Thought of the day

I thank whatever gods may be / For my unconquerable soul. / I am the master of my fate / I am the captain of my soul. ~William Ernest Henley, Invictus

Government's promises are like the Ringgit, they depreciate with time.

Tuesday, August 18, 2009

National Day Rally speech (Part 2 - Healthcare)

We are preparing for our long-term future by strengthening our social safety nets. After food and shelter, I think good health is one of the most important basic requirements which human needs have.

It's more important than money. Singaporeans know that we have good doctors, good hospitals. Their worry is whether they can afford it, especially in the future after they retire and grow old. Actually it should be after they grow old and retire.
We have done many things to mitigate this worry. We have a 3M (Medisave, MediShield, Medifund) system designed precisely to keep healthcare affordable to all, even and especially the low income group.

And we've steadily improved & upgraded & extended the 3M system so Medisave now covers long term outpatient treatment, MediShield now provides higher insurance payouts, Medifund, we've increased the amounts, it's giving more help to the needy to settle their outstanding hospital bills.

So as a result MPs see fewer cases of residents unable to afford health care and medical social workers report that the Medifund is adequate to cover hospital bills.

We will continue to improve this and to widen the 3Ms progressively but we have to do it carefully because we want to keep the system working and there are pitfalls.

But I know that Singaporeans are still concerned. We see medical science advancing, we see new technologies, new drugs, new procedures, people can live longer, but it costs more.

And those who are in their 50s looking after aged parents, they feel the burden and they wonder what will happen to me when my turn comes. They ask: 'I'm all right now, what about the future?'

We need to gear up our health care systems to prepare for this ageing population and we are doing that.

So today I'd like to explain the implications of our ageing population and how we are preparing our health care system to cope. What does it mean when we say our population will be older? It means there will be more demand on health care because older people are sick more often.
But also means it's a different pattern of health care. Younger patients don't go to hospital so often. When they go to hospital it's an acute problem which can be treated within a few days and then they go home well.

I remember I was admitted to hospital once as a teenager for an appendicitis operation and my doctor who was a wise old man said, I'm so happy to treat you because you're a young man, I treat you, you will go home well.

When I treat my older patients, I see them, they get better, after a while they come back again and I have to treat them again. It's much more complicated.
But now we have many more older patients who are admitted more frequently with multiple complaints. After a few days in hospital their acute condition probably has stabilised, they no longer need intensive and complex treatment but they are still not well enough to go home.

You may not need to have their heart monitor, you may not need to have the blood, oxygen monitor, you may not need to have the nurse look at your every two hours or the doctor look at you twice or three times a day but you're not quite ready to go home and you still need several weeks to recuperate and to get better before you can be discharged.

After they go home they may still need continuing medication for underlying long-term conditions. Maybe they have diabetes, maybe they have heart disease, they may need aspirin, they may need statin, so many things which you have to take not just when you are sick but for the rest of your life. And even when you're at home, you may get sick again and you may have to come back again.

So we have to respond to this by putting in more resources into our hospital system, building new hospitals. We got the Khoo Teck Phuat Hospital coming up in Nee Soon, we've got Jurong General Hospital coming up in the west, and that's good.

Well, the buildings are easy to do, getting the people to man them, the doctors, nurses, specialists, physiotherapists, that takes more doing but we are in the process of doing that. It needs money. We are in the process of increasing the budget too.

We need to improve our 3M system. We're doing that too. All these are necessary but by itself more is not the solution to the problem. Because we also have to get the whole system to be structured properly so that it will be adapted to cater to the ageing population and to structure it properly, it means we need step-down care.

What is step-down care? I think Khaw Boon Wan has been talking about this for some time but let me explain it again because it's a vital idea and a crucial part of our solution.

Step-down care means slow medicine: community hospitals, nursing homes, GPs doing more work, home care, people taking care of sick people at home, organised properly. all this can provide competent, appropriate care especially for the elderly patients.

Step down care today is provided mostly by VWOs. They do an excellent job but they will need government help to deal with more elderly patients.

And one key thing we must do with this step-down care is to link up our acute hospitals, Tan Tock Seng, Khoo Teck Puat Hospital and so on with community hospitals, together.

And that they can, so that you can have the best of both worlds. Patients are sick, they go to the acute hospitals, they need fast medicine, ICU, MRI, surgery, all the, in cases, intervention and high tech medicine.

Then after they get better, they go to the community hospitals, Ren Ci, St Andrews Community Hospital where there are doctors and nurses who can look after the patients and you have physiotherapy and occupational therapy and rehab but they don't need the high-end medicine.

The patients go there, they receive slow medicine, they take some time, get well enough to go home. If in the slow medicine case, you need fast medicine, you shift back to the acute hospital, doctor can see to you.

And that way you get appropriate care, you save money & we also free up beds in the acute hospitals for more cases which need to be admitted.

This is all in principle but just to understand what it really meant, I decided to go and have a look by myself. So I went to visit the new Ren Ci Hosp which is co-located with Tan Tock Seng.

And here you can see Ren Ci on the left and Tan Tock Seng in the background on the right hand side and behind. Ren Ci has new management and they are working with Tan Tock Seng to realise this new arrangement.

Tan Tock Seng will guide the medical care of patients at Ren Ci, the 2 hospitals will be connected together soon with a bridge so you can just wheel the patients across, you don't need an ambulance & Ren Ci will maintain its community outreach.

It's got many volunteers and these volunteers do a very valuable job helping to keep patients active and happy. And here you see the volunteers helping the elderly lady get her muscles controlled and built up again, practising fishing for something, and cheering her up.

So I think Tan Tock Seng, Ren Ci is a good model. Other acute hospitals should also tie up with community hospitals in the same way.

