Deep changes in social spending

Finding a cure for rising costs in healthcare

Occupational therapist Giang Thuy Anh, 28, with a patient during mobile horticulture therapy in Yishun Community Hospital's acute geriatric ward. The programme, which takes plants to the patients' bedside, was started last year to improve their level
The dining lounge in Yishun Community Hospital's acute geriatric ward, which is managed by Khoo Teck Puat Hospital. Come 2030, those aged 65 and above will almost double in number to comprise a quarter of Singaporeans.ST PHOTO: LIM YAOHUI
Occupational therapist Giang Thuy Anh, 28, with a patient during mobile horticulture therapy in Yishun Community Hospital's acute geriatric ward. The programme, which takes plants to the patients' bedside, was started last year to improve their level
Occupational therapist Giang Thuy Anh, 28, with a patient during mobile horticulture therapy in Yishun Community Hospital's acute geriatric ward. The programme, which takes plants to the patients' bedside, was started last year to improve their levels of cognition and better engage them.ST PHOTO: LIM YAOHUI
Staff at Care Line, a 24/7 helpline run by Changi General Hospital, which seniors can call if they need help such as medical attention. It was launched in the eastern region in November 2016 and was expanded to cover Tanjong Pagar and Radin Mas this
Staff at Care Line, a 24/7 helpline run by Changi General Hospital, which seniors can call if they need help such as medical attention. It was launched in the eastern region in November 2016 and was expanded to cover Tanjong Pagar and Radin Mas this month.ST PHOTO: SEAH KWANG PENG
Staff at Care Line, a 24/7 helpline run by Changi General Hospital, which seniors can call if they need help such as medical attention. It was launched in the eastern region in November 2016 and was expanded to cover Tanjong Pagar and Radin Mas this
Health Minister Gan Kim Yong advocates raising the re-employment age beyond 67 gradually and lifting it altogether eventually, but adds that it is better to work with employers in a collective effort on this issue.ST PHOTO: BENJAMIN SEETOR

The health budget in two years is expected to be almost on a par with that of defence now, traditionally the biggest government spending item. Even as spending has to go up, Health Minister Gan Kim Yong maps out to Insight Singapore's strategy for keeping cost increases under control.

In 2011, Dr Wong Sweet Fun and her colleagues from the newly set up Khoo Teck Puat Hospital (KTPH) in Yishun began seeing a trend of high re-admission rates, especially among elderly patients and those with chronic conditions.

It turned out that a lack of coordinated care and support for patients - such as follow-up visits by doctors and nurses in their homes - prevented them from taking charge of their health, says the 57-year-old senior consultant in geriatric medicine at KTPH.

A programme to address this was launched the same year. Among other things, it sends nurses to patients' homes to provide follow-up care. As a result, the average six-month re-admission rate for the first 400 patients on the scheme was slashed by over 60 per cent.

The increased emphasis on primary care and prevention is an outcome that might give heart to policymakers trying to work out how to pay for ballooning healthcare costs, which are in the spotlight ahead of next month's Budget, amid talk of raising taxes.

Come 2030, those aged 65 and above will almost double in number to comprise a quarter of Singaporeans.

And in two years, healthcare spending is expected to be almost on a par with that of the budget allocated to the Ministry of Defence currently - traditionally one of the highest among all ministries.

This, even as countries in the region spend more than ever on defence amid terrorism and cyber security threats.

But while healthcare costs go up, given Singapore's ageing population, a quiet revolution in healthcare spending policy is taking place to stop spending from ballooning.

REBALANCING ACT

One big effect of this demographic clustering will be a shift in disease patterns towards chronic diseases.

Whether this pattern occurs at a slower or faster pace depends on whether Singaporeans can stay healthy, and the Ministry of Health (MOH) is taking steps to encourage this.

Just as how the Education Ministry espouses the belief that "every school is a good school", Health Minister Gan Kim Yong says that "all doctors are good doctors".

Just two in five Singapore residents now see a regular family doctor, as some still think that hospital specialist care is superior, and some hop between doctors.

