MOH Budget Speech (Part 2) - Are Healthcare Facilities Adequate?

07 Mar 2006

By Mr Khaw Boon Wan, Minister for Health

"Are Healthcare Facilities Adequate?"

1 Mr Andy Gan asked if our healthcare facilities are adequate. Frankly speaking, healthcare facilities will never be fully adequate. This is because in healthcare, supply does create its own demand, particularly if that demand is heavily subsidised.

2 Among health economists, there is a well-known observation called "Roemer's Law" which states that "a built (hospital) bed is a filled bed". It is therefore wise to keep public hospitals slightly under-supplied and run it at high occupancy rates. That is why I resisted tackling the overcrowding in TTSH by simply expanding it. By forcing the hospital to understand its sources of overcrowding, we discovered outdated policies like free treatment for foreign workers infected with chickenpox, and cumbersome discharge procedures which kept patients unnecessarily in hospital.

Alexandra Hospital @ Yishun

3 But we cannot sit on the cap forever. Periodically, we need to expand our facilities to meet real rising demand. That is why we are building a new general hospital in Yishun. Mr Steve Chia asked for some details. The site has been finalised. It is a good site, near to Yishun MRT and bus interchange. Planning of the hospital has started. A design competition is on-going right now. We expect to ground-break before next Chinese New Year, and eventually open the hospital in phases from 2009.

Pathology Department

4 Dr Tan Sze Wee asked me about the rebuilding of the Pathology Department at SGH has been aborted. I have not heard such a rumour. We are going to build it on a new site within the SGH campus. Planning has begun and we hope to open the new facility around 2010.

New Equipment

5 Besides buildings, we will continue to invest in new equipment. Mr Andy Gan has noted a rise in high-tech diagnostic machines. It has been so for many years and in fact is a factor which contributes to rising healthcare cost. But we will pace it appropriately, balancing between inevitable cost increases and enhanced healthcare standards. As a principle, I prefer the public hospitals to be slightly behind the curve but not too much behind. For example, the latest high-tech scanning equipment is the 64-slice CT scanner, costing a few million dollars. The first unit was brought into Singapore in 2004 by the private sector. Others have since bought such scanners, including public hospitals.

6 By being slightly behind the curve, we allow ourselves some time to evaluate each new machine and establish its cost-effectiveness. Ultimately it is not investment in technology for its own sake, but investment in patient outcomes that matters. Given the high cost of such equipment investment, I agree that wherever it is possible to share it with the private sector, public hospitals should do so. But sharing has to be done at the right price, and certainly not at the expense of public patients.

Adequacy of Manpower

7 Mr Andy Gan also asked about the adequacy of nurses. We will continue to both train locals and recruit foreigners from abroad. Last week, NUS announced the launch of Singapore's first Nursing Degree, for year of admission 2006. This is a milestone event for our nurses. The first batch of nurses will graduate in 2009.

Cross-Cluster Referrals

8 Dr Tan Sze Wee worries that cluster polyclinics may game on their block budget, and refer subsidised patients from polyclinics to hospital A&E Departments of the other cluster, so as to save on cost. Let us look at the data. Less than 2% of polyclinics patients were referred to hospital A&E Departments for further care each year. The vast majority of such referrals were within each cluster. There is some cross-cluster referral, but tiny. So I am glad that the data does not validate such a worry. Indeed our doctors are largely ethical and we should be proud of them.

Managing Chronic Diseases

9 Let me now spend some time on chronic diseases which Dr Lily Neo raised earlier. This is a big topic. It affects a large number of patients, particularly the elderly, and consumes a large amount of resources. No country has managed it well. There is much scope for transformation and improvement.

10 It is my goal to transform the care of chronic diseases so that patients with chronic diseases can enjoy better care, at lower cost and with less hassle.

Family Physicians Play Important Role

11 To achieve this goal, family physicians play a critical role. Recently, I visited one in Toa Payoh and I am impressed with her practice. She has a base of regular clientele, many elderly with chronic diseases. She knows them well, including their family members. When one of her patients suffered a fracture, she arranged for a physiotherapist to provide home therapy twice a week, instead of simply leaving the patient to stay in the hospital for a long period. After a month of home therapy, the patient was able to walk. Unnecessary inpatient treatment was avoided, and the money saved from inpatient charges was used to engage the therapist.

12 When another patient was diagnosed with terminal cancer, she personally arranged a shared-care programme with the hospital cancer specialist. This way, she was able to continue the patient's intravenous antibiotics at home. That was the patient's strong preference, to spend his last few months in the company of family members, rather than wasting precious time waiting in crowded hospital clinics. The patient eventually passed away peacefully at home, avoiding unnecessary hospitalisation which would not have made any difference. His family got to spend quality time with him at home. When death came, this family physician was there to sign the death certificate.

13 This is what good family physicians can do to bring about better care at lower cost and less hassle for their patients, instead of simply referring them to hospital specialists. There are many such good family physicians in Singapore. But we should grow their numbers and profile them to the public, so that such care would become standard best practices here.

14 I asked our hospitals and our polyclinics to help facilitate this transformation. The hospitals have an interest to see this succeed. Many of their patients in the specialist clinics can be competently treated by family physicians, at lower cost. They are keen to partner with willing Family Physicians through shared-care programmes at the community level.

