Speech by Dr Lam Pin Min, Minister of State, Ministry of Health at Yong Loo Lin School of Medicine Keynote Address 2014 on 5 September 2014

Professor John Wong, Chief Executive, National University Health System

Associate Professor Yeoh Khay Guan, Dean, Yong Loo Lin School of Medicine, NUS

Associate Professor Grace Ong, Faculty of Dentistry, NUS

Associate Professor Chui Wai Keung, Head, Department of Pharmacy, Faculty of Science, NUS

Associate Professor Chow Yeow Leng, Director of Education Alice Lee Centre for Nursing Studies Yong Loo Lin School of Medicine, NUS

Distinguished Guests,

Colleagues and friends,

Ladies and Gentlemen,

1.             Good evening. It is my pleasure to address you - our next generation of healthcare leaders at this year’s Keynote Address 2014. Healthcare in Singapore has come a long way, built on the efforts of our pioneers, and it heartens me to see so many of you stepping forward to take up the torch. You must have heard so much about the pioneer generation package and the speed at which our population is ageing.  I have thus decided to focus my theme on this topic and share how as a nation, we can celebrate ageing.

2.             Our healthcare system has done remarkably well over the past decades, and is admired the world over for our achievements. Our average life expectancy has improved from around 60 years in the 1950s, to 82 years in 2012. According to World Health Organization statistics, we are ranked 2^nd in the world for infant mortality, and 9^th for life expectancy. In 2007, we were ranked 3^rd in healthcare infrastructure in the World Competitiveness Yearbook, and recently, our healthcare system was named as the 2^nd most efficient healthcare system in the world by Bloomberg.

3.             And yet, despite our successes, we must not rest on our laurels. The responsibility lies with us to carry on this tradition of excellence, so that our fellow Singaporeans may live long, live well and with peace of mind. However, there will be many challenges ahead, challenges that are vastly different from those that our predecessors faced. Foremost among these challenges will be our ageing population.

Our Ageing Population

4.              Like most developed countries, ageing is the single biggest demographic challenge for the Singapore Government. The percentage of our population aged 65 and above is about 10% today; but that is projected to double to 20% by 2030. Ageing is a coin with two sides. One side is falling fertility rates, which stands at 1.23 and is probably one of the lowest in the world, while on the other side is actually the increased longevity. With improved nutrition, medical care and technology, we have achieved one of the highest life expectancies in the world.

5.             We have currently 420,000 seniors and this is expected to increase to 900,000 by 2030.  There is serious implication on the society as the old age support ratio will decrease from the current 5.9 to the expected 2.1 in 2030.  The burden on the young working population will be very significant if nothing is done to address this issue.

6.             With a rapidly ageing population, we can envisage two scenarios for the future. The first is one where ageing poses a significant challenge for our country. In the arena of healthcare, elderly patients generally seek acute care services more frequently, and also have longer stays in hospitals. This graph shows the average length of stay and admission rate to our public hospitals by age group, and you can see that both increase significantly with age, particularly the hospital admission rate. This will pose a greater demand on our acute hospitals, and we are already seeing signs of that today.

7.             Our seniors also have greater chronic and long-term care needs. National survey data shows that the prevalence of chronic diseases like diabetes, hypertension, hyperlipidemia and stroke increase with age. The National Mental Health Survey in 2003 also found that the prevalence of impairment in Activities of Daily Living, or ADLs, increases significantly with age. The number of elderly Singaporeans aged 60 and above with 3 or more activities of daily living (ADL) limitations requiring human assistance is expected to nearly triple between 2010 and 2030. In addition, the number of persons aged 65 and above with dementia is projected to more than double from about 20,000 today, to more than 50,000 in 2020. All this added together means that the long term care needs of the population will increase significantly with rapid ageing.

8.             While these trends will result in increased resources and expenditure spent on healthcare, seniors also participate less in productive economic and social activity, causing a double strain on our society and economy. Furthermore, shrinking nuclear families will become increasingly strained in caring for their elderly, and there will be an increasing number of vulnerable seniors, for example, those living alone or with a frail spouse.

