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17 Mar 2004
By Mr Khaw Boon Wan
Venue: Parliament
QUALITY HEALTHCARE
"Putting Patients at the Centre"
Mr Chairman
1. Several Members asked if the corporate missions of the clusters are properly aligned with our objective of keeping healthcare affordable to all. Mdm Ho Geok Choo asked what their mission is. For example, is it to get more patients?
2. Dr Chong Weng Chiew and Dr Ong Seh Hong felt that if doctors' and CEOs' income depended on patient volume, they are bound to compete for more patients and revenue, pushing up healthcare cost. I put these comments to the two clusters' CEOs.
3. Dr Lim Suet Wun explained to me that pay and promotion would depend on a number of performance measures. Workload is not the only measure but it could not be ignored. "Not to consider workload means that those who work hard and those who don't, are paid the same." In his cluster, his doctors are pushing projects which improve the care for asthma patients and reduce their admissions. The diabetic foot care programme to prevent amputations is another. As he put it, "less amputations hurt our bottom line, but we enjoy doing it".
4. Similarly, Prof Tan Ser Kiat explained that his cluster doctors are measured on a number of indictors. Revenue and patient load are not the only criteria.
5. At the end of the day, it is values that count. If a doctor is solely interested in maximizing his income, the public health sector is not the right place for him. We need to gather around us, like-minded people who share a common objective to serve. They will be rewarded adequately but their passion must be towards their patients. Then they are qualified to join the Fellowship of the Ring. Our job is to expand the Fellowship. I therefore spend considerable time sharing my thoughts and values with the staff.
6. My advice to both clusters is simple. Put patients at the centre of our focus, not clusters or hospitals or doctors, but patients. At the same time, bear in mind the need to keep healthcare affordable, which means doing more with less without compromising clinical quality. At the most fundamental level, these must be the key performance indicators, a point which Mayor Zainul Abidin touched on.
7. Let me illustrate the patient-centric philosophy with some examples.
#1 ELECTRONIC MEDICAL RECORD (EMR)
8. First, sharing of electronic medical record. One in four of our patients need to cross clusters. For example, a patient may begin with a consultation with a doctor at NUH. Subsequently, he may decide to seek another opinion from a doctor in SGH. If we focus on the clusters' benefits, we will probably make it inconvenient for the patient to cross the border. So, duplicate medical records will have to be created. Tests may have to be repeated at unnecessary costs.
9. But if we focus on the patient's benefit, we will quickly realize that the correct decision is to facilitate the transfer and make it seamless. One cluster's gain is not another cluster's loss. It is not a zero-sum game. The patient's care is what counts. This is the approach I take towards cluster competition and cluster cooperation.
10. Two weeks ago, when DPM Lee re-opened AMK Polyclinic, he was shown how IT was being used to allow doctors in the National Health Group Cluster to access medical records of the patients once they have had one encounter with the Cluster. For example, if an AMK Polyclinic patient were admitted to say, NUH A&E Dept, the NUH doctor would be able to check, real-time, the medical records of the patient in other NHG institutions, even though it is the patient?s first visit to NUH. This is the power of electronic medical records or EMR.
11. Last week, the SingHealth Cluster also illustrated the capabilities of its EMR to the public. The objective is identical, which is to exploit IT for the benefit of patients. I am glad that for their pioneering efforts, SingHealth took one of the top 5 spots in the CIO Asia Awards.
12. I am moving this initiative up the next step. We are working to link up the EMR of both clusters, so that a patient, once served by a member of a cluster, will enjoy the benefits of the EMR in subsequent visits to any member of any cluster.
13. This has powerful applications. For example, patients would no longer need to re-register at counters, a tedious and time consuming process. They can avoid being sent for repeat tests and x-rays if these have been carried out recently by doctors in different institutions, a point made by Dr Lily Neo. A&E doctors can access the patient's medical record, to look out for drug allergy, or other pertinent clinical information which may influence the treatment to be rendered.
14. We are not there yet in linking up the EMRs of both clusters. But I am determined that the key pieces are put in place within 12 months. It is complicated but it can be done.
#2 REBUILDING OF AH
15. Second example, the rebuilding of Alexandra Hospital. MOH made a commitment to rebuild AH. We are seeing through this commitment.
16. There are good reasons why AH should be rebuilt. It is already 65 years old. The buildings are old and sprawling. Patients and visitors have to walk long distances to get different treatment or services. Although the staff has done a wonderful job in sprucing up the place, it is becoming expensive to maintain.
17. The question is, what kind of hospital should replace it.
18. In the last 25 years, we have rebuilt all the public hospitals, except AH. From Changi to Woodbridge, they have all been given a new lease of life.
