From Moment To Moment

09 Mar 2010

By Mr Khaw Boon Wan

Venue: Parliament

1 On the first day of Chinese New Year, I received news that Dr Chee Pui Hung had passed away peacefully at home.  He was 87.  As I wrote in my blog, “I lost a friend, a supporter and a critic” whom I respect.  Dr Chee was a legend and was larger than life.  Within the medical community, he was widely and affectionately referred to as the “A-gong” of the Medical Alumni, who held together the large community of doctors, dentists and pharmacists.  He lived life to the fullest, had a successful medical career, brought up 3 children well, and even dabbled in politics in his early days.  I am told that he had even chided a couple of Ministers in public when he disagreed with some of their policies.  In his unique way, he contributed to Singapore. 

2 Many years ago, my father too passed away during the Chinese New Year period.  He lived a full life, without any bad habit, kept slim, remained active and socially engaged in retirement.  Several days after all the children who lived overseas had returned to their respective homes following several days of New Year Reunion with him, he had internal bleeding in his brain one night while watching and fallen asleep in front of the TV.  My mother rushed him to the hospital in an ambulance.  I took the first flight out to Penang but missed him by an hour.  The suddenness was traumatic for the family, but after the emotions had settled, we knew it was a good death and quietly wished that we could go just as swiftly when it was our turn to do so.

3 The Japanese call this “pin pin korori”.  “Pin pin” is to keep healthy, bouncing and dynamic; “korori” is to roll over and die.  The phrase is so commonly used that the Japanese simply abbreviate it as PPK.  To PPK means to live a long life without illness and when the time is up, to simply die peacefully.  There are pokkuri temples, promising the worshippers PPK.  Although Japan has been in recession for two decades, pokkuri temples are doing rather well.

4 I studied the Japanese approach carefully because they have the most experience dealing with ageing.  How advanced is ageing in the Japanese society?  Let me share some observations. In 1963, Japan started giving silver cups to every Japanese who crossed 100.  That year, they gave away 153 cups.  There are now 40,000 centenarians.  They have just reduced the cup size by 15% to save on silver.  Their ageing problem is magnified by a very low birth rate.  More adult diapers are now sold there than children’s diapers.  There are now 23 mil children but 44 mil pets! Pet care is big business in Japan. Yesterday Straits Times carried a picture of Japanese man as he piggy backed his pet, like a kid.  Even pets are ageing, so they have pet food that is calibrated by age bands.

5 As noted by Dr Lam Pin Min and Dr Lily Neo, we have a good healthcare system.  As current and former Head of GPC for Health, they know what they are talking about.  Our system has brought us much success: low mortality, increased longevity, high clinical standards and among the most cost-effective in the world.  But ageing of the population will bring new problems.

6 We hope for PPK, but what if we do not simply “roll over and die”? The Chinese have a saying: “久病无孝子”: “hard to have a filial son after a prolonged illness”.  Out-sourcing the care of parents is not the solution.  The scene in “Money, No Enough 2” of children dumping their old mother at the gate of a nursing home struck a chord, precisely because that is what we all fear.

7 I know death is a morbid subject and we have just celebrated Chinese New Year.  But let me assure you that this speech is not about gloom and sadness; it is about living well and celebrating life.  We are ageing, but there is much cause for optimism.  Today’s seniors are very different from the seniors of the past.  I am 58 and my residents in Sembawang often told me that I look younger.  To answer Indranee, ageing can be fun. Ageing may not be so bad. When our children become seniors, they will in turn be even better than the seniors of today.  Where’s the evidence? More Singaporeans are exercising, jogging, brisk walking and engaging in many other sports.  I must thank Minister Mah Bow Tan, the HDB, the NParks and the PUB for creating an increasingly health promoting environment.  In Sembawang for example, my residents are making regular use of the park connectors and the cycling tracks, as well as the sports complexes nearby.  My GRC MPs, including Dr Lim Wee Kiat, and I are now working with the NParks to refresh the Sembawang Park so that it keeps up with the needs of modern Singaporeans.  But we will ensure that it retains its natural, old world charms.  Ms Irene Ng’s observation yesterday that some parks have become too “artificial, plastic”, I think, was timely.