9.             So far, I have painted a rather grim picture. It’s how you interpret a half-filled glass of water – is it half full or is it half empty?  There is an alternative scenario. This is the scenario of productive longevity- one where longer years of life is translated into longer years in active ageing, such as in the community or workplace, , while functional and cognitive decline are delayed and seniors spend many happy, fulfilling years free of disability. For our country, this means that our silver generation becomes an added force for social and economic development, and costs of disability and healthcare are lowered.

10.         Is this possible, or just wishful thinking? First of all, we must have a more positive mental map of ageing – chronological age is not just associated with disability. With better education, nutrition, and medical care, the profile of our seniors today is very different from in the past. For example, research has shown that more than 4 out of 5 seniors aged 65 and above have no ADL limitations. A senior with a remaining life expectancy of about 20 years can expect to spend 90% of those years free of ADL limitations.  

11.         In reality, 65 years is not a magical age that divides society into those who contribute meaningfully, and those who become a burden to the society. In fact, the world’s oldest nations are also some of the world’s richest and most productive nations. Nations who will be able to ride the wave of ageing will be those who can successfully keep their seniors healthy, engaged and productive, and tap on the tremendous wisdom and experience that they have accumulated over the years. These include countries like Japan, Germany and Italy.

12.         The challenge we face therefore is not ageing itself, but how we can leverage on the longevity of our seniors to maintain the dynamism of our society. Instead of seeing ageing as a challenge or burden, we must see it as an opportunity and something to be celebrated.

Action Plan for Successful Ageing

13.         The Ministerial Committee on Ageing, or MCA, is developing a national action plan for successful ageing, to make this second scenario a reality. This plan has two aims- achieving increased productivity from longevity in seniors’ third age, and helping seniors to live autonomously and age with dignity even in their fourth age.

14.         The holistic plan will cover 7 diverse areas- lifelong learning for seniors, employment, volunteerism, urban infrastructure, healthcare, retirement adequacy, and research into ageing. It will tackle challenging issues like achieving retirement adequacy for our seniors who are living longer, encouraging senior learning and volunteerism, protecting vulnerable elderly, developing housing options that enables seniors to age-in-place, and harnessing the potential of the people and private sectors.

15.         As part of this plan, the MCA has begun holding a series of public consultations to hear the aspirations and suggestions from Singaporeans on what we should do to collectively plan for successful ageing for our seniors and for ourselves in time to come.  We will also engage voluntary welfare groups, businesses, unions and academia. It is a conversation that involves both old and young, and if some of you have the opportunity to participate in some of the public consultation sessions, I hope you will eagerly contribute.

Health and Wellness

16.         To achieve health and wellness for our seniors, we are working on two broad thrusts. The first is to achieve productive longevity. We are developing a comprehensive framework to achieve better health for seniors, which includes efforts in health promotion at the workplace, where people spend most of their day. For example, we have started a program for taxi drivers at the Woodlands and Loyang Service Centres where health screening is offered to drivers, with personalized follow up with community nurses once they results are ready. We have also started a programme among retail shift workers at Clementi and Yew Tee NTUC, incorporating health screening and workplace safety assessment, and ergonomics education.

17.         We are also developing wellness programmes in the community. The People’s Association’s Wellness Programme was launched in 2008, and has been rolled out to all 87 constituencies at the end of 2012. It features regular health screening, physical exercise programmes and social interest groups to keep seniors physically, mentally and socially active, such as Mahjong and Karaoke interest groups.  There are many other community organizations who are working hard on this front as well. For example, the Council for Third Age promotes active ageing by funding programmes in lifelong learning and senior volunteerism.

