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03 Mar 2008
By Khaw Boon Wan
Venue: Parliament
1. Last week, I came across an article with a seductive promise: “5 easy steps to living long and well”. It is a serious article quoting the evidence gathered from a study on more than 2,300 healthy men over many years. When the study began in 1981, their average age was 72. At the end of the study, which was recently, 970 men or 41% had survived into their 90s. The study was published last month in The Archives of Internal Medicine.
Secrets to Longevity
2. “The take-home message,” said Dr Laurel Yates, a geriatrician at Brigham and Women’s Hospital who led the study, “is that an individual does have some control over his destiny in terms of what he can do to improve the probability that not only might he live a long time, but also have good health and good function in those older years.”
3. The prescribed 5 easy steps are: abstain from smoking, manage weight, control blood pressure, regular exercise and avoid diabetes. Unfortunately the last is usually inherited. I score 5 out of 5 but I believe that good genes and good karma play an important part too. The study focused on men but the prescription is probably applicable to women as well. In the same issue of the journal , there was another study which monitored 500 women and 200 men ranging in age from 97 to 119. This study showed that a large proportion of people who lived that long, with minimal or no assistance, did so despite long-term chronic illnesses. In other words, some of the oldest of the old survive not because they avoid illness, but because they were able to delay or even prevent disability.
4. As life expectancy grows, there will be many more such studies and articles. Dr Lily Neo mentioned Okinawa and their experience of dealing with longevity. I went there last year and spent several days there. I visited a village called Ogimi with 3,500 residents. 17 of the villagers are more than 100 years old - 16 female, one male. I have never, in one sitting, met so many over 90 years of age, mostly ladies.
5. I have met many Singaporeans in similar age groups here, but largely in nursing homes and chronic sick hospitals. The Okinawans were different. They are active, busy and happy, and live independently. Few are bed-ridden in nursing homes. They were quick to share their secrets with me. Less scientific and more anecdotal, their prescription: sleep well, be happy, eat lots of vegetables and stay active.
6. These are some positive aspects of ageing. But ageing of the population is not all bed of roses. Dr Lam Pin Min’s comment on dementia is just one illustration. Indeed, the ageing of population is the greatest challenge confronting healthcare systems around the world. Look at the US, which spends 16% of their GDP on healthcare. Medicare alone which funds the medical care of the elderly takes up 3% of the US GDP. One quarter of Medicare spending goes towards supporting the last year of the patients’ lives. This raises questions about the appropriateness of such spending.
Slow Medicine
7. One reason is that current healthcare systems largely skew the practice of medicine towards high-tech medicine, at great financial cost and often with low quality of life for the patients. I have been referred a book titled “Slow Medicine” written by a geriatrician (Dr Dennis McCullough) at Dartmouth Medical School who is promoting a different approach – “a family-centred, less expensive way” as he put it. He felt that for many elderly patients, “modern medicine in its hospital-based, medication-obsessed, high-tech impersonality may hurt more than it helps”.
8. He has many practical tips for children of elderly parents and worth sharing. First, while the parent is still vital and lively, children must not fool themselves that this happy situation will last forever. This is the time to re-insert themselves back into the parent’s life, to accompany them to doctor visits, and at the right moment, to even raise unpleasant topics like the advanced medical directive or living will.
9. After a few more years, he said, it is time for the children to address the “can you still manage at home?” issues and to help create routines that compensate for a slipping memory and slightly wobbly balance. Then medical crises will inevitably arise. The children should then be vigilant to protect and “rescue the elderly from standard medical care”. By that, he meant medical care should, all the while, favour the tried-and-true, over the high-tech. For instance, instead of a yearly mammogram, a manual breast exam for the very old may suffice. And home tests for blood in the stool may replace the draining routine of a colonoscopy. These are very practical tips.
10. He added that the pace of care should be slowed to a crawl, hence the title of his book: Slow Medicine. For doctors, that means starting the medications at low doses and increasing them gradually. For children, that means learning not to panic and yell for an ambulance on every apparently bad day.
11. Though both comforting and worrying, it is a valuable contribution to the global discussion on ageing and how best should families cope with it.