However, Mr Gan wants that figure to go up to five out of five eventually, including those who see a regular team of healthcare professionals.

When that happens, primary care can become the bedrock of Singapore's healthcare system, with chronic conditions managed by a network of general practitioners (GPs), polyclinics and community organisations, while hospital services are tapped only in cases of need - a shift away from the current more hospital-centric model.

When GPs and polyclinic doctors see patients at the start of chronic ailments, they will be able to delay or prevent the progression of these diseases into more complex conditions that will cost a lot more to treat in hospital. For example, uncontrolled diabetes may lead to kidney failure and stroke.

 

Seeing regular family doctors ensures continuity. A closer, trusting relationship between the patient and a regular team of healthcare professionals will lead to more personalised management of their various conditions. This results in optimised treatments and, ultimately, lower healthcare costs.

To tip the scales in this rebalancing act, MOH is investing more in primary care.

For example, subsidies under the Community Health Assist Scheme - catering to lower-and middle-income patients who see private GPs - have been enhanced over the years.

Private-public healthcare collaboration is also being encouraged.

Just as how the Education Ministry espouses the belief that "every school is a good school", Health Minister Gan Kim Yong says that "all doctors are good doctors".

A scheme where hospitals get funding support to refer stable patients from specialist outpatient clinics to GP partners was initiated by MOH in 2014.

Last year, it rolled out a scaled-up primary care network scheme to GPs, after being piloted in 2012.

These groupings allow individual doctors to pool resources and offer services such as health counselling provided by their nurses, and eye screening for diabetics, which they would not be able to provide on their own.

There are now 10 such networks, with 340 GPs on board.

Of course, it is all the better if Singaporeans can remain active and keep visits to the doctor at bay.

Sometimes, all it takes is one simple step, says Mr Gan, who is also chairman of the Ministerial Committee on Ageing.

An opportunity to start doing so was just a few metres away from his office on the third floor of the College of Medicine building in Outram, where a broken-down lift forced staff and the 58-year-old minister to take the stairs earlier this month.

He says: "(This) is a good thing. So I joked with the staff, 'Maybe we should never repair it, just leave it as it is and we walk every day.'"

THE DOLLARS BEHIND THE DECISIONS

In Budget 2017, $10 billion was allocated for healthcare expenditure, and the amount is expected to go up to at least $13 billion by 2020.

This will rival the $14 billion and $12.9 billion allocated to defence and education expenditure in Budget 2017 respectively.

Between 2010 and 2015, the Government's share of overall national healthcare expenditure, including private healthcare costs, grew from about 35 per cent to more than 40 per cent. As a partial result, the share of the individual's contribution fell from about 40 per cent to about 30 per cent.

 

In terms of finances, maintaining a balance between three components - individuals paying, risk-pooling through insurance schemes such as MediShield Life and, finally, government subsidies - is critical, Deputy Prime Minister Tharman Shanmugaratnam tells Insight, adding that the Government currently pays for 70 per cent of the subsidised healthcare system.

On whether the Government's share of the bill will rise above the current 70 per cent, Mr Gan says: "It may be 70 per cent, it may be 60 per cent, it may be 80 per cent, we don't know."

He noted that this will include capital expenditure, such as the costs of building new hospitals - three of which will be ready by 2020.

The Government should never wind up paying for 100 per cent of subsidised healthcare, because this creates a "pretence" that healthcare is free in Singapore, warns Mr Tharman. "If you go to 100 per cent, it means people will just pay vastly more taxes."

TOUCH AND HOLD, NOT TOUCH AND GO

When 45-year-old MOH deputy secretary for development Teoh Zsin Woon was in primary school, the way in which healthcare was delivered to students via the School Health Service operated "like clockwork".

"You get nagged to brush your teeth by the drain (as part of a nationwide campaign), the school asks you to go to the dental clinic, the nurse will come to check your body weight, height and eyes, and they will also get your vaccinations done," says Ms Teoh, who has spent a substantial part of the past year shadowing community volunteers on home visits to seniors in older neighbourhoods.

