Last December, I came across an article in Zaobao titled “Old Man Living Alone Has Lingering Concerns” (独居老伯 心有牵挂). It describes an old man, Mr Huang Ji Fu (黄吉富), who lives alone after his wife had a stroke. She had to be admitted to a nursing home because he was unable to take care of her at home. His thoughts were however never far from her.

As our population ages, the demands on aged care will increase. However, aged care involves not just responding to the functional or health related issues of our seniors but their social and emotional needs as well. Ultimately, what matters is the quality of life they have as our seniors age. We can all empathise with Mr Huang. Even as we all age or become frail, we will want to be cared for at home and be together with our loved ones, just like Mr Huang.

Therefore, a key focus of the Ministerial Committee on Ageing is to expand the scope of intermediate and long-term care in Singapore, to facilitate ageing-in-place. We plan to expand and enhance home-based care to better support caregivers to care for their loved ones within their homes, rather than in an institution.

We also intend to expand and develop a wider network of day care centres within the heartlands so that care can be brought closer to home. We plan to build new centres that may be bigger and provide integrated services for seniors who are functional and healthy, as well as seniors with healthcare needs. These centres will not only provide a place for them to socialise, but also access services such as nursing, rehabilitative services and dementia management programmes. Seniors living with their children who are working can then be supported by these centres, while their children have the peace of mind that their parents are being cared for by professional staff in the day.

An example of this is the Touch Home Care centre which recently opened in Jurong. A team of nurses and occupational therapists are stationed at a satellite centre in a void deck from which they deliver home-based nursing care to bed-ridden patients in the west. They also tap on local housewives to provide housekeeping and local GPs to provide medical care to clients that they help.

Another centre is the Bedok Multi Service Centre operated by the Salvation Army which I visited. They provide day care services as well as day dementia, day rehabilitative services and nursing care for seniors living in the nearby HDB blocks, while their caregivers go to work. Demand for their services is overwhelming! Instead of expanding their Bedok centre to cater to the demand, I suggested that they consider using the centre as a platform to stage services to their clients at their homes. This will provide holistic care to their clients and complement the care that they provide at the centre.

The government will continue to invest in building more of such centres in the community. We will also work with aged care providers on manpower and financing initiatives that can help build up their capabilities. This will in turn make home and community-based care a more viable option for Singaporeans. We will also study how to enhance the care for patients who are discharged from hospitals, in their homes, in the immediate few months post discharge. This would enable caregivers to better cope with the transition and pre-empt potential re-admissions into hospitals which can be traumatising for both our seniors and their caregivers.

However, for patients who are very frail and have little or no care support, institutional care will still be necessary at some point. In view of our significant senior population post 2020, we still need to invest in building more nursing homes to ensure that our seniors who require institutional care will have access to the right care. Based on past utilisation and future demographics, we project that we will need up to 15,600 nursing home beds by 2020. Beyond the current capacity of some 9,000 nursing home beds, we have some 1,800 additional beds in the pipeline from our replacement and new nursing home projects which are already being planned and developed.

In developing new nursing homes, we will study how the rehabilitative services within these homes can also cater to other seniors living in the neighbourhood as well. We will look at how nursing homes can provide respite care options for caregivers living within the community.

The intermediate and long-term care sector will be a key focus for my Ministry in the next few years. My Ministry will be working hand in hand with partners within this sector to scale and improve the quality of care, so that we will be ready to provide holistic, accessible and quality care for a larger senior population in the years to come.

A reporter asked me whether being the Minister-in-Charge of Ageing Issues was an additional ECA (Extra Curricular Activity) for me. I said that it was not an “ECA” but a “CCA” (Co Curricular Activity)!

Indeed, an ageing population will be a major force shaping our society over the next one or two decades. We will see about 400,000 Baby Boomers turn 65 years old between now and 2020. However, the bulk of Baby Boomers, or about 600,000 people, will turn 65 years old between 2020 and 2030. 600,000 people today is equivalent to about the size of Ang Mo Kio, Choa Chu Kang, Toa Payoh, and Yishun taken together!