8 As we discuss this year’s budget and reflect upon our achievements, I agree with Dr Fatimah Lateef that we focus on how we can shape the future to meet our aspirations.  I heard Members’

many thoughtful comments.  Let me pick up their key points.

More Elderly People

9 First, the past decade has seen our resident population grow from 4 to 5 million.  Will the next decade see another million being added to our resident population?  The Economic Strategies Committee has noted our physical constraints and Singaporeans have also been voicing their concerns.  So I doubt it will be a “6-million people decade”.  But even a “5.5-million people decade” will mean a substantial increase in demand on healthcare services as Singaporeans are getting older.  In 2000, life expectancy at age 65 was 82 years. Now, it is 84, an increase of 2 years.  With medical advances, this may increase further to 86 in the next decade.  I think this is success.  It means that many more Singaporeans can live to their 80’s and 90’s.  With better nutrition and lifestyles, many remain well.  But yes some will get  sick.    

10 We are gearing up for this demographic change.  We are adding more beds, more clinics and more staff, more nursing homes, day care centres.  I have shared our expansion plan before and given time constraints, I will not repeat it.  Let me just highlight the next big event: the opening of the Khoo Teck Puat Hospital (KTPH) in Yishun.  Over the next few months, we will open it in stages.  Indeed, it will start treating outpatients and conduct day surgeries in three weeks’ time.  The ambition of the hospital team is to make KTPH a hassle-free hospital.  I look forward to that.  

11 The change in patient profile from younger to older patients will have a significant impact on healthcare delivery.  PM spoke about this during his National Day Rally last year.  Young patients recover quickly and return to status quo soon upon discharge.  Elderly patients take longer to recover and sometimes full recovery may not even be achievable.  They merely change their status from an acute patient to a chronic patient.  Many need some transitional care in a community hospital or a nursing home, and occasional re-admissions to the acute hospital.   This is why it is so important for close coordination and effective collaboration between the acute hospitals and their clinical partners in the community. Done right, this will free up acute beds for patients with more serious conditions and reduce cost for those requiring less intensive care in the community.  Dr Lam Pin Min referred to this as “seamless, integrated care”.  I code-name it as ‘hassle-free healthcare system’.  One key enabler is the National Electronic Healthcare Records (NEHR), to allow all providers common access to an individual’s critical medical information, so that they can develop and coordinate shared care plans.  This will reduce unnecessary repeat tests and medication errors, and bring us one step closer to the vision of “One Patient – One Medical Record”.

12 I gave the team planning the new Jurong General Hospital (JGH) the project brief to build a hassle-free healthcare system to serve the residents in the west.  They accepted the challenge.  Being ambitious, they self-imposed an additional target: to make JGH a paperless hospital when it opens.  Meanwhile, the hospital teams in KTPH, CGH and TTSH are also trying to do the same for their respective regions.  They will compete to deliver the best ideas.  I told my MOH colleagues that this is our priority in the next decade.  Indeed, I think this assignment will take us a decade to complete.

Caring for the Elderly

13 Second, with more elderly patients requiring care in the community, including those with dementia, we are expanding our long term care sector.  This is a point emphasised by Ms Indranee Rajah and Mdm Cynthia Phua. Many chronic patients can be cared for at home by their family members and their maids.  But as Dr Lily Neo and Mdm Cynthia Phua observed, distress among caregivers might arise. I agree that the carers need training and support, and we will help them. 

14 All elderly patients want to age at home and many children want to take care of their elderly parents at home.  We will build up home nursing capabilities, and are working with several partners to do so. We must avoid seniors becoming permanent residents in nursing homes.

15 We are working with the Home Nursing Foundation (HNF) to scale up their operations.  They will also extend their services beyond the low-income group to also help the higher-income group access appropriate home nursing care.  Many patients do not need subsidies but may not have the knowledge and the contact of how to meet their needs.  HNF is working with a TTSH team to ensure a smooth handover for patients newly discharged from the hospital.  Once the patient is home, HNF will coordinate with other providers to meet the patient’s care needs in the community. We will launch this new initiative within the next couple of months, targeting patients in the central region.  