Changi already partnering St Andrews Community Hosp in the east. We will build similar sister community hospitals to match Khoo Teck Puat Hospital in the north, to match Jurong General Hospital in the west.

And this arrangement will draw on the strengths of both parties - govt professional teams delivering high quality care & VWOs, good at pastoral care, community outreach.

But the community hospitals cannot be the end of the story because you cannot stay in hospital forever, you must go home.

You want to go home. And patients are best discharged home as soon as possible so that they can be with their families, so that they can be in familiar surroundings, they'll be more comfortable, happier, much better & cheaper than leaving them in the hospital.

I think families want this too but at the same time, families tell us and we know that it can, they need some help and support at home very often because they need caregivers and maids and the caregivers and maids may need some professional training to look after the seniors.

They could require nurses to visit them more frequently, check on the patient's condition, refer back to doctors in the hospital if necessary.

Nowadays nurses can do many things. Nurse comes, attaches the sensors, reads an ECG, emails back to the doctor, doctor can make a reading & then adjust the prescription or if need be, call the patient back.

Home Nursing Foundation is doing good work in this respect and I think they need to ramp up, we need more of this. GPs need to do more things with patients at home, monitoring and supervising their care.

So we want people at home, we would like to help you to have your patients at home and we are working on upgrading home care. It's one of MOH's priorities.

This is not sexy, glamorous medicine but this is how we can help Singaporeans look after their elderly, look after ourselves when we are elderly, look after our healthcare costs. We have to think about the whole system, provide the right treatment at the right place to patients with different needs.

So I hope that doctors will give full support to this. I hope the step-down care and VWOs will also work together with this because they are crucial.

And we also need the patients' cooperation & support. Please don't insist on being in the high acute hospital getting high-tech fast medicine.

If the doctor advises you that you'd be ok, go to the community hospital, it's more suitable, you get better, more appropriate treatment. So we need everybody to cooperate so that we can deliver good, affordable healthcare & benefit all our patients.

This is what the doctors and the hospitals can do.

But I think one important business in medicine, in healthcare is what we ourselves can do to stay healthy, by maintaining healthy lifestyles.

I think you know what to do because every teacher tells children in school, and we tell you this all the time: eat more fruits and vegetables, exercise regularly, don't smoke, keep your weight down.

It's easy to say, very hard to do. And I was reading one doctor lamenting how difficult it is to persuade people to lose weight in America where they have a big problem.

And she said: I advise my patients to lose weight. Then my patients look at me. And I said: Yes, I know but please try.

So please try. It's a change in attitude. You need lifestyle changes. It requires discipline, perseverance. So lectures & speeches won't work. Necessary but won't be enough. The best way is to harness social links & interests to help individuals to stick to their good habits.

So we have community programmes which combine fitness with fun, with social activities. Brisk walking clubs. I think Northwest CDC has got a very popular activity going.

Qigong groups. Here's one group, all races participate. And so on.

One innovative scheme which encapsulates neatly what we need to do is the Wellness programme which Lim Boon Heng has been promoting & piloting in Jurong as well as a few other constituencies, with three components:
Medical check-ups, regular exercise and social networking. So it becomes fun. And here you see the seniors are the ones who are dancing, not the ones who are looking.

I think they are enjoying themselves. Successful, popular. I went to visit the one in Jurong.

And what really struck me was that all the seniors were cheerful & enjoying themselves, happy.

So we will progressively expand this to cover the whole island. And we will reach out to more seniors so that we will help them to stay well & stay healthy.

Before I leave healthcare, let me just talk briefly about H1N1. That was at the beginning. That has been a big challenge for us these four months.
I'm very glad that Singaporeans have responded well to this unexpected virus. We were very worried when the news first broke in April of Swine Flu in Mexico. We knew it would reach us very soon but we knew very little else - How dangerous was it? How treatable was it? How badly would we be affected?

So at the onset we reacted strongly. We raised our alert status to Orange. We did temperature scanning at entry points, masks and gowns in hospitals and clinics, we did home quarantine for suspects. And many people home quarantined themselves after they came back from overseas.

Very soon it became clear that H1N1 was different from SARS - more contagious, fortunately less deadly. So we stepped down, orange to yellow, but we kept up our efforts to block the virus, to delay community spread, to buy time. So we wouldn't be overwhelmed by a huge spike of cases overnight.

The whole of Singapore responded. The whole of the population responded. We had learnt our lessons from Sars. And we succeeded in delaying community spread, and slowing the impact on us.

Perhaps we were lucky but I think what we did made a difference. I'd like to thank everyone who was involved in this - the doctors and nurses, the hospital staff and GPs, those taking temperatures at the entry points, teachers & principals in our schools & kindergartens health officials and so many more, you worked under a lot of stress, there must have been some worry, concern over what the dangers might have been, but you didn't shirk from your responsibilities, you continued to perform under pressure.

There was even one case where neurosurgery had to be carried out and the surgeon carried out the neurosurgery fully garbed up in PPE (personal protective equipment): gown, N95 mask and did brain surgery.

I think Singapore owes this team and all of them a debt of gratitude.

This is how our health care system should work, not just against flu but all the time and for our long-term well-being.

We have a good health care system, universally available and affordable to all. It is the envy of many countries.

The Americans spend five or six times as much as us, their outcomes are worse, the British spend maybe double or three times what we do, their outcomes also not as good, and when they analyse their systems they tell their people: the closest model to what they want to be is what Singapore is, with the 3Ms.

So we have a good system, we must improve it but don't upset it and discard it because we are doing right and good by our people.

We will be ready for an ageing population. Each of us will also play our part to stay healthy and well and that's the way for Singaporeans to enjoy not just long life but good health and active golden years.

No comments: