Opening Ceremony Of Singhealth Scientific Conference

15 Oct 2004

By Mr Khaw Boon Wan , Minister for Health

Venue: Shangri-La Hotel

Last month, I was in Shanghai to attend a WHO Regional Meeting. There were two dozen health ministers there, many from the South Pacific. I felt pretty good in their company. I asked them about their population size. One said: 2,000, another, 12,000. It made me feel like a little giant among them.

Over 5 days, the underlying theme was how to raise the quality of healthcare while cutting cost.

Bottomless Pit: Insoluble Problem

This is of course not new. It has been hotly debated for years. Meanwhile, healthcare cost continues to balloon. Forty millions Americans have fallen out of medical insurance. Companies are crying out against ever-rising insurance premiums.

Healthcare seems like a bottomless pit. You can keep pouring in resources, and it will still hunger for more. The simple reason is that there is no limit to scientific discovery. As medical science creates new drugs and new equipment, while extending life, it generates new demand for more resources. Its very success deepens the pit.

Is there a way out? I will be dishonest if I say that we can solve the problem of rising healthcare cost. Nobody has done it. I will be dishonest if I say that we can make ALL healthcare services affordable. No country has achieved that.

Americans are spending nearly 15% of their huge GDP on healthcare. But it continues to grow. Sadly, despite such heavy investments, barely one in five Americans thinks that their healthcare system works well.

No Illusion

So we must not have any illusion that we are special and we can solve this problem. Realistically, we can only seek to partially manage the problem, by acknowledging its gravity and learn to live within our means. It means setting priorities; it means rationing.

Not all demand can be met. In fact, not all demand implies a genuine clinical need. 3D or 4D ultrasound picture of the fetus in the womb is clearly not clinically indicated. So we must never subsidise it. But if you are prepared to pay in full, we may provide it.

Setting priorities has to be a collective effort, involving the government, the people, the private sector, the NGOs and VWOs. Collectively we prioritise and try to stretch every health dollar available to us. We must not waste precious health dollars on non-essentials. We must make sure that every precious health dollar goes to generate maximum benefits.

To succeed, we need everyone to play his part: patients, relatives, doctors, nurses, administrators, politicians, practically everyone.

The Art of Lexus

While there are no complete solutions to this problem, we must not simply give up and carry on as before. Outstanding societies achieve outstanding performance because they strive for the seemingly impossible. We too should aim for good AND affordable healthcare.

We should aim to lower our cost AND yet expand our lead in healthcare in the region. We should continue to learn from the best overseas and adapt, NOT adopt, their best techniques and practices and improve on them.

When Toyota decided to build Lexus, they studied the best cars from GM, Mercedes, BMW, to the tiniest details. They then introduced the Lexus offering quality and performance comparable to the established marques, but at competitive prices and became hugely successful. We too can be equally successful in healthcare.

Let me share with you several strands of thoughts to guide us in managing this problem in a more sensible way.

(a) Don't Waste: Shape Up

First: hospitals, as the largest consumers of healthcare dollars, need to shape up to do more with less. They must not become a black hole, sucking in resources in an unrestricted way.

Can it be done? Why not?

How? I suggest we take a leaf from the manufacturing sector. They start with the assumption that they are not perfect. They then apply their minds religiously to seek out better ways of doing things. That is how prices of computer chips keep on falling, while capabilities keep on rising.

While patients are not microchips, there are generic principles in managing productivity and process improvement which are equally applicable in the healthcare sector.

After we published hospital bill size data in the Internet, the NUH paediatricians took a serious look at why their patients with gastroenteritis were treated more expensively than in KKH. Dr Lim Suet Wun sent me this email on their follow up response. "They found they were overusing expensive IV treatment. So they increased the use of nasogastric tube and oral treatment. They also cut down on brand name solutions and used generics. They were also over-testing, so they cut it down where appropriate. Many other things were done. Average length of stay has fallen and patient feedback improved. Bottom line: they have shown improved outcome and lowered their costs."

Dr Lim went on to stress this: "All this has been doctor initiated, with nurses, health science and management backing them up."

(b) Don't Come to Hospitals: Do More Outside

Second, while we should actively pursue process improvements within hospitals, the big breakthrough is likely to happen outside of hospital. Hospitals are complex organisations, inherently clumsy and expensive to run.

Wherever feasible, patients should be treated outside of hospital, in community setting. Day surgeries are excellent examples of such innovation. Years ago, patients undergoing cataract operation had to stay in hospitals for 3 days. Now, these are routinely done as day surgeries, with patients only staying a few hours in the hospital. The saving in resources is significant.

I understand that NCC and NKF are exploring setting up an outpatient chemotherapy centre. The intent is to carry out chemotherapy in a community setting, as a way to bring down cost of delivering chemotherapy. I wish them success.

(c) Don't Fall Ill: Change Behaviour

Third, we are gaining greater understanding of disease prevention. For example, a recent global research concluded that virtually all heart attacks could be predicted on the basis of nine risk factors and these risk factors are the same all over the world, irrespective of race or sex.

