MOH Budget Speech (Part 3)

17 Mar 2004

By Dr Balaji Sadasivan

Venue: Parliament

AN EXCELLENT AND COST-EFFECTIVE HEALTHCARE SYSTEM

1 Our healthcare system is a good system and has improved the health of Singaporeans. On average, our system has increased the life expectancy of Singaporeans by 3 months every year, over the last 20 years. The life expectancy was 73.3 years in 1984. Today it is 78.9 years. We expect it to exceed 80 years by the end of the decade. Singaporeans enjoy a higher life expectancy than most people in the world; it is higher than even that of the US, the country that is the origin of most of the recent advances in medicine.

2 Our challenge is to maintain this high quality system at an affordable cost. To do this, our healthcare delivery must be as efficient as possible. Healthcare is an expensive service. More than half the cost in healthcare involves paying for the services of skilled people, - doctors, nurses and other paramedical professionals. Our healthcare system can be more efficient if we use the services of healthcare professionals in an efficient and appropriate manner. For example, if a patient has caught the flu and has a cough, he could decide to see a lung specialist. He would make an appointment at the specialist clinic, wait a while and see the specialist. The specialist can treat the cough and prescribe a cough mixture. But if the patient says to the lung specialist, "this medicine is for my cough, but my nose is stuffy, do I have a sinus problem?" , the lung specialist will refer him to the Ear, nose and throat doctor or ENT doctor. He goes to the ENT clinic, waits a while, and then get his sinus checked and will be given more medication. As the patient is about to leave the ENT clinic, if he says to the doctor that he feels bloated, he will be referred by the ENT doctor to a doctor looking after the digestive system. If he thinks, the problem is at the upper end, the referral is to the gastrologist, if he thinks the lower end is causing the problem, the referral is to a colorectal doctor. If the ENT doctor is not sure, the patient is referred to both. This is an example of expensive and inefficient delivery of healthcare. But if the patient had seen a GP, the GP would have treated all the complaints in one consultation. Many patients are seeing specialists when a primary physician can take care of the problem. This is why our specialist clinic attendances are growing at a rate of 6%. This is also driving the cost of healthcare upwards.

3 This does not mean that patients don't need specialists. At times they do need to see a specialist but the problem that the public faces sometimes is that they may not know when and which specialist to consult. If every family in Singapore had a family doctor, than, by consulting the family doctor or GP, they would know when they need to see a specialist and when the family doctor can take care of the medical problem. The family doctor can serve as friend and mentor to the patient and as gate-keeper who directs traffic within our sophisticated healthcare system. The family doctor, whether a GP or a polyclinic doctor is the key to the proper matching of health resources in our system to the health needs of the patient.

The role of primary care

4 My ministry has therefore instituted measures and programs to encourage Singaporeans to see their family physicians and general practitioners in the private and public sector. Singaporeans must also play their part. Where a medical problems can be settled at GP clinics or polyclinics, it should be done so, and when the medical problem has to be referred, it should be directed to the right specialist. Such habits will reduce costs and build a long term doctor-patient relationship where there is commitment to care and trust between the patient and the primary care doctor.

5 My Ministry has programs to facilitate primary healthcare for special groups by improving accessibility of subsidized care. For example there are many less well-off elderly who do not live near polyclinics. Getting to polyclinics can be inconvenient and for such elderly patients, my ministry brings affordable healthcare closer to them through the Primary Care Partnership Scheme (PCPS). Under this scheme, my Ministry engaged private general practitioners and dentists to provide common outpatient medical and dental conditions to needy elderly. These elderly pay polyclinic charges for such services. The number of elderly on the scheme has increased over the last one year, as a result of our outreach efforts, which include road shows at Senior Activity Centres and door-to-door promotion at 1 to 3-room HDB flats. More than 15,000 elderly are now on the scheme, compared to 5,000 elderly one year ago. They are served by 570 GP and 210 dental clinics. We will continue to promote the scheme

6 Night clinics were previously set up so that lower income Singaporeans could have the convenience of subsidised medical attention at night, instead of having to wait until the following day. 7 night clinics have been set up thus far. The polyclinics deploy their own doctors and also engage private general practitioners (GPs) to provide the night clinic services. Each clinic employs an average of 3 doctors and sees about 57 patients a night. The cost per patient of providing polyclinic service at night is much higher than that during the day. We will review these services to see if this is the most efficient way of providing primary healthcare. The clusters have no plans to expand night clinic services.