Over the past few years, we have been promoting active ageing. However, increasingly, we will also have to think about caring for our seniors who fall ill or may end up with functional disabilities.  An ageing population will mean a higher need for both acute care in hospitals, as well as longer term care in nursing homes and other community facilities.  Many of the voluntary welfare organisations I meet tell me that they have to move from providing social day care for seniors to providing rehabilitative and other healthcare-related services because our seniors have aged over the past decade or so, and are getting more frail.

We estimate that by 2030, there will be 117,000 seniors who are semi-ambulant or non-ambulant, more than 2.5 times that of today.  And the impact goes beyond healthcare. We could see more than 80,000 seniors living alone, some of whom could also have health needs. How do we care for and engage our seniors? How do we make sure that the living environment within our city is one that encourages our seniors to be part of the community and not apart?

In my mind, there are three immediate challenges:

• First, we need to ensure that the capacity of our aged care infrastructure is able to meet the needs by 2020 and beyond.
• Second, we need to enhance the quality of care services, both in terms of increasing the care options that seniors have, as well as enhancing the level of care services.
• Third, we need to ensure that seniors and their caregivers can afford these care services.

The ramp up in aged care services is more easily said than done. We need a concerted effort across the aged care sector and beyond. We will need additional resources, not just financial, but manpower with the right skills and in the right numbers. We will also need to tap on the expertise of social service professionals and healthcare professionals to create and deliver better and new forms of care, that not only address the functional, but the psycho-emotional and social needs of our seniors. Singaporeans must accept the need for more aged care facilities to be developed across the island, and in locations within our HDB heartlands so that they are easily accessible.

The challenges are huge but not insurmountable. In the past months, I have visited many seniors activity centres, rehabilitative centres, nursing homes and hospitals. The passion among staff and volunteers within the aged care sector is our most valuable asset.

Together with my colleagues from the Ministerial Committee on Ageing, I hosted a dialogue session today with the leaders of the various organisations providing aged care. We wanted to share our plans to scale up aged care services, and hear their views on what we can do to achieve an expansion in aged care services and how we can enhance the quality of care for seniors. There was no lack of bold and innovative thinking among professionals within our aged care sector. During the dialogue, many useful comments and ideas were raised as to how we can work together to address the issues of manpower, financing, and care integration. Some also shared with us their thoughts on how best practices in other countries can be applied here. We will study the suggestions that were raised very seriously. Their views, ideas and suggestions will form a critical part of the plans and policies that the government will put in place to prepare Singapore to meet the needs of an ageing population in the years ahead.

Our seniors today and tomorrow should be able to age gracefully and with dignity as an integral part of our society. They should have the option to be cared for with love from their families and the community. That, I think, is the purpose we all share.

Of the three new ideas, the proposal to set up Community Health Centres (CHCs) received the strongest and broadest support from the GP community. Naturally so, as many of our physicians recognise that with more ancillary support services available in the community, they will be better able to deliver good primary care, especially for older Singaporeans with chronic illnesses. Some suggested that CHCs can provide administrative support, such as claims and data submissions, and relieve the doctors from such chores to focus more on patient care. There was also a suggestion to include a pharmacy within these CHCs for the convenience of patients. These are useful feedback and we will study them carefully. The configuration of the CHCs must meet the needs of our patients and GPs.

I also discussed with GPs the possibility of bringing together private sectors doctors, nurses and allied health professionals to create Family Medicine Clinics (FMCs) in the community. This way, we can offer holistic team-based care which many of our chronic and elderly patients will need and appreciate. The reaction was more mixed.  Some solo GPs were understandably concerned about the possible competition FMCs may pose to them. A few GPs also expressed reservations over team-based care. But there were also GPs who were keen to collaborate under this model. Our Regional Health Systems are currently in preliminary discussions with GPs who have come forward to explore setting up FMCs. Some have come as a group to operate a FMC, while others are thinking of running clinic sessions in FMCs even as they continue to run their own clinics.

The third idea that I have asked for feedback is the provision of specialist services in Medical Centres (MCs) sited within the community. With the support of specialists in these MCs, GPs can co-manage patients with more complex but stable conditions in the community as part of shared care programmes. GPs can also refer their patients for selected surgical procedures that can be safely managed in the community. Many of the GPs whom I have spoken to are supportive of this idea. Singaporean will also find this more convenient compared to going to hospital Specialist Outpatient Clinics.