19. For the new hospital to replace AH, will it be more of the same?
20. Members are aware of the transformation of our public libraries. From a boring depository of books, they have become "lifestyle destinations". Dr Tan Chin Nam told me that their approach was to treat every new library project as a prototype to try out new ideas, new innovations in library services. As a result, every new library is an enhancement over the previous one.
21. I posed the challenge to the AH rebuilding team: do to your new hospital what Chin Nam did to public libraries. I don't mean to turn hospitals into lifestyle destinations! Specifically, build a hospital where patients will be treated as you would wish for yourself or your loved one.
22. To meet this challenge, the hospital will have to be designed with patients unambiguously at the centre of focus, with technology fully exploited for the benefit and convenience of patients. It will be a hospital where patients do not get lost or get pushed from pillar to post. It will be a hospital with minimal bureaucracy and paper work.
23. It will be a hospital which is well-linked to the polyclinics, GPs and nursing homes in the neighbourhood, and to which the patients can be transferred seamlessly and in a way that makes the most sense to them. It will be a hassle-free hospital.
24. This is a tall order. I would be pleased if they can achieve half of what I have sketched.
25. The hardware aspect of building a hospital is the easy part. We have done it many times before. It is the software that will determine if they succeed in this mission.
26. The AH team is brainstorming these software issues, in collaboration with many partners, including IDA. We will not know which ideas will work. They will use the next couple of years, to try them out at AH. And for those that work, to adopt them at the new hospital.
27. I have asked them to consult widely, ask the patients, ask their visitors, and certainly involve the stake holders in the neighbourhood: the GPs, the polyclinics, the nursing homes, the MPs and the grassroots leaders. Whoever can bring value to the table, involve them.
28. I have also told them to avoid building a huge hospital. Every city needs a couple of huge hospitals. We already have them: SGH, NUH and TTSH. I suggest that they limit their new hospital to about 400 beds: large enough to cover a range of different medical specialties, and yet small enough to remain patient-friendly.
#3 HOSPITAL IN THE NORTH
29. Third example, the general hospital in the North. During the last Elections, DPM Tan promised a hospital in the north. He appointed SMS Ho Peng Kee to head a committee to identify a good site for such a hospital.
30. We are seeing through this commitment.
31. Currently, we do not have any hospital in the north. All our hospitals are in the south. I have been studying the ambulance travelling time between the north and our A&E departments. They are within acceptable limits, but at times, pressing the boundary.
32. There are already more than a million people in the north and northeast. They can well justify a general hospital. So we shall site the rebuilt AH in the north. My Ministry has been working informally with Ho Peng Kee and we hope to settle the siting of the Northern General Hospital soon.
#4 JURONG HEALTH-CONNECT
33. Fourth example, integrated healthcare services in the West. I have been discussing with Minister Lim Boon Heng on existing healthcare services in Jurong. There are many players: a tertiary hospital in NUH, a community hospital, several nursing homes, an upcoming Polyclinic at Jurong West, and many GPs. So the residents are adequately served.
34. There was a plan to build a new Jurong General Hospital, as pointed out by Mdm Halimah. A site has been reserved. We could proceed with this plan. But I persuaded Minister Lim Boon Heng that it is better to postpone the Jurong General Hospital plan for the time being.
35. Let's focus, instead, on the software of delivering healthcare services to see if we can transform existing services to serve the Jurong residents better through greater use of IT, adoption of innovative ideas that link up the various players in a seamless manner. The idea is to put patients at the centre, with services re-organised around them.
36. I think such a patient-centric, software-driven project in Jurong is much more meaningful than simply building another general hospital.
37. We have tentatively codenamed this project: "Jurong health-connect". It is to pilot a new concept of care at our polyclinics with virtual links to day care facilities, nursing homes and community hospital. Close cooperation, weekly joint management meetings, single case files for each patient across the continuum of care.
38. It will attempt what Dr Tan Cheng Bock outlined yesterday: "manage chronic disease like diabetes and hypertension in a proactive manner, outside of hospitals". A public and private partnership that not only treats the disease but also prompts the patients to manage their risk factors so as to avoid more costly hospitalization.
39. This will enable us to serve patients better for both acute illnesses as well as chronic diseases. In the US, it was reported that quite a large proportion of diagnosis and treatment traditionally carried out in a general hospital could in fact be done in a community setting. This is less traumatic for the patients, besides saving them money. Can the Jurong West Polyclinic be the nerve centre for this new concept of care? If so, it may have to be enhanced physically to provide a wider range of services.
40. For the elderly requiring long term care, there is the St Luke's Community Hospital and several nursing homes and day rehabilitation centres run both privately and by VWOs. But services are fragmented as they are facility-centric. Can we bring the services to a higher level by linking them up through IT and also to NUH and AH so that the care of patients can be centrally coordinated, even as they progress through the various healthcare facilities?