Smoking six to ten cigarettes a day doubles the risk of heart attack. Smoking 20 sticks a day raises the risk four times and 40 sticks, nine times. The other risk factors include obesity, low daily fruit and vegetable consumption, a lack of exercise. As you can see, most of these risk factors are within our control. It is in our hands to change our health status, but we have to make an effort, starting from today.

Unfortunately, it is easier to pop a pill than to change behaviour. So I read that Americans are going for obesity surgery, when it would be cheaper and more pleasant to go for aerobics in the gym. That American insurance pays for obesity surgery must have skewed behaviour in a perverse way. We must not go down this route.

In Singapore, we are promoting healthy lifestyle. As healthcare workers, your role is crucial. Patients who are newly diagnosed with some serious conditions are at a most susceptible state of mind to receive advice. As doctors, nurses, pharmacists and therapists, you have many opportunities every day to influence patients to adopt healthy lifestyle. Some doctor friends of mine find it very rewarding to add a few words of advice during every consultation.

For my healthy lifestyle objective, my hope is to "die young, as late as possible". But when the end comes, it will be a good death, and not a painful, lingering and undignified death that bankrupts the family.

(d) Know Our Genome: Custom Make Treatment

Fourth, advances in life sciences and molecular biology can potentially correct genetic defects, cure diseases or even prevent illnesses. Last week, I read in the IHT that scientists are even developing a vaccine to treat addiction to nicotine. As we understand our genome better, we can look forward to individualised treatment, customised according to our genetic makeup.

This is still largely frontier land. But let's hope that the billions of research dollars being pumped into life sciences will lead to real disease prevention and cure, and shrinking healthcare needs. On the other hand, it will be a disaster if such research instead leads to rising healthcare demand, enlarging an already bottomless pit.

(e) We Are Mere Mortals

Finally, we must not allow scientific triumph to get to our heads and colour our judgment. Medical science can keep many human organs alive for days and weeks, never mind the overall quality of life for the patient.

It takes considerable wisdom to acknowledge when we have hit the limit of medical science and when to let nature takes its course. Such decisions are never easy to make. See the recent court case in UK where a High Court Judge had to rule on whether or not to let a critically-ill premature baby die peacefully if she stops breathing, instead of the doctors scrambling to revive her. A sound decision can only be founded on the basis of a strong trust between doctors and their patients. Where patients trust their litigation lawyers more than their doctors, the outcome is senseless defensive medicine, at great cost to society, with little or no value to patient care.

In US, a large chunk of its Medicare budget is spent on the last few days of the terminally ill. A litigious society coupled with a flawed medical insurance system has produced such a sad perverse outcome. We must never reach such a sorrowful state.

To avoid this pitfall, we need strong clinical leadership with sound values and balanced judgment, combining both compassion and reason, treating their patients with both their hearts and their heads. Fortunately for Singapore, we have many such clinicians in our midst.

Conclusion

Fellow colleagues. We work in "an ailing industry", ailing not because of our patients but the industry itself is in need of a cure. Unfortunately, there is no cure. But we can do a lot to mitigate its impact.

As one recent Harvard Medical School article (by Beth Potier of Harvard News Office) put it, we need to "think outside the box for new solutions". How to reinvent primary care? How to fundamentally change medical practices?

Harvard Medical School is tapping Harvard Business School, to initiate skunk works, aimed at fostering the kind of out-of-the-box thinking that could lead to breakthroughs. Reading the Harvard article cheered me up considerably. It means that we are not alone in this search for a solution.

One group "discussed giving patients around-the-clock online access to medical records and promoting peer learning with other patients". Another commented that "Health care is way behind every other industry in terms of using information technology". He added: "The guy at Hertz (Car Rental) knows more about you when you walk up to the counter than your doctor does".

The article went on to say that "From patient-specific Web sites to letting patients schedule their own appointments and e-mail their doctors, the (skunk works) team came up with many ways that technology can smooth this new model of health-care delivery."

These are the same ideas and comments that I have shared with you in the last one year that I am in MOH. So there are many out there who share similar thoughts. We should closely monitor such efforts, even as we make our own contributions to the solution.

Our clusters have similar skunk works in progress. You are familiar with your own cluster's work. So let me quote one example from the NHG cluster. They have teams of doctors and nurses to improve quality AND cut cost at the same time. One such team looked at discharge procedure after day surgery. Usually there is considerable delay, as nurses look for MOs to review and discharge the patients. But the poor MOs are always busy in the clinics or the wards. The skunk works team decided that nurses, properly trained and following prescribed carepath, are fully qualified to do the discharge assessment. The result is a faster, better, cheaper and safe way to do things. Patients, doctors and nurses are happier all round.

We have some of our best brains in healthcare sector. This gives us optimism that the problems are at least being addressed by some of our best talent. But we should have no illusion that there will be a complete solution. What we can achieve is to build a system where we can continually innovate and which incentives rational behaviour.

On this note, I am happy to, declare the SingHealth Scientific Conference open.