18.         We are also actively building Senior-friendly Communities across Singapore, through the City for All Ages project. CFAA’s vision is to create a people movement across the island to build an inclusive and caring environment in every town. The aim is to make Singapore a senior-friendly city, and the best place for our seniors to grow old in. CFAA provides a platform for constituencies to find out the needs of the seniors in their communities and implement ground-up initiatives to address these needs.  In the process of doing so, we want to involve Singaporeans living in each community – whether grassroots leaders, volunteers, merchants, professionals or young people, seniors themselves – in playing a part to build senior friendly kampongs in their communities.

19.         The second thrust is to achieve more patient-centric and appropriate health services for our elderly. We must first recognise that a fundamental paradigm shift is required in meeting the needs of our ageing population. Our healthcare system has been built on our acute hospitals, which have served the more acute, episodic healthcare needs of a younger population well in the past. However, as our population ages, our seniors’ needs will become more chronic, preventive, rehabilitative and palliative in nature, needs which our acute hospitals are not best suited to serve. We therefore we need a fundamental transformation of our models of care, to be less reliant on our acute hospitals, and to provide more integrated, patient-centric care across many different sectors including primary care, community and home care.

20.         This is why we set up the Regional Health Systems or RHSes. Each RHS is a network of healthcare facilities and providers, including an acute hospital, community hospitals, nursing homes, day care centres, primary care clinics, and home care services. The goal of the RHS is to orchestrate holistic, patient-centred care across the entire healthcare continuum, promote preventive care to keep our seniors healthy, and to build up the capabilities of primary and community care. There are currently six RHSes in Singapore, each reaching out to a specific region with unique health needs, depending on their demographic profile.

21.         We are transforming primary care to be more patient-centric and able to better manage chronic diseases. For example, Toa Payoh polyclinic is transforming care based on the NUKA model from Alaska, which emphasizes the importance of team-based care and community participation.  An example of hospital and primary care integration is seen in the NUHS-Frontier FMC collaboration. This is a programme where care coordinators right-site NUH patients who are suitable for further management in the community to the FMC. Patient care is coordinated between the hospital specialist and the family physician at the FMC, with continuity of care maintained through shared care protocols.

22.         In our specialist outpatient clinics and acute settings, we are also striving to achieve more patient-centric care, instead of organ-centric care. Elderly patients often have multiple co-morbidities for which they may by seeing multiple specialists, which can result in fragmented and sub-optimal care. Under NUHS’s Outpatient Risk Stratification programme, run in collaboration with St. Luke’s Hospital, suitable patients admitted to SLH have their multiple NUH SOC appointments consolidated as one single Family Medicine appointment at SLH, in consultation with NUH specialists. This helps give patients more appropriate care, and reduces fragmentation.

23.         Within the Regional Health Systems, we are also actively building up community aged care options, to allow our seniors to age-in-place in a dignified manner. Earlier this year, MOH had announced our intention to aggressively expand capacity in community aged care. We aim to more than increase our nursing home capacity from 9,800 beds at present to 17,000 beds by 2020, increase the number of day care places from 2,500 at present to 6,200 by 2020, and more than double the number of home care places from 4,500 at present to 10,000 by 2020. This will significantly improve the accessibility of services for our seniors.

24.         At the same time, we are also transforming the models of care in the community. We are putting in place more comprehensive home care services to meet the wider needs of seniors and their caregivers at home. For example, earlier this year we added home rehabilitation and home environment assessment to the suite of subsidised home care services. The Interim Caregiver service provides 12-hour, 6 days a week caregiving service to seniors at home post-discharge from hospital, to ease their transition back at home. We are also working on better support for dementia patients and their carers in the community.

25.         Concurrently, the National Geriatrics Services Taskforce, made up of senior geriatricians, nurses and allied health professionals from our healthcare institutions, is also working hard on identifying current gaps in our system of delivery of geriatric services, reviewing international models and best practices, and developing new patient-centred and appropriate models of clinical services and care delivery.

26.         We are also enhancing end-of-life care significantly, for our seniors who have reached the final stages of their lives. Minister for Health Mr Gan Kim Yong recently announced MOH’s Palliative Care Plan, which includes expanding both inpatient- and home-based palliative care services, the development of new National Guidelines for Palliative Care, and efforts to increase the awareness of palliative care services among the public.