Integration of primary, secondary and tertiary care

7 In the healthcare clusters, better vertical integration of hospital and primary care services have resulted in shared care programmes between hospitals, polyclinics and general practitioners and Disease Management programmes. This enables the co-ordination of management of diseases across the spectrum of care from primary to secondary to tertiary care to achieve better outcomes. For example, the Singapore National Asthma Programme to manage severe asthmatics at both hospitals and clinics help reduce hospital admissions for asthma.

Health Education

8 Health education is important and besides using various media, it is also conveyed through the polyclinics or by GPs, who can obtain free health education materials from the Health Promotion Board (HPB) either directly or through the Singapore Medical Association and the polyclinics. Doctors and patients can also download health education materials from HPB's website. Patient education tools have also been developed by HPB to help GPs provide education to patients with chronic conditions.

The sick elderly and Right Placement of care

9 Our elderly utilize more health care services because there are more health problems as a person grows older. There are challenges here, - to delivery care at the right place at the right time. The community hospitals and nursing homes whose focus is rehabilitation provide lower cost and a more holistic care compared to acute hospitals. Elderly patients sent to the appropriate facility have better long term recovery. Wrong placement on the other hand results in unnecessary financial and social costs. A patient who should be rehabilitated in a community hospital but instead goes to a nursing home may not receive the optimum care to get back to their full rehabilitation potential. On the other hand the patient who is better taken care of in the community hospital but stays in a more costly acute hospital may be consuming heath resources that he does not need.

10 Lack of awareness of different healthcare services must be tackled. My ministry intends to pilot an Aged Care Assessment Programme (ACAP) to promote right placement of care in hospitals, community hospitals, nursing homes, day rehabilitation facilities and the patients' own homes as appropriate. We will train health care professionals in the acute hospital to be familiar with the criteria for step down and rehabilitation services

Workplace Health and Mental Wellness at work

11 Prevention is better than cure and getting the public to lead a healthy lifestyle in a healthy environment will reduce the consumption of healthcare services, as more people remain healthy. Two-thirds of Singaporeans work and spend a minimum of 8 hours in the workplace daily. No company wants poor health amongst its employees. My ministry is serious about healthy lifestyle amongst working Singaporeans. Workplace health programs promote healthy lifestyle among employees such as regular exercise, healthy eating, smoking cessation and mental wellness. To encourage workplace health, my ministry gives a grant of up to $5,000 to companies to start workplace health promotion programs. They can also apply to the Skills Development Fund for funding workplace health promotion training. We recognize that a collaborative approach from employer and employee is effective. Mr. Yeo Guat Kwang has pointed out that NTUC is actively promoting this. The Health Promotion Board and NTUC will launch a pilot project to reward employees for participating in workplace health activities. Singapore National Employers Federation or SNEF is also HPB's key partner to promote healthy lifestyle in the workplace.

12 Mr. Yeo raised the issue of mental wellness of workers. Stress is a concern and mental wellness is important to work effectively. HPB conducts public education programs on stress management and managing depression for workers, students and the elderly. The Institute of Mental Health has plans to implement an Employee Assistance Programme to provide confidential counseling either through the telephone or in person for employees.

Medical and healthcare manpower

13 We have a number of questions from MPs on medical manpower, training, morale and communication skills. One key challenge is to safeguard our medical standards whilst we strive to achieve optimum numbers of skilled and competent healthcare professionals to meet the healthcare needs of Singaporeans and support the regional medical hub. Healthcare manpower is highly skilled and takes many years to train. There must be the right mix of skilled manpower - doctors, nurses, pharmacists, therapists and health science professionals because healthcare is an industry that has many parts and specialized disciplines. All must move together for smooth progress.

Protracted Training required

14 The protracted training required to develop these professionals poses a major challenge in managing manpower. It takes up to 12 years from an entry medical student, to become a medical specialist; and perhaps another 10-12 years to reach the pinnacle of excellence in the specialty. 3-4 years is required to train entry-level practitioners for the various other healthcare professionals like nurses and therapists. But it takes many more years of training and experience to produce highly skilled nursing professionals and therapists. There are no quick-fix solutions, but we are enlarging our local base of professionals as well as drawing talent from overseas.