There are still outstanding issues that need to be studied. For example, several GPs shared that the much cheaper drugs provided by polyclinics and public hospitals are preventing patients from seeking care at GP clinics. We are exploring possible solutions, including lowering the cost of drugs provided by GPs for patients under the Primary Care Partnership Scheme (PCPS).

I would like to thank the public hospitals for hosting the engagement sessions and the GPs who have contributed constructive feedback. While the engagement will continue, we will proceed to incorporate some of the suggestions into our master plan. I hope our GPs will continue to offer useful feedback and co-create the master plan with us.

On several occasions, MPs, the media and Singaporeans I met have asked me whether we can ease the current squeeze on the capacity of our restructured hospitals and whether our new hospitals and other healthcare infrastructure can be built faster. We have indeed accelerated our hospital building programme over the past few years, to keep pace with the rising healthcare needs of the population. Ng Teng Fong General Hospital and Jurong Community Hospital, and Yishun Community Hospital, will open in 2014-2015. We are also building a number of nursing homes, which will be opening over the next few years.

I had indicated earlier that MOH is studying whether we can bring forward the opening of Sengkang Hospital, scheduled for 2020. The planning team has completed their review and I am happy to share that we would be targeting to bring forward the building completion date to 2018, and to open the hospital thereafter in phases to serve the residents living in north-eastern Singapore.

However, adding more beds to the system is only part of the solution. We also need to find more innovative and cost effective ways to deliver health-care services and to optimise the use of our healthcare capacity. That is why the Sengkang hospital, when it is ready, will need to work closely with other healthcare partners (e.g. nursing homes, GPs and home healthcare providers) in the same region to provide coordinated and seamless care.

Over the past two months, we shared with our stakeholders the draft Primary Care Masterplan and we have received valuable feedback and suggestions. We hope to finalise it by early next year. MOH is also working on a master plan for intermediate and long-term care to address the challenges of our aging population. I will share more of this later.

As we build more healthcare facilities, we will need the continued support and understanding of Singaporeans, especially those who live in the vicinity of these facilities, so that we can meet Singapore’s immediate and future healthcare needs.

It required officers looking after drug subsidies, the Primary Care Partnership Scheme (PCPS), Medisave400 and Medifund to work together to find the most meaningful ways to bring bill sizes down to a reasonable level for all Singaporeans. There was a very conscious effort to look at things from the patients’ point of view, and define what is truly affordable for them. We debated long and hard, but ultimately agreed collectively that what mattered most to patients was the out-of-pocket payment they had to make, not for a single visit to the doctors but cumulatively over a period of time, and relative to their household disposable income. We had a clear affordability target to work towards, and while our longer term ability to sustain healthcare subsidies was still an important consideration, there was a tacit understanding that helping patients afford the care they need was the priority. It felt like a step in the right direction.

We certainly couldn’t have done it without the invaluable inputs from various stakeholders. We met clinicians, administrators, GPs and medical social workers (MSWs) in the public healthcare institutions to test our ideas and get their reactions on the proposed changes. They helped us to better understand some of the issues they faced on the ground and fine-tune our recommendations. Indeed they were our anchor to the ground.

The MSWs are a really passionate lot. They welcomed extending subsidies to cover the middle-income group, so that discretionary aid and more of their time can be channelled towards more needy cases. Ultimately more chronic patients will be able to afford the care they need. We were heartened by their feedback. The administrators helped us to think through the implementation challenges, the scale of means-testing necessary and lead-time for IT system and process changes. And the GPs gave us a good sense of the real impact on chronic patients that could now benefit from the enhanced PCPS. None of them complained when some of the meetings had to take place over lunch, dinner or even the weekends. I was glad to have these passionate health care partners aiding us tirelessly behind the scene. Their passion to help their patients was clear and their suggestions/feedback were instrumental in helping us improve and finalise these policies to bring benefits to patients as soon as possible. They galvanised my colleagues and I to work even harder.