16 Mr Terry Lee suggested the use of mobile medical services. Some VWOs do run mobile clinics to bring medical care and treatment to patients at home. SATA is one example. St Andrew’s Community Hospital is another.  Recently, it launched a new “hospital-on-wheels” service to “bus” its team of doctors and nurses around Singapore.  We are open to all practical ideas. 

17 Third, a minority of elderly patients will unfortunately require long term care in a nursing home. In Europe, up to 7% of the elderly patients live in nursing homes.  We now have 62 nursing homes, serving 2% of our elderly population.  This is not excessive, neither is it grossly inadequate as we are still a young society and family bonding is still strong.  There is, however, variance in the performance standards of our nursing homes. While some well-run nursing homes are full with a long waiting list, a few others have significant vacancies.  We will push the weaker nursing homes to upgrade, so that resources are put to optimal use.  Still, there is scope for some expansion.  We are currently planning three new nursing homes and rebuilding three old ones in larger facilities in better locations within HDB towns. 

18 But we must not make it too easy for irresponsible children to abandon their parents.  Abandonment is not a major issue here but we do encounter some from time to time.  Last week, Ms Indranee Rajah quoted one case involving her resident.  When it happens, it is a very sad situation.  I will talk more about this later.  

19 Prof Pauline Straughan asked about the impact of the increased foreign worker levy on nursing homes. We have assessed, the direct cost impact is small.  But separately, we have just increased our subvention to them by about 7%, to help them cope with the higher cost of treating patients with more severe disabilities, what we call category 3 and 4 patients.

Quality Professionals

20 Fourth, we will back up the physical expansion with the necessary manpower. In the public sector, we have been adding more doctors, nurses and other healthcare professionals, to improve the staff-to-patient ratio.  We launched this in 2007, when we set aside $1.5 bil to recruit 7,700 more healthcare professionals.  We are now halfway through this 5-year plan.  I am pleased to report to Dr Lily Neo and Mrs Straughan that we are on track to achieving the target.  Our headcounts have increased by 44%. Our doctor staffing level has gone up from 6 doctors to 8 doctors per 10 beds.  Nurse staffing level has gone up from 20 to 26 nurses per 10 beds.  I met a group of hospital Medical Social Workers last month. They told me that with so many new recruits, many have no offices and the hospitals are rushing to add new work stations.  Staff retention is equally important as Dr Fatimah Lateef emphasised.  Although staff attrition rates have come down from 8 to 6% for doctors and from 10 to 7% for nurses, it is an ongoing challenge.  With two new private hospitals coming on stream, we must expect significant attrition.  The only practical way forward is to ramp up training and foreign recruitment.

21 Last month in Sembawang branch, I bade farewell to a young Branch activist who left to start her medical education in Australia, New South Wales.  I asked her about the intake size for her batch.  She was not sure of the total number, more than 300 in her batch, but among the 60 international students in her batch, she noted that 40 were Singaporeans!  I blogged about it and said that I would find a way “to get our kids back” to Singapore.  And I will.  The restructured hospitals are studying an idea of offering a pre-employment grant to these medical students, to help them with their cost overseas, in return for a bond to serve after they graduate.  It was an idea that Dr Lily Neo planted in my head some years ago and I think it is doable.

22 We have also been enhancing the value proposition of a career in the public sector.  We are investing in biomedical research and supporting those with research interest.  For the young doctors, we are ramping up training opportunities.  This will allow every young doctor to reach his maximum potential in his chosen specialty, including as a Family Physician.  We are setting aside $120m to strengthen our specialist training programmes over the next 5 years. 

23  We are also building up geriatric care capabilities. We will encourage GPs to undertake further postgraduate training in geriatric care, so that they can better manage these patients in the community. In addition, we will also need more specialist geriatricians. We have 48 now. Over the next 3 years, we expect a 30-40% increase. We have incorporated geriatric medicine as a core module of our medical student undergraduate training, and have introduced incentive allowances for geriatric trainees, over the more popular specialties. Next to the new KTPH, we are planning a community hospital. My project brief to the team is let’s go to the next level. They are thinking about it.  Among the fresh ideas being considered is to base an institute of geriatrics and gerontology there.  It can be a think tank of practical people to help conceptualise and facilitate successful ageing, working closely with government agencies, NGOs and the community leaders.

