or MSW, service in public hospitals. I observed several of them – how they interviewed their patients, skilfully probed their financial background, and addressed their concerns. I was tutored on effective means-testing along the way.
3. Later on, when then-Health Minister Howe Yoon Choong assigned me to set up and run a newly built hospital at Kent Ridge, the National University Hospital (NUH), I had to set up many new departments. Someone recommended Ms Daisy Vaithilingam to me to head up the new MSW Department. She had then just left the public service and was looking forward to her retirement. I met up with her and, although she was 25 years older than I, we got along rather well. She was, I think, inspired by my vision for the NUH and decided to postpone her retirement. As a new hospital, the NUH was championing a new way of running public hospitals – more customer-centric, less hassle, managing patients with compassion and kindness. Our focus was to look after the bottom half of the population who cannot afford to pay and have no choice. If we treat them well, the other half who can afford to pay and have a choice will come back to us.
4. Despite her age, Daisy was energetic. We often walked the hospital floor together, talking to patients in the wards, in the clinics, assessing their problems. While financial issues brought us to the patients, often there were other underlying causes that we needed to address: family disputes, relationship problems, work stress, difficulties with in-laws, mismatched expectations, or just general angst with the society at large.
Prepared for politics
5. I was not trained as a social worker, but those years spent talking to patients, observing how professional MSWs work, taught me many things about life, including how to cope with its many difficulties, surprises, dreams and disappointments. It was emotionally draining at times. I saw the good side of human nature, as well as its ugly side.
6. There was once an obviously well-to-do businessman who simply refused to pay his hospital bill. For added drama, he tore his hospital bill in front of us and challenged us to sue him. Of course, we did and he ended up paying much more than the original bill. On the other hand, I remember a poor farmer from a neighbouring country whose daughter had a severe lupus problem. They were poor and, as foreigners, could not be subsidised, so her bills were quite large. I did the best I could to allow them plenty of time to pay up, without levying any late interest charges. They could have simply disappeared and left me with a large bad debt. I trusted that they would not fail me. At the most, if I had misjudged them, I was prepared to clear the bad debt out of my own pocket. They did not betray my trust – after each harvest, they would come with a bundle of cash and gradually paid up the bills in full.
7. Managing these financial cases prepared me for my subsequent political life. These experiences taught me empathy, honed my listening ear, and allowed me to put myself in the sufferers' shoes. They also strengthened my conviction to help enhance our hospital funding system, so that Singaporeans do not have to fear large hospital bills, even if they are not well-off.
Beyond 3Ms
8. At that time, I had just gotten involved in the first M of our 3Ms framework: Medisave. I had the privilege and wonderful opportunity to work for SM Goh Chok Tong, then Health Minister. He is the architect of our 3Ms financing framework. I started off helping him to work out the details for Medisave and had it launched in 1984. When the second M – MediShield – was launched in 1990, I was also in the Health Ministry. When the third M – Medifund – was launched in 1993, also by SM Goh, then PM, I was his Principal Private Secretary.
9. The Netherlands Health Minister visited me last month with a big team. They were fascinated with our 3Ms framework and asked many probing questions. Across the Atlantic, the US is planning to reform its healthcare system. Many views by experts have been put forward. Some proposals included promoting health savings accounts and high-deductible hospitalisation insurance: the former is like our Medisave and the latter like our MediShield.
10. We have clearly done something right. My job now is to extend the same time-tested 3Ms philosophy to the long term care sector with the 3Es: Eldersave, ElderShield and Elderfund. Like the 3Ms, we will take time to systematically build up the 3Es, so that Singaporeans can age with peace of mind, with access to good and affordable long term care, whether at home, at nursing homes, or at a community hospital. It can be done. It must be done.
11. As MSWs, you are close to your patients and will have views on how we can improve and make our 3Ms and 3Es work for Singaporeans. I welcome your views.
Beyond Almoners
12. After 60 years, the MSW service has come a long way from the time when you called yourselves Almoners. With increasing sophistication and as our population ages, the MSW service is a growing industry. Your job scope has gone far beyond financial counseling and giving alms to the poor. Today, MSWs form an integral and critical part of the medical team, caring and supporting our patients in diverse ways. MSWs conduct psycho-social assessments of patients and their support systems to assess their ability to function within the community. You provide counseling and emotional support for patients who experience difficulties coping with their illnesses, or who have relationship problems, or financial hardship. You play a very important role in discharge planning, for example by placing patients in step-down care facilities. You help patients and families gain access to relevant community organizations and resources. You help families cope with loved ones who are terminally ill by focusing on their achievements, rather than their impending departure. You help coach families about HOTA and get them to overcome their grief over a sudden death by considering the wonders of giving life to others. You help the dying to face their next journey with peace of mind. You have to do all these in multiple languages and dialects. We need to recruit more from the minority race so that we can speak their language to handle the sensitive issues like HOTA. We also need to work with religious leaders.
13. The profession has clearly grown, both in number and also in capabilities. You now run specialized programmes in our hospitals. To highlight two examples: the ASIST programme in SGH provides training in suicide risk assessment and intervention for many healthcare and community front-line staff. The Job Club at IMH helps psychiatric patients acquire useful job skills. .
14. We are ramping up your number so that you can do all this good work, without yourself being mentally and emotionally drained. Last year, the public sector increased the number of MSWs by 27%, to almost 200. We have the budget to do more. But it is not just quantity. To upgrade and retain talent, we are providing MSWs with opportunities for clinical attachments and postgraduate training. Last year, under the Healthcare Manpower Development Programme, 16 MSWs were awarded scholarships to pursue Masters and other postgraduate training programmes.
15. We will do more. MOH is piloting initiatives for university graduates from other disciplines to pursue graduate-entry studies, for them to be qualified as MSWs. I have heard that NUS wants to start a post-graduate degree in MSW and we should support this. MCYS has developed an accreditation scheme for social workers. This will help to ensure professional standards of social work in Singapore and enhance the professional status of the profession.
16. Your care and compassion have touched the lives of many: the cancer patient with no money to pay for his treatment, the HIV patient who contemplates suicide, the elderly patient who is abandoned by his family. These are complex issues and often involve multiple psycho-social elements. In these situations that often appear bleak and hopeless, MSWs provide hope, care and comfort. Let me convey our deepest appreciation to all MSWs, for your commitment and dedication to your patients.
17. Happy 60 years of sterling service to Singaporeans!