But our work is not done. My team will continue to review the new changes and see where else can we improve. We will also need to extend the same patient-centric approach to systematically look at other areas of concern for healthcare affordability, such as long-term care for the elderly. The holy grail will always be to make healthcare and long-term care truly affordable for everybody no matter their circumstances, and also to sustain this for future generations as well. The latter means we have to constantly rethink about who deserves more help within the society, given that healthcare resources are ultimately finite. This is not a decision that the government can make on its own, but rather one that we should make collectively as a society.

So we certainly hope to hear more great ideas from you. We may not always move as fast as the Internet, but yes we are listening, and will strive to do our best. After all, we could also be patients one day.

Scott Tan
Deputy Director, Healthcare Finance Division
Ministry of Health

We are at the brink of a Silver Tsunami, with the first cohort of Baby Boomers turning 65 years old next year. And many more people will turn 65 over the next 10 years. In my dual roles as MP of Hong Kah North and Mayor of South West District, I have received a lot of feedback on elderly residents’ concerns over healthcare costs, managing chronic conditions, coping with diseases that limit mobility and affect their independent living, and financial security. I have also come across younger residents who are faced with the financial and emotional burden of caring for an elderly person in the family, which is often made more challenging with the onset of dementia. Over time, we will also see more elderly who are single or who are married but on average, have fewer children who can care for them, compared to the elderly of today.

I believe that we need a whole-of-government approach to reviewing policies and putting in place measures to help the elderly age-in-place. Beyond healthcare policies, we need to address family and social support, as well as enhance our existing programmes to encourage the elderly to live active lives. I am thus excited to be part of the Ministerial Committee on Ageing (MCA), which is chaired by Minister Gan in his capacity as the Minister-in-charge of Ageing Issues. Given the complexity of ageing-related issues, the MCA comprises four inter-agency subcommittees to address issues such as encouraging active ageing and employability, ramping up institutional long-term care and home-care capacity, and developing a pool of care-giving staff.

Under the leadership of former Minister Lim Boon Heng, the previous MCA has had success in achieving barrier-free access in our neighbourhood. This has not only benefited the less mobile elderly residents, but families with young children as well.

Nonetheless, I believe we can do more to build a more elderly-friendly environment. In his Committee of Supply speech on Ageing Issues this year, Minister Lim outlined his vision for a “City for All Ages”. Given my personal interest and background in real estate and land management, I look forward to building upon Minister Lim’s vision and realising it under the new MCA. The design of a liveable environment has to take into account the elderly person’s sense of security, well-being and familiarity with the surroundings. It should also facilitate ageing-in-place. By that, I mean that we should allow the elderly to age gracefully and receive the care that they require within the community itself. To achieve this, we may need to intentionally provide for interaction spaces for social activities, and increase eldercare services that serve both medical and social needs in the neighbourhood. These measures will allow our elderly to continue to live in, and be engaged within the community, amongst their families and friends, such that their golden years will be rich and meaningful ones.

Even as we come up with ideas to do this, we recognise the need to engage local communities to understand the needs of an ageing society. The Marine Parade Pilot, which was announced by ESM Goh in Dec 2010, allows us to consult and engage our elderly residents on this issue. The Marine Parade estate has more than 20 percent of its total population aged 65 years old and above, making it an ideal town for an in-depth study of the local elderly population. The first phase of the pilot, which focused on assessing the implications and needs of an ageing community, has just been completed. We are currently looking at the detailed findings and thinking through possible interventions.

I firmly believe in the value of public consultation and engagement towards shaping effective government policies and initiatives. Throughout the course of the Marine Parade Pilot, we will actively seek the opinions and participation from the local community, grassroot leaders, and members of the general public, and I would like to encourage you to come forward if you have suggestions on how we can better serve the needs of an ageing society.

How the ”PCPS King” inspired me

I met the ”PCPS King” (my nickname for him) during a focus group meeting organised by AIC (Agency for Integrated Care). He was the first General Practitioner I met that championed how the PCPS scheme was helping the elderly of the lower socio-economic group. He had more than 100 regular patients using their PCPS Card. Many of these PCPS holders were initiated by his Dental neighbour who was also on the PCPS’ panel of dentists. The Dental Surgeon had referred PCPS patients to him for medical care.