Raising intake of students

15 We have raised the annual intakes of students. For example the intake of medical students in NUS has risen from 150 in 1996 to 230 in 2003. We have also lifted the quota on the number of female medical students and for the 2003 intake, about 43% were females. We have also recognized more overseas medical schools - from 24 to 71 schools in 2003. For the past three years an average of 100 doctors from recognized overseas medical schools were registered per year. The Singapore Medical Council has also allowed the clusters to employ doctors with non-registrable degrees under temporary registration, provided such doctors are very closely supervised. For the past three years, the total number of such doctors registered average 120 per year. The 13.9% vacancy in junior doctor positions in the last quarter of 2002 was reduced to 6.2% in the last quarter of 2003; to put in another way, the number of filled positions had risen from 1470 to 1656. For medical specialists, although there is a 40% specialist cap, we are still some way from reaching this as specialists presently only comprise 35% of all fully and conditionally registered doctors in Singapore. With the development of the regional medical hub, we will require more specialists to provide good quality care both in the public and private sectors as well as to moderate health care cost increases.

Nurses

16 For nurses, the intake of nursing students into the Institute of Technical Education (ITE) had increased from 146 in 2001 to 204 in 2002 and 238 in 2003. Nanyang Polytechnic (NYP) had also an increased intake of nursing students from 588 in 2001 to 707 in 2002 and 854 in 2003. More lecturers are being recruited by ITE. NYP is also actively recruiting clinical instructors. NYP had increased the number of lecturers and clinical instructors from 73 in 2001 to 87 in 2004. In the short term, they have not been able to fill every vacancy for clinical instructors yet because of a general shortage of nurses.

17 The clusters continue to recruit foreign nurses to supplement locally trained nurses from Nanyang Polytechnic (NYP) and the Institute of Technical Education (ITE). Measures will be implemented to reduce the attrition rate of foreign nurses and to encourage the better ones to commit to a long term career with us. A new work pass, which will replace the existing Q2 pass, with effect from Jul 04 will benefit many foreign nurses by allowing them to bring in their dependants. This may help to retain good nurses. MOH is also looking into reducing the waiting time for good foreign nurses to obtain permanent resident status.

18 Vacancies for nurses in public sector institutions have been reduced from 4.1% in 2002 to 2.4% in 2003. The number of public sector nurses increased from 8575 in 2002 to 9065 nurses in 2003. The attrition rate of public sector nurses in 2003 was high, about 14%. The two healthcare clusters have targeted to reduce the attrition rate to 10% by 2005. A multi-prong approach is being taken to achieve this, including balanced work schedules, job redesign, improving career pathways, training and development programs and review of nurse's salary to ensure competitiveness.

19 In developing healthcare manpower, we have heard much about other professionals and retrenched workers who switched vocations to enter healthcare. The Strategic Manpower Conversion Programme (Healthcare) implemented by MOH and the Singapore Workforce Development Agency (WDA) is for mid-career workers who want to take up job opportunities in the healthcare sector. Under this programme, mid-career diploma courses have been launched to train registered nurses and diagnostic radiographers. The trainees are provided with full sponsorship and a training allowance. The first two batches of 109 trainees are undergoing the 2-year accelerated diploma in nursing at Nanyang Polytechnic and for the third batch starting in July this year, the target is 100 new trainees. Half of the trainees already have university degrees and the feedback on the programme has been positive. NTUC and the National Heart Centre have also launched the Skills Training and Employability Enhancement for Retrenched Workers or STEER, for training of Enrolled Nurses, Healthcare Assistants and Health Attendants. There are a total of 215 trainees for STEER, out of which 114 trainees have graduated from the Healthcare Assistant and Health Attendant programmes, and 101 trainees are currently undergoing the training for Enrolled Nurses (44 trainees), Healthcare Assistants and Health Attendants (57 trainees). There are also on-the-job programs run by ITE together with participating healthcare employers. These include various types of ITE Skills Certificate in Healthcare including outpatient, inpatient, homecare and clinic practice skills which takes one year to complete as well as a similar Skills Redevelopment Programme which takes 9 months to complete. ITE also run short skills based programs of 3 months for health service, housekeeping operations and patient service and a 6 month course on Rehabilitation Therapy.