24 We are also upgrading our nurses so that more can take on greater responsibilities and deliver more complex care as Advanced Practice Nurses (APNs). We are targeting 200 new APNs over the next 5 years. 

25 Another important group of health care professionals are the Allied Health Professionals (AHPs).  We have started regulating optometrists and opticians.  Later this year, I will table in Parliament a bill to regulate the other professions. We will target the registration of physiotherapists, occupational therapists and speech therapists this year. Some 1,300 therapists will be involved. 

Better Mental Health

26 Fifth, we are enhancing our mental health programme, a topic raised by several members.  We made this commitment in 2007 when we rolled out a National Mental Health Blueprint and backed it up with a $123 million budget. The strategy includes offering a range of treatment options from acute care in IMH to follow-up care in the community. We are making some headway; we now have many more Community Mental Health Teams to facilitate the early detection and treatment of mental health cases within the community. We have developed programmes for at-risk groups such as caregivers and out-of-school youths. We also have an employers-led alliance that promotes the importance of mental wellbeing at the workplace. 

27 However, as noted by Dr Lam Pin Min and Mdm Halimah, the biggest obstacle to an enhanced mental health programme is stigma and unfounded prejudice. Mental illness makes people fearful. High-profile crisis incidents lead people to think that the mentally ill are all dangerous and should all be locked away. The lack of public empathy for the mentally ill arises from misinformation and ignorance. 

28 With treatment and support, most mentally ill patients can recover and function in the community. Mdm Halimah, Mr Ong Ah Heng, Ms Indranee Rajah and Dr Amy Khor have asked about the follow-up care for discharged IMH patients and crisis support. I heard with concern Dr Amy Khor’s account of a resident who committed suicide last month after discharge from IMH.  I do not know the details of this case and whether there are systemic gaps which could have prevented this tragedy.  We should try to minimise suicide rate but unfortunately, not all suicides are preventable.  IMH carefully select the patients to be discharged: they must have responded positively to treatment, have adequate family or social support, and pose minimal danger to themselves or to others. IMH then teaches such patients and their families on the need to comply with medication and regular follow-up to avoid future relapses. Those with higher risk of relapse are followed up closely by the Community Mental Health Teams. IMH now runs a 24-hour hotline that provides advice and support to families and patients during periods of crisis.    

29 Our follow-up care is getting better but we know there are still gaps.  MPs’ comments earlier confirm this.  I am therefore adding a further $57m for mental health initiatives, on top of the $123m already committed.  This is a significant $180 m commitment to enhancing our mental health programme. Part of the new budget will be used to increase psychiatric nursing manpower. Another will go towards setting up a long term monitoring and risk assessment system.  It will help identify and provide support for patients who default follow-up appointments for treatment, thereby reducing the number who relapse because they do not take their medication.

30 For this strategy to work, we need the support of the community, accommodation and job opportunities, so they can lead normal lives again. Hence, I fully agree with Dr Lam Pin Min, Dr Fatimah Lateef, Mdm Halimah and Mdm Cynthia Phua that working with employers, community partners and the grassroots is a must.  IMH’s “Job Club” has successfully placed more than 380 patients over the past 2 years, with the help of enlightened employers. And I share Mdm Halimah’s hope that more such enlightened employers will come forward to offer such job opportunities.   IMH will work with VWOs and the community to tap on their resouces to help expand IMH’s outreach to the discharged patients.

31 Dr Fatimah Lateef asked about the use of Medisave for schizophrenia and severe depression.  Five months after implementation, it has benefited 500 patients who withdrew a total of $160,000 for their outpatient treatment. 