41. Is it worth doing? I read the Hansard recently and there was at least one sitting during which Dr Lily Neo made some suggestions on how public and private sector healthcare services could be integrated to provide the elderly and the chronic sick with a better level of care. Dr Neo proposed more ideas on this issue today, including having holistic treatment for the elderly and one-stop diagnostic centres. The question is how to convert intent into practical ideas which can be executed on the ground. We know who to call now to help us in this project. Besides Dr Lily Neo, Dr Tan Cheng Bock will be invited to join the Fellowship of the Ring. Perhaps, Dr Tan Cheng Bock shall be Gandalf, our wise counsellor.
42. Minister Lim Boon Heng was persuaded by my plan and signed on to the Fellowship quite early. He brought with him his full GRC backing on the ground. So Mdm Halimah is in too. We will work together to flesh out Jurong Health-connect and make it work for the residents there.
HEALTHY LIFESTYLE
43. As providers, we will put patients at the centre of our focus. But I hope Singaporeans in turn will put their health as their centre of focus. They can do so by adopting a healthy lifestyle. Not merely chanting the mantra, but actually doing it.
44. Mr Ahmad Khalis asked how Singaporeans' attitude towards healthy lifestyle has changed over the years.
45. Well, the cup is half-full and half-empty. On the one hand, many more Singaporeans have moved to the right side of the divide. The percentage of Singaporeans doing exercise regularly has gone up, from 14% in 1992 to 20% in 2001 (1 in 5). The percentage of Singaporean smokers has fallen from 18% to 14% over the same period. Tens of thousands of Singaporeans exercise in our public parks, especially during the weekend. Mayor Teo Ho Pin is a champion of healthy lifestyle in his CDC. He started brisk walking clubs and was pleased to note the steady increase in the number of clubs and the number of participants. Occasionally, he would organise joint brisk walk among all the clubs and would be able to gather 10, 20 thousand walkers in one session.
46. On the other hand, many are still not exercising regularly. Many are still over-weight. Many with hypertension and diabetes
still do not know that they have such problems. So we are getting better, but we certainly can do more.
47. Promotion of healthy lifestyle requires a multi-pronged approach. This is because young children, working adults and older individuals have different needs. To reach all Singaporeans, we need the public, private and people sectors to work together.
48. MOH is grateful to MOE for its efforts in getting our kids to acquire a healthy attitude from young. We are grateful to MND for their many parks. I am especially pleased to read that NParks is expanding and adding more park-connectors. We also thank the Singapore Sports Council for their many sporting activities, including the annual Singapore Marathon which several MPs and I took part recently. We thoroughly enjoyed ourselves.
49. At the workplace where more than half of the population spend significant amount of their time, we have a great opportunity to promote health. Where the company CEO and management are personally committed to health, their company will tend to have the right environment for everyone to follow.
50. That is why it is so important to set personal examples. I have been in MOH for nearly 8 months now. I have never used the lifts. Initially, I would not bump into anybody in the staircase. But now I do, and often.
51. MOH does not have an office gym, because there is a good one within the SGH campus. I use it regularly during lunch time. Compared to my previous offices in MTI and MITA, it is a bit inconvenient because I have to change into shorts and drive there. But after a while, I realise that it serves an additional purpose. Hopefully, the taxi drivers and patients in the queue will be inspired to follow suit.
52. Mr Ahmad Khalis asked if there were statistics to prove that healthy lifestyle did reduce sickness rate. There are many, looking at different risk factors.
PREVENTIVE & ELDERLY CARE
53. Dr Lily Neo spoke passionately about elderly care. She has done so often in this House and has made many good suggestions.
54. We have to work together to get the elderly to stay physically, mentally and socially fit. Being old does not necessarily mean being frail and disengaged from society. In fact, there are many elderly Singaporeans who remain active.
55. I was at the 96th Birthday Party of Venerable Shi Chin Yam of Man Fut Tong recently. She is tirelessly raising funds for her inmates. At the party, she told us that she is launching a new project: to build an orphanage. At the age of 96!
56. Maintaining a healthy lifestyle, since birth, is the key. Managing and controlling the risk factors are important. The cost of screening these risk factors is inexpensive. Unfortunately, many are still unaware of their risk factors.
57. At the grassroots level, many of us are organising such mass screenings. At the workplace, simple health screening for hypertension and diabetes can uncover hidden health problems. I hope more companies can offer this for their workers.
58. I am for more opportunistic screening. Every day, 1% of Singaporeans seek medical consultation. While the doctors attend to the patients' immediate needs, there is an opportunity for them to also screen the patients for the common risk factors if this has not been done recently, and document the results in the patients' EMR. In this way, we update the EMR regularly, making it a lifelong medical record for each Singaporean. This can potentially transform the practice of medicine in Singapore and bring the management of chronic diseases such as diabetes and hypertension, to a higher plane.