But as generations before her graduated from schools and started to age within the four walls of their homes, the lack of a standardised model that can bring basic healthcare services to one's doorstep has produced a gap that Ms Teoh dubs "the social last mile".

 

The lines between healthcare and social support have increasingly become blurred, but health and social care providers may not be adapting well to this change on the ground, she notes.

For example, an elderly man living on his own may be able to see the best doctor in a specialist clinic, but all that comes to nought if he forgets to take his medication, or if there is nobody to take him to the doctor for regular appointments.

Another elderly woman may have bought a blood pressure monitor, but her condition will not improve if she is not taught how to monitor her blood pressure daily.

Such a "touch and go" approach where specific responsibilities are neatly delegated to different institutions has to go when it comes to helping elderly patients, she declares.

In its place, institutions must "touch and hold" - wrap a patient into the embrace of various care services that can detect and coordinate services around his needs, instead of subjecting him to the impossible challenge of navigating a complex labyrinth of services on his own.

Ms Teoh is now hawking a set of "ABCs" in her push to address this gap: Active ageing, Befriending, and Care and support.

One of the initiatives under this vision is MOH's Community Network for Seniors scheme, which was piloted in April 2016 and aims to enhance integration and the pooling of resources for services related to the elderly.

It has linked up more than 600 seniors who live alone with befrienders or volunteers, and referred about 800 seniors with complex needs to MOH. But problems remain, such as the duplication of efforts in some areas and the under-detection of other needs.

"We are definitely not there yet," she admits. And time is not on her side, as MOH needs to ramp up its efforts to meet Singapore's increased demand in this area by 2030.

But even as hospitals are being built and options for assisted living services or developments are being studied, the delivery of care, she stresses, does not have to hinge on the existence of bricks-and-mortar facilities or even the headcounts of doctors and nurses.

By working with partners such as Pioneer Generation Ambassadors, MOH can detect what are the needs on the ground, and direct services and resources to available community spaces. For example, exercise programmes for the elderly conducted by the Health Promotion Board need not be restricted solely to senior activity centres.

They can also be done at residents' committee centres or community clubs in neighbourhoods with elderly people who have not been keeping active.

Instead of building hospitals nearby, new community nursing posts can also be set up in these spaces to help elderly patients manage chronic conditions.

Age, she says, is relative, pointing out how 70-year-olds are able to care for 100-year-olds in resilient communities such as in Japan, and how older volunteers are commonly seen in community befriending programmes for seniors here.

Her minister agrees.

In fact, Mr Gan advocates raising the re-employment age beyond the current 67 years old gradually, and lifting it altogether eventually.

Seniors who are willing and able to work should be allowed to do so for as long as they want, even as he also wants to encourage senior volunteerism for those who do not want or need to work.

These are "important issues" that he discusses from time to time with Manpower Minister Lim Swee Say.

Asked why the re-employment age cannot be removed right away, he says that this would be a burden on employers, given that current laws prescribe that employers have to provide an Employment Assistance Payment if they are unable to offer re-employment to eligible employees who turn 62.

"It is better for us to work with the employers now in a collective effort, and that has always been the way we work with employment issues - in a tripartite manner," he says.

Other improvements to the integration of community health and social services are under way.

This month, MOH and the Pioneer Generation Office began organising "kampung meetings", where staff from the regional health systems, community nurses, social service organisations, the People's Association and senior activity or care centres are brought together to share plans and coordinate the services that can be offered or hosted by various organisations.

Care Line - a 24/7 telephone helpline for seniors launched in the eastern region in November 2016 - was expanded to cover Tanjong Pagar and Radin Mas this month.

Ms Teoh says she is unsure if she can ever declare success in such efforts, as new needs will emerge along the way.

She adds: "But we are trying to take a perspective that is no longer institution-centric, and provide seniors with a service that is equivalent to what was offered by the School Health Service in the past."

A version of this article appeared in the print edition of The Sunday Times on January 28, 2018, with the headline 'Finding a cure for rising costs in healthcare'. Print Edition | Subscribe