Different Approach Needed
12. Indeed, modern healthcare systems are not well-designed for the demands of ageing. They are geared towards acute care in hospitals, that is, treatment for only brief but severe episodes of illness, sometimes requiring high-tech care. But insufficient thought has been given to long-term chronic care. Good models are rare and far-between anywhere in the world. Proper chronic care should be carefully designed for the long term, with appropriate level of resources, usually low-tech care, and most critically with strong co-operation by patients and their families. Chronic care is a very different care regime from acute care. But when high-tech acute care is mindlessly extrapolated to cover long-term chronic care for the elderly, it is not at all surprising that problems in the US and the West have arisen.
13. Everyone is searching for a better model to handle long-term chronic care of the elderly. We too are evolving our model. I agree with Mdm Halimah that there are still many gaps in our current step-down care sector and we must fix them. Fixing them however requires careful thought. Some elements or operating philosophies are better researched and appear sound, but we cannot be sure until they are tested through time and actual experience. This calls for carefully-planned experimentation and small-scale pilots, close monitoring and review, and if proven, scaling up. Such initiatives include, among many others:
(a) Greater emphasis on preventive medicine;
(b) Better management of chronic diseases at outpatient level;
(c) Better integration of care between hospitals and step-down care facilities; and
(d) Right-siting of patient care in more appropriate and lower-cost settings.
14. Many Members have shared their thoughts on this important subject and I thank them. I have noted Dr Lily Neo’s comments on possible public-private-people partnership as a model of providing eldercare. Indeed, we should widen participation, both in provision as well as in funding. Ageing of the population is a growing problem, and we should not underestimate its impact. The Japanese are well-known for doing very careful research and wide consultation before they launch any major policy change. Yet, when they launched their national long-term insurance scheme a few years ago, they found that their initial projection of demand and funding needs were off by a wide margin, after just one year of implementation! They have since been trying to curtail demand and raise premiums. This is an important lesson for us who are involved in the planning of eldercare services. Do not underestimate the demand, especially if it is going to be subsidised too generously. Make a strong disctinction between what is demand and what is genuine need. If services are heavily subsidies or provided for free, demand will be very high.
15. Let us discuss some of the points raised.
Promoting Healthy Living
16. First, I agree with Dr Lily Neo that we must promote healthy living and healthy ageing. But Singaporeans must participate actively in order to benefit. This is a continuous and often uphill endeavour. But we persevere.
17. Healthy living starts with awareness. This year, HPB will roll out the nurse educator programme. The nurse educators will hold classes at community centres for patients and their families on how to manage their chronic conditions. We will work with PA and the grassroots to promote these programmes.
18. We will leverage on screening. Many MPs did a lot of work promoting community screening in the early years. We are consolidating the programme and raise it to a new level. From this year, HPB will roll out an Integrated Screening Programme. All Singaporeans above 40 will be reminded to go for screening for major chronic diseases.
19. We are embarking on preventive efforts to promote healthy ageing. Last year, we embarked on a pilot “Wellness Programme” at 6 constituencies. This comes under the committee chaired by Mr Lim Boon Heng. This includes a platform for health agencies and service providers to encourage positive changes in seniors’ lifestyles and health behaviour.
Improving Primary Care
20. Second, when medical care is needed, primary care is the best first point of contact for chronic-ill and elderly patients, except for genuine emergencies.
21. Good primary care is essential to meet the chronic disease challenge particularly. Medisave can now be used for outpatient treatment of 4 chronic diseases.
22. Overall, we are pleased with the progress. From April 1, we will extend the scheme to the remaining two major chronic diseases -- asthma and chronic obstructive pulmonary disease, under similar terms. This will benefit up to 180,000 more Singaporeans.
23. Dr Fatimah asked if we would extend the scheme to other illnesses, for example, mental illness. We will keep options open, but for the moment we focus on the key chronic diseases with established treatment protocol and measurable clinical outcome. We also must not forget that Medisave at current contribution rates is only designed for inpatient treatment. It was never designed for outpatient care. Extension to expensive outpatient care is an exception, and we should resist any temptation to broaden its use liberally, or it will surely be depleted prematurely.
24. Mdm Halimah Yacob proposed that we extend the Primary Care Partnership Scheme (PCPS) to cover some chronic diseases. Currently, PCPS covers acute primary health care, like coughs and colds. Any extension to chronic care will raise the risk of over-consumption and over-servicing. But a case for extension can be made, if we can manage the potential problem of abuse. We will study it carefully.