59. Through the proposed Jurong health-connect, we hope to pilot some of these ideas.
60. As for the financing for elderly healthcare services, it is built upon the 3M framework of Medisave, Medishield and Medifund. Over the years, we have added the ElderCare Fund and Eldershield.
61. Dr Lily Neo also stressed the greater promotion of preventive healthcare. She earlier pointed to the "miniscule" budget of HPB, and supported a bigger budget for HPB/MOH for this purpose. I must first thank her. I am always grateful when MPs voice support for a bigger budget for MOH.
62. MOH has and will continue to support worthy initiatives especially in the area of health promotion and preventive care. Effective programmes, however, need not always be costly. Much can be achieved if we have champions who are passionate and creative.
63. We should also bear in mind that while in principle, nobody can disagree with more preventive healthcare, it is possible to go over-board. There is a recent rather controversial trend in the US where millions of people have been diagnosed with one or often, several "pre-disease" conditions. The controversial question is what to do with such pre-disease conditions?
64. Preventive medicine is at its best, if pre-disease diagnosis leads to lifestyle changes: cut out salt, cut out sugar, eat less, exercise more, lose weight.
65. Preventive medicine is at its worst, if pre-disease diagnosis leads to over-treatment and over-medication: often expensive drugs paid for by insurers or the state.
REGIONAL MEDICAL HUB
66. Let me turn now to Members' points about making Singapore a medical hub.
67. Dr Lily Neo spoke about having competitive costs in order to attract foreign patients. I agree. As is the case with other sectors of the economy, if we do not have a good handle over our cost-competitiveness, we will not be able to fully maximize our potential as a regional medical hub.
68. An important part of our strategy is to recruit and train many more doctors and nurses. Matching supply of healthcare workers with demand is the key to ensuring that becoming a medical hub does not push up overall healthcare cost. If foreign patient load grows, without corresponding increase in doctors and nurses, then healthcare cost is bound to rise.
69. I therefore agree with Dr Wang Kai Yuen on the need to review our control of medical school enrolment and have flexible, market-based manpower policies. We certainly should not inadvertently protect a cartel. I am tackling this at various fronts.
70. First, we have increased the NUS medical intake from 150 to 230. The next increase in intake will be when a new graduate medical training programme with Duke University starts in the SGH campus.
71. Second, MOH has expanded the list of recognised foreign universities and medical schools to 71. I hope to do more
72. Third, we have allowed fast-track entry of foreign-trained specialists already registered in UK and Australia. As a result, the number of foreign-trained specialists practising in Singapore has grown by an annual rate of 23% since 1999. Can we do more? I posed this question to the Specialist Accreditation Board recently: why can't we allow fast-track accreditation of all US-board certified specialists? The SAB has allowed this for 9 specialties and is looking into the others, as there are significant differences in training structure and duration.
73. Fourth, we are getting our hospitals to re-design jobs and re-engineer their processes to make nursing a desirable profession again. This will improve students' attitude towards nursing as a profession.
74. Fifth, we are exploring setting up a local degree course in nursing in our university to provide the next generation of nursing leaders.
75. Sixth, we are recruiting foreign nurses from countries like the Philippines and China. There is a global shortage of qualified nurses. Despite our efforts, the clusters still have more than 200 nursing posts unfilled. We have to work harder on this front.
76. Dr Lily Neo pointed out that in order to sustain our advantage in quality, we must pay attention to medical training. Absolutely true. I hope the Duke University partnership at the SGH Campus will help stimulate and add diversity to our medical education scene, as the school will emphasise clinical research.
77. I agree with Dr Gan See Khem that the public sector has a role to play in regional medical hub, but we need to manage it properly because by mandate, our hospitals' focus is to serve Singaporeans. However, where the hospital has the capacity to do more, having acquired a strong reputation for excellence and strong finances, it can proactively pursue international patients on their own or with private hospitals. I am using Singapore National Eye Centre as a test case and learn from the experience.
78. Mayor Zainul Abidin and Dr Lily Neo talked about marketing Singapore and gave useful suggestions. Mr Gan Kim Yong suggested that we should focus on specialties where we have a competitive edge and adopt a "total approach" in promoting them. Singapore Medicine has identified a few areas that will be intensively marketed. These are specialties that treat diseases affecting large patient populations, and include ophthalmology, gynaecology, oncology and cardiology. Singapore Tourism Board is also in active dialogue with healthcare providers, travel agencies, hotels and other service providers to ensure that the diverse needs and requirements of our foreign patients are catered for. The issue of medical visas raised by Mr Ahmad Khalis and Mr Gan Kim Yong is being reviewed. The objective is to make it easy for foreign patients to come here for treatment.