Morale of Doctors

20 We believe that the morale of our healthcare workers is good or even excellent. Our regular 6-monthly survey of doctors indicated that over 90% of medical officers are satisfied with their work and postings. Doctors have traditionally worked long hours. During my years as a trainee, I routinely worked more than 100 hours a week for many years. Because this was a historical practice, it does not mean that we should carry on making our doctors work long hours. All over the world, in the US and Europe, steps are being taken to reduce the working hours of junior doctors. We too are gradually reducing their working hours. In terms of reduction of hours, in 2003, 18% of our junior doctors in public hospitals performed more than 6 night calls per month, compared to 26% in 2002. Our medical officers currently work an average of 60-65 hours per week. The clusters are also making efforts to ensure that junior doctors do not work more than 30 hours continuously. We cannot change the working hours dramatically overnight, because it will affect patient care. But as more young doctors graduate from our medical school, the working conditions of our young doctors will continue to improve over the next few years.

Training of doctors in the Hospitals

21 Are senior hospital doctors too preoccupied with daily workload that they have no time to teach the junior doctors? MOH survey of medical trainees in 2003 showed that over 70% of the trainees gave high ratings on the supervision received from their seniors. The survey showed that trainees have been given time for training and almost 90% of trainees indicated that they participated in various organized learning activities. The workload of the trainees were not onerous as more than 60% of the trainees saw fewer than 20 patients per day in the wards, while about 70% of doctors saw fewer than 60 patients per week at specialist outpatient clinics. We are assured that on the whole, there is a satisfactory level of supervision and training for our trainee doctors in the hospitals.

Communication skills training for doctors and nurses

22 The good practice of medicine requires good inter-personnel skills. EQ is as important as IQ. Communication skills and the ability to empathize are skills needed for good medical practice. We can teach communication skills, but empathy must come from the heart. Medical students in Singapore undergo a communication skills programme to enable them to communicate effectively with patients and relatives. This comprises many hours of course work lectures, role-playing and mentored interaction with patients. The programme, administered by the NUS Medical Faculty together with the Faculty of Business Administration, supplements the students' practical exposure to communicating with patients during their 3-year clinical postings. For practicing doctors and trainees, programs on communication skills are organized by the Healthcare clusters, NUS and professional bodies like the Singapore Medical Association (SMA) and College of Family Physicians. Experienced GPs and family physicians are involved in such programs. Nursing students in the Institute of Technical Education (ITE) and Nanyang Polytechnic (NYP) undergo course modules on communication skills which are also acquired in practice sessions and clinical postings. Good senior clinicians serve as role models who teach our young doctors to understand the human condition and empathize with patients.

Further Nursing Education, sponsorships and the nursing degree programme

23 To upgrade the skills of nurses, the clusters have a sponsorship programme for Diploma training for nurses. Nurses who are working for VWOs under MOH funding can also apply for training sponsorship from MOH if the training is relevant. MOH provides funds under the HMDP for the upgrading of training of public sector healthcare nurses. This has resulted in an increasing number of nurses doing fellowships in well known overseas centers, - about 50 nurses in 2002 and 60 nurses in 2003. Under the Visiting Experts programme, nursing experts have been invited to teach nurses in specific nursing skills. The Ministry of Health together with the Ministry of Education is currently considering a degree course in Nursing at the proposed Outram Campus.

The Health Manpower Development Programme

24 The continuous training of health professionals is essential to provide high quality healthcare services. The Health Manpower Development Programme (HMDP) has a Fellowship scheme, through which doctors are sent to eminent centers overseas for training, as well as the Visiting Experts scheme, where top foreign experts are invited to train local professionals. About 45 visiting experts are invited annually to train our health professionals in the various healthcare disciplines. The budget for the HMDP Fellowship and visiting experts is about $6.5M per year.

CONCLUSION

25 All of us want Singapore to enjoy the best healthcare in the least expensive way. This is my Ministry's goal. We want excellent doctors, excellent nurses, and excellent allied health professionals like therapists, radiographers etc. We also want a logical well structured system that will draw out the best of what our healthcare professionals can offer. We want to remain healthy and not see health professionals if we can. But should we need to seek medical care, a family doctor should be our contact point with the healthcare system. We must encourage all Singaporeans to have a primary physician who can advise and guide them on healthcare matters. Healthcare is not just the concern of the government and healthcare professionals. All Singaporeans have a part to play to ensure that the healthcare system continues to be both efficient as well as of high quality.