Dr Lam Pin Min and Dr Fatimah Lateef described the problems faced by caregivers of patients with dementia. It is a real problem. Talking to them in nursing homes, you cannot help not being affected, when your loved ones cannot recognise you. It is easy for outsiders to say that children do not visit their relatives in nursing homes. But the poor patients cannot recognise them at all. It is heart-wrenching.
25. For caregivers in general, we will try to support them more. There are workshops and support groups that teach caregivers coping strategies and provide information on where to seek help if needed. We intend to expand our supportive efforts. (However, MOH is in no position to grant caregiver’s allowance. We will focus on training and counselling caregivers. Any financial assistance that they may need to cope with their expenses will have to come through other agencies.)
Integrating Care
28. Third, I agree with Mdm Halimah, Dr Lily Neo and Dr Fatimah Lateef that we must better integrate the healthcare system with the community to provide appropriate care for the elderly. From next month, we will upgrade the Integrated Care Services into an Agency for Integrated Care (AIC). Starting with CGH and NUH, the AIC will equip public hospitals with resources including additional care coordinators. This will cost $20 million over 4 years. These coordinators will help ensure that patients who are fit for discharge but who have multiple complex care needs, are transferred to appropriate step-down care providers and receive necessary medical and social services.
Right-Siting Care and Resources
29. Another key focus for MOH is to ensure patients get the most appropriate treatment in the right place, or “right-siting”.
30. Mdm Halimah and Lily Neo suggested that we subsidise home-based care of the elderly, including home hospice care. At present, there are several service providers offering home-based services to patients who are unable to leave their homes. Last year, MOH provided $3 million in funding to these providers. We will do more but we are taking a careful approach as the direct home care model is very expensive and manpower-intensive. We know that the elderly prefer to be at home, and the treatment should be at home. Between the two it is cheaper to do it in an institution, due to economies of scale. It is a balancing act. We need to study the underlying patient needs carefully.
31. Mdm Halimah commented on ElderShield. We have enhanced ElderShield last year. The ElderShield cash payouts help cater to varying needs of the severely disabled, allowing choices for care in the home or in other facilities. Cash is the most flexible way to help with the cost of long-term care. For those who prefer a higher payout, there are 7 ElderShield Supplements to choose from. It is not an easy product to market. Many people still do not know much about it.
Expanding Infrastructure
32. We will expand the step-down care infrastructure. Much of this may be care that is not medical in nature. Indeed we should be careful not to “over-medicalise” this sector. We will work with MCYS and other entities to facilitate the development of new services.
Developing Manpower
33. Dr Lam Pin Min commented on the manpower strategy to cope with the rapidly-ageing population. I agree with him that current numbers will not be adequate. MOH has extended its Health Manpower Development Programme to cover the step-down care sector, providing them with the opportunity to pursue advanced skills training. In addition, MOH has worked with MOE to train more physiotherapist and other allied health professionals locally. This year, our target is to train 210 physiotherapists, occupational therapists, diagnostic radiographers and radiation therapists. This is a substantial increase from the past. We target to further increase the intakes by another 40% by 2012.
Conclusion
34. Everyone wants to live long and live well, without being a burden to the family. In Okinawa, the ladies told me of their top wish: “pokkuri shinu”. “Pokkuri” refers to the popping of a bubble. They want their lives to be fun and happy, and at some stage, just simply “pop” and die in sleep.
35. My father led such a life. He worked hard, loved the family, had no vices and one night, in front of the television went into a coma and drew the last breath a few hours later, surrounded by the family members. I missed him by an hour as I was not in Penang.
36. Not everyone is so lucky. My mother suffered nearly 3 years of cancer pain. We had to try high-tech medicine first but when the poor prospects became clear, we went for palliative care and “slow medicine”. She was able to die peacefully at home, in familiar surroundings. This time round, I was able to return to Penang in time and be there as a loved one passed on.
37. As we busy ourselves with our work and our family, we should sometimes take a pause and reflect on how people spend their last moment. Death is not a taboo subject to be left unspoken. In fact, the more we think seriously about death, the more likely we will know how to live life to the fullest and make each moment and each day the most meaningful possible.