I had read about how some of our elderly could ill afford dentures. My heart warmed when I realized how there were indeed many that had fallen between the gaps and how meaningful the PCPS can be in helping out the needy.

At that time, my claims for PCPS ranged from insignificant to nonexistent. So, I was peasantry in comparison.

Spreading the word around

We simplified things for our patients by writing to MOH to obtain the colourful brochures, went over to the nearby Community Centre to obtain a sample application form. We then photocopied many copies, stapled the two together and gave it to the elderly we met on monthly chronic medical care visits. My staff gave them clear instructions to get their children to fill in the forms, informed them how sensitive information like income was required and after filling them all in, to get their children to mail the forms. I’m therefore glad to read that the Ministry is looking into fine-tuning the application process.

Meanwhile, the evident appreciation from the patients makes it all worthwhile. On one notable occasion, a lady returned with her recently arrived PCPS Card. So profuse the thanks, she teared and held my hand in hers. I choked in emotion. To me each happy face was a humbling experience. Despite rising cost through the years, they continue entrusting their healthcare in my hands. It is not easy financially to continue seeing a private GP for regular chronic medications.

Getting Closer to Family…

When you are someone’s family doctor for more than 10 years, it offers you a lot of insights into a family’s dynamics. Through the years you also empathise with how they are challenged with stagnating incomes and changing market forces.

Take this family – 12 years ago, he was the sole breadwinner – a 36-year-old lorry driver supporting his homemaker wife, he has 2 young toddlers and a healthy 65-year-old mother. His take-home monthly pay then was $2,000. Today, he is 48 years old, still a lorry driver, with 2 teenagers, a wife and his mother is now 75 years old. He still earns $2,000 a month.

We gave him the application form twice to apply for his mother. She obtained her card a couple months ago after much guidance. The first time he read the brochures, he discarded the idea. He did not understand the concept of ”per capita monthly household income” and felt at $2,000 a month take-home pay, he was earning too much.

I hardly saw him as a patient except when he was too ill to drive. His blood pressure was always high. We do free blood pressure checks at the waiting area but he does not return to recheck. His wife said he avoided us as it meant spending more money.

Dropping the age to 40 years and increasing the per capita monthly household income criteriaI had my thoughts about how tweaking the PCPS scheme made sense each time I met families like these. For my patient who is the lorry driver, the enhanced PCPS changes will help not only his mother but also himself who will be eligible under the new changes.

The changes are meaningful to family physicians managing the rising burden of chronic medical diseases. Problems like Diabetes Mellitus need to be well controlled upon the first 5-10 years of diagnosis. If we miss that window period, long term risks of complications go up.

Most of us do not become family physicians in private practice only to take care of those who are in good health and can afford to pay. We want to continue taking care of those who need medical care and are a step behind because we know we are strategically placed and trained to help manage their medical problems before they escalate to complications.

I have placed the brains of my clinic assistants in the washing machine regarding this scheme. Initially they ignored me when I told them to get down to helping the old folks to fill in forms. To them it was more work photocopying, stapling, explaining and even more work with internet submissions, invoices, accounting etc…

However, believe me, if you were to see all my elderly folks’ faces when they returned flashing their pretty cornflower card – you will gladly be dishing out forms and doing internet submissions too. What these patients save is very significant to them. Now my clinic girls are keen to help whenever they can. They have probably discovered the priceless satisfaction in helping others.

We are a rapidly progressing society, but should not be so jet speed that we cannot pause a little and give back when we can. I look forward to MOH simplifying the processes for everyone. I am confident the enhanced PCPS will bring us all closer to caring for those a step behind.

Dr Tammy Chan

“Your family doctor downstairs is just another fellow human like you. You are comfortable with him and there is often friendship and mutual respect. S/he has a life, has kids, has an iPhone to take self portraits too.”

Outpatient affordability as a priority

I mentioned in my previous blog that one of my priority areas is to review healthcare financing to ensure basic healthcare remains affordable to Singaporeans. Outpatient cost is one of my immediate focus. Even though individual outpatient bills are usually manageable, for patients with chronic diseases, they can add up. Cumulative bills can typically cost $700 or $1,600 a year at a GP or Specialist Outpatient Clinic respectively before subsidies. While these may not be as high as hospitalization bills, with outpatient care not well covered by the 3Ms, it can pose a financial burden, especially for the needy amongst us. It’s not surprising thus that whenever my residents talked about healthcare issues when I met them, outpatient cost often came up in the conversation.