Diabetes

15 Let us take diabetes as an example of how this can be done. It is a common chronic disease, affecting one in eleven Singaporeans. Diabetes occurs when the body is unable to control the blood sugar level. When poorly controlled, doctors can almost predict what will happen to the patient at different stages over 20-30 years. In early stages, there are no symptoms and many patients are unaware. Left untreated, the condition will deteriorate over the years. Many suffer greatly from multiple organ failures towards the end.

16 Many diabetic patients start treatment late, ending up going to multiple specialists for treatment of their many problems as and when each problem surfaces. It is not unusual for a diabetic patient to consult a cardiologist for his heart problem, an orthopaedic surgeon for his leg problem, an eye specialist for his eye problem, and a neurologist for his loss of sensation. The suffering, the time spent at each hospital clinic and the cost of treatment can be unbearable.

17 Yet that need not and should not be the case, if their diabetic condition is detected early. The simple trick is to help the patients control their blood sugar, look out for early signs of complications and treat the complications before they become a big problem. Many of the complications of diabetes can be avoided totally or delayed for many years.

18 Many diabetic patients are well educated. They have the ability and the motivation to help themselves. We should re-orientate our healthcare to work with these patients and enable them to lead a long and healthy life. We actually have some success stories right here in Singapore.

19 For example, SGH and AH have Diabetes Centres to run structured disease management programmes for the patients. Their staff work with the community and employers to screen the population. Those with mild diabetes are referred to their Family Physicians for follow-up. For those with more severe diabetes, the centres take a team approach, involving specialists, non-specialists, diabetic nurses, dieticians, podiatrists and eye technicians.

20 Diabetic specialists assess the patients thoroughly at the beginning of the programme and draw up individualised treatment plans. Non-specialists and other team members then take over and work with the patients, to control their blood sugar and to screen for complications at appropriate intervals under the supervision of specialists. Once the conditions have stabilised, they are referred back to their Family Physicians for routine follow-up.

21 The key is to make patients and their family members the main carers of their diabetic condition. Patients are taught individually and in groups, to enable them to help themselves. They adopt healthier eating habits with the help of dieticians. They exercise more and they reduce their weight. Many are even able to adjust their insulin dosage with help from nurses.

22 The outcome has been very satisfying. Patients' blood sugar level is better controlled. Complications are detected earlier and treatment to prevent deterioration initiated earlier.

The Challenge Ahead

23 We should expand such success stories to benefit many more patients and other chronic diseases, like asthma. Both clusters are spearheading structured disease management programmes for their chronic patients and have good results to show. For example, patients under the asthma programme are less likely to end up with emergency asthma attacks. The programme must have saved many lives and avoided unnecessary deaths due to asthma. Another disease management programme is for heart failure patients. Results are also encouraging.

24 I am cheered by these innovations and their success stories. Quietly and unglamorously, our polyclinic Family Physicians, working jointly with the hospital specialists, are helping our chronically-ill live longer and healthier lives.

25 Let us help push these programmes nationwide. To succeed at the national level, many things will have to happen. Time does not permit me to elaborate, but they include successful implementation of concepts like: right-siting of care, "one Singaporean, one Family Physician", "one Singaporean, one electronic medical record", effective partnership between GPs and specialists, opportunistic health screening, co-operation and compliance by patients, and so on.

26 This is a tall order and that is why no country has so far done it well. I am counting on our being small and compact and better organised. I think it can be done. We are building a Health Centre at Jurong West to be one focal point to deliver this transformed service, for the residents there. If it succeeds, I will replicate it elsewhere. It will be a one-stop health hub providing a range of services from, say outpatient specialist, diagnostic and day surgery services to chronic disease management for common chronic illnesses. It will also be a place for health screening and health promotion. If we can tear down barriers between public and private, GPs and specialists, hospitals and step-down care homes, and leverage on technology. I see an opportunity for a transformation of the way we traditionally manage chronic illnesses.

27 If we do it right, year by year, we can see improvements, not only in service standard, but also in health status of the patients. Let us start with a couple of common chronic diseases, say diabetes or hypertension, where there are established clinical guidelines on how such diseases are best managed over time, and slowly get more GPs and specialists and patients to join the programme and embrace the new approach.

28 Earlier, I said that we are studying how Medisave can be liberalised to pay for costly outpatient care. I see an opportunity to leverage on this initiative to help nudge the profession and patients towards this direction.

29 Dr Tan Sze Wee asked for data on government spending on primary healthcare. More than 60% of the government's subsidies go towards hospital care, while 7% is spent on primary care. Canada, Australia and New Zealand spend up to 30% of their health budget on primary care. But these figures are not comparable because our data does not include the spending by patients on private GPs here who take care of 80% of the primary healthcare market.

IPCs

30 Response to Mr Low, any organization which wants to be a charity has to apply to the Commissioner of Charities for registration under the Charities Act. Charities which want to receive tax deductible donations have to be approved as IPCs.

31 The approval authority for IPCs has been delegated by the Ministry of Finance to Central Fund Administrators (CFA), one of which is MOH. Any health charitable organization which wants an IPC status must submit an application to MOH for evaluation, which include whether it is a registered charity, whether its activities are beneficial to the Singapore community as a whole, and whether the proposed activities and services are relevant to the healthcare sector.