Back To Basics

32 Mr Chairman, healthcare is a complicated subject.  It is also highly emotional and gets politicised easily.  Just observe the current debate on health reforms in Washington: it is largely politicking.   Health systems are therefore distorted in all countries, becoming dysfunctional when distortions become extreme. To reduce distortions, we have consciously tried to stick to the basics.

33 First, as stressed by Dr Lam Pin Min, health outcome is largely a personal matter.  Doctors and nurses can only point the way forward; the patient must play his part.  This is especially so in the case of chronic illnesses.

34 Second, there is no free healthcare.  Every healthcare service is eventually paid for by the patient, either through taxes, or reduced wages.  Ultimately, patients and their families pay for the bills.  Our job is to make sure that the cost of delivery is as low as possible.  This means cutting out abuses and other moral hazards.

35 Third, specialisation and subspecialisation have brought about much medical advances, benefiting many acute patients.  But as noted by Dr Fatimah, there is also such a thing as over-specialisation, over-subspecialisation.  For the elderly with several chronic illnesses, treatment by multiple subspecialists is often not the best approach.

36 Fourth, despite medical advances, we are still mortals and will die one day.  Three weeks before Dr Chee Pui Hung died, I visited him in his house.  We had a good chat for the last time.  He had been frail but rejected all attempts by his attending doctors to get him hospitalised.  He had the money and the medical network to get the most up-to-date sophisticated medical interventions, but he knew that they would be futile.  The interventions might extend his biological life by a few days, few weeks, but he knew that the hospitalisation would in fact reduce his social interactions and quality time with his loved ones.  He wanted every hour of his remaining life to be with his family and friends, in the comfort of his home.  This is a wise man.

37 Fifth, when cure is no longer available, care becomes the most valued by patients.  The highest form of care is underpinned by love and compassion. Last month, I visited the St Joseph’s Home in Jurong and watched the Saintly Sister Geraldine in action.  She had many wonderful stories to tell, all inspiring.  In her gentle, soft-spoken way, she leads her team of nurses, carers and volunteers, caring the patients with selfless dedication and love. 

38 I asked her if she had difficult patients or family members.  She said “yes” and related one incident when the son of a patient demanded that the nurses brush his mother’s teeth within 15 minutes after each meal.  He said that he loved his mother and such a service level would be in line with the “patient-centric” mission of the Home and a demonstration of love and compassion.  Sister Geraldine gently but firmly reminded the man that a place in a nursing home is a gift; it is not a right.  If every patient imposed such a demand, they would not be able to cope.  She added that a nursing staff, whether an employee, or a volunteer, or a Catholic nun, and no matter how kind and compassionate, is not the son of the patient. The man got the message: the love of family members cannot be delegated away. 

39 That is why it was so sad to hear Ms Indranee Rajah speaking about a case of abandonment of parents by one resident.  Our hospital nurses have also begun to come across cases of children refusing to take back their parents after discharge.  They demand that their parents be sent to a nursing home instead.  The numbers are still small, but we must not allow this to become a trend.  I have told our hospitals to be firm with such irresponsible children.

40 Three years ago, I spent several days in Kenya’s Masai Mara Reserve watching wild animals in their natural habitat.  It was the season for the annual “long march” as 2 million wildebeests, a type of antelope, migrated northwards from the Serengeti National Park in Tanzania, in search of water and food.  Along the way, many would perish as they crossed rivers infested with crocodiles or got hunted down by lions and cheetahs on the savannah plains. 

41 One late afternoon, we were positioned near the edge of Mara River as a group of wildebeests, numbering tens of thousands, attempted a river crossing.  There was much hesitation, as they could see crocodiles waiting in the river.  Almost ritualistically, a leader would eventually emerge, go into the river alone, test the water and suddenly make a dash across the river.  The rest would then follow in a mass stampede.  I prayed for their safety, but inevitably, the weakest could not make it.  Most made it and continued their journey northwards.  Some, visibly old and frail, dared not even cross and were left behind on the south side of the river. 

42 Just as we gathered our cameras and videos to return to camp, we saw a small group of wildebeests, numbering about 30, which had already made a successful crossing, yet surprisingly backtracked.  They re-crossed the river to re-join presumably their family members which had failed to make the crossing.  Instead of moving on with the rest of the pack, they risked their lives in order to be with their family members.  It was very moving and very touching; it was an instinctive expression of family bonds, love and sacrifice.