What You Can Do

27.         You may be wondering then, what then can you do, as young students and future healthcare professionals? How can you contribute to this national effort, to make our country the best home it can be for our seniors? I would like to leave you with four thoughts tonight.

28.         Firstly, even as students, you can play a big part in community outreach. For example, students from the Yong Loo Lin School of Medicine have been running a very successful programme for elderly living in rental flats in Taman Jurong, where they go door-to-door to perform health screening, and also organize other health education and follow-up activities. Not only has this programme benefitted the elderly, it has also yielded many insights for effective community outreach. I am very encouraged that many of you are also involved in other outreach activities, such as health screening events. I hope such efforts will continue to grow.

29.         Secondly, as you consider your future careers, I would urge you to consider disciplines that are more salient to the needs of the ageing population, such as geriatric and palliative medicine. These disciplines were under-subscribed in the past, but I am glad to note that they have been growing in recent years.

30.         We will also need a significant increase of skilled manpower in the intermediate- and long-term care sector over the next few years, as we ramp up capacity. We will need many more doctors, nurses, dentists, and allied health professionals serving in the community, outside the four walls of the hospitals, caring for seniors who are often needy and vulnerable. I would like to urge all of us to consider contributing to these services in the future, whether on a full-time, part-time or even volunteer basis. It is a fulfilling task which offers the opportunity to make a real difference in seniors’ lives.

31.         But no matter where you end up, to better care for our elderly, we all need to learn to practise what has been called “slow medicine”. This means taking time to understand patients’ needs holistically, not just their medical needs but also their psycho-social, functional and even spiritual needs. It means working in multi-disciplinary teams to meet these needs, instead of in specialized silos. It means slowing down to think about what patients really need, instead of just adding on another medication to their already-long list or ordering yet another CT scan. It means taking time to talk to patients and their families, explaining their conditions and treatment options, and discussing their concerns and care preferences. It means involving the patients’ families and caregivers in the decision-making process, and paying attention to their needs as well.

32.         We must also recognise that there will come a point in everyone’s lives where  more aggressive treatment, more high-tech interventions, will only needlessly prolong suffering, instead of improving quality of life. And at that point, we need to know how to help patients run their last lap with comfort, humanity and dignity. I trust that this is what we would want for our own selves, and our loved ones. This means that all of us need to have at least some basic knowledge in end-of-life care, and to be comfortable in talking about these issues with patients and their family members.

33.         Thirdly, we need more research into the area of ageing. We need to better understand the medical and psycho-social needs of our elderly, and the interventions and methods of care that are more effective in improving their health and well-being. We need to know how to improve preventive care for the elderly, and delay functional and cognitive impairment as long as possible. You don’t have to wait until you have graduated for this- in fact, I note that many students are already engaging in research and even publishing papers in international journals.

34.         Finally, just as we are trying to change the conversation to celebrating ageing, we ourselves need to change the way we look at our seniors. We must never see our seniors as a burden, but as an integral part of our society whom we must do our best for. Our seniors, faced with the uncertainty and challenges of ageing, are often worried and fearful. We need to journey patiently with them, to bring reassurance and comfort.

35.          As healthcare professionals we can go even further, to be advocates for our seniors. We, who will so often interact with seniors in our day-to-day work, can speak out for and champion their needs. And on a personal level, we must do our best to help the seniors that we know, whether family or friends, to live life to the fullest, and in so doing inspire others to follow suit. We must treat them with the love and respect that they truly deserve.

Conclusion

36.         In conclusion, while the situation of an ageing population is not unique to Singapore, we have the opportunity to make Singapore the best place in the world to age in. We want to be a country where our seniors are cherished, where ageing and longevity are celebrated, and where our seniors live long and fulfilling lives. As young people and future members of the healthcare profession, you can play a huge part in building a Nation for All Ages for our seniors.

37.         Thank you.