43 I prayed for them even more deeply, as the night would bring more dangers and they would be in a smaller group then.  These were wild beasts but their behaviour that afternoon of not abandoning their family members was not beastly at all.  

44 Mr Chairman, our population is ageing and living longer.  We have a good healthcare system but past solutions will not work as well for the future.  That is why we have been quietly restructuring our healthcare delivery system and gearing it up for a future with many more elderly patients.  It is a quiet revolution: no fanfare, no sensational headline news.  But if we do it well, our efforts will show positive results in ten years’ time. This I promise.

45 We have a lot to do. We need to work harder at keeping patients well in the community, avoiding unnecessary hospitalisation, achieving greater integration between hospitals and the community partners, and helping patients achieve successful ageing at home.  We are not alone.  Every country is trying to figure out the best solutions.  The efforts are not just happening in the public sector, nor are they restricted to the healthcare sector. Industries are seeing an important role for themselves in tackling the ageing problem.  In Japan, Toto, the largest toilet producer, makes a toilet that has arm supports to help the old get off the toilet.  They were the first to come up with a toilet seat with an integrated bidet.  When I first saw it in Japan many years ago, I thought it had to do with infection control.  But they explained that using water to cleanse, rather than paper, reduces effort for the seniors.  Zojirushi, an appliance maker, has a kettle that sends a wireless message if granny does not use it by a certain time each morning.  It is a clever non-intrusive way for families to check that things are all right with their elderly. 

46 There are many such pockets of excellence and innovation all over the world.  In healthcare, I regularly remind my colleagues that we must challenge ourselves to match the best performers in each class.    But the job is not mine alone.  My Ministry can only provide a supportive environment. 

47 Successful living and successful ageing are personal choices.   Dr Chee Pui Hung provided an example.  There are many others.  Prof Chan Heng Leong, a former Head of Medicine in NUS, is another.  A brilliant doctor, a dedicated academic, a good family man.  He could have earned more in the private sector but chose a public career to teach and treat the poor.  In retirement, he continued to contribute, in the University and at the hospital.  When his time was up, he refused further medical interventions and passed away peacefully at home, surrounded by his loved ones.

48 The last few days of these wise people are not mournful partings but quiet celebrations of having lived a fulfilling life.  Friends and family members drop by to talk about the past and the good times together.  Some, I suppose, may even karaoke and sing (nightclub mamasan) 金大班’s 最后一夜: “红灯将灭,酒也醒, 此刻该向它告别” (“the lights are dimming, even the drunkards are gradually sobering, now is the time to say goodbye”).  I don’t think Members need any translation, as I am told this is a favourite karaoke song of many MPs. 

49 Indeed, Mr Chairman, everyone, rich or poor, will say goodbye one day.  And we all want to end well.  To end well, we need to stay well and live a healthy and fulfilling life.  We have different starting points but all can live well.  Over the weekend, I was so happy to read about Jeremy Lim’s achievements at his GCE ‘A’ level examinations.  He was an NKF Ambassador when I first met him several years ago.  He was born with a brittle bone disease and told me that a severe cough could fracture his ribs.  He is wheel-chair bound but has never allowed the disability to hold him back.   As he put it to ZB: “we cannot determine what life will bring us, but we can determine our life journey”.  He added: “I cannot walk like other kids, but I can still do many things that other kids can”.  He told ST: “I focus on the things that I have, rather than the things that I don’t”. 

50 Life is really a series of successive moments.  We cannot change the past moments and we do not know what the next moment will bring.  But we can all seize the current moment and live it to the fullest helping others and touching their lives.  How?

51 Lao-tzu’s prescription is 2,500 years old but I think it remains relevant today: “上善若水, 水善利万物而不争”: “be like water which nourishes all life, but itself does not derive any gain”.  We should all live a life like water. We are here to help others, be kind to everyone else, not to help ourselves. This is a high ideal, but we can all try to get close to it.