However, regular outpatient care is critical in helping patients manage their conditions well, reduce possible complications, and slow down the progression of their conditions. It also helps them avoid unnecessary hospitalizations, keep them in the community and give them better quality of life. In the long term, it helps keep overall healthcare costs low. Hence, our focus in making outpatient affordability a priority.

Early Intervention in helping Singaporeans manage chronic conditions

For a start, we will be expanding our Primary Care Partnership Scheme (PCPS) to benefit more Singaporeans. By lowering the age criterion from 65 to 40 years old, and raising the household income criteria from $800 to $1500 per household member per month, more Singaporeans will be able to receive subsidised primary care at private GPs and dentists, both for common ailments (e.g. coughs and colds), as well as treatments for their chronic diseases at an earlier age. Under the new criteria, a family of four with a household income of up to $6,000 a month will qualify for the scheme. Up to 700,000 Singaporeans will potentially qualify for the scheme with this change.

At the reception after PM’s speech, one of my grassroots leaders appealed to me that the withdrawal limit of Medisave300 should also be reviewed. He would be pleased to know that this is indeed what we intend to do, although PM did not mention it. To further help Singaporeans with chronic conditions defray some of their out-of-pocket costs, the annual Medisave withdrawal limit under Medisave 300 for outpatient treatments of chronic diseases will be raised from $300 to $400. Some 110,000 patients will stand to benefit with this policy change.With rising drug costs, we also recognise the need to fine-tune our current drug subsidy framework to provide more help and to benefit more Singaporeans. The higher subsidy limits for certain standard and non-standard drugs reflect the Ministry’s attempt to address some of these needs.

Helping the elderly age within the community

Since its genesis, Medifund has served as a healthcare safety net for many Singaporeans. With rising healthcare needs, it is critical that this safety net continues to provide the much needed assistance to our low-income patients.

Currently, Medifund is only limited to residential ILTC services such as community hospitals and nursing homes. I’m happy that the Government will be extending the scope of Medifund to community and home-based Intermediate and Long Term Care (ILTC) services, such as day rehabilitation, dementia day care, home medical and home nursing. I’m certain that this change would help take some financial burden off the needy while allowing them to opt for non-residential care in the community as they recover.

There will always be calls for us to do more but we must be mindful and be responsible for the implications of the policy changes. Healthcare review is complicated and let’s progress carefully while avoiding the pitfalls which many countries have fallen into. Nonetheless, I’m encouraged that we have started our journey in making healthcare even more affordable for all Singaporeans.

My generation was ingrained to be “super-efficient” nurses. We were expected to be technically-savvy, to complete every task before our shift ends and be terribly obsessed with tidiness and cleanliness of our wards and surroundings. Under the apprentice-based system that we were brought up in, preceptors and mentors were unheard-of roles. Learning comes from observing and emulating our “experienced” nurses and senior trainees. Work was regimented. Rules must be followed and patient care routines cannot be compromised. But that did not deter us from doing what we love best, patient care in every sense of the word.

Nursing has evolved by leaps and bounds. Today, nursing is knowledge-based. Nursing practices are evidence-driven. Patient safety and clinical quality have become unwavering tenets of a safe healthcare delivery system. Competencies anchor our practice to encompass larger and more diverse roles.

Our nursing curriculum and practice environments have been enhanced to provide learning opportunities beyond the clinical domain, to include health policies, information management, research, and fine arts, amongst others. Nurses have equal and ample opportunities to upgrade and pursue specialties and niche areas. With their nursing background, many have extended their circle of influence and moved into new domains like quality management, operations and corporate planning. Many are also assuming leadership roles, imparting knowledge and expertise at local and overseas conferences, taking on professorial responsibilities at academic institutions, engaging in research as principal/co-investigators, and contributing to the strengthening of institutional capabilities. In short, nursing today is sans borders.

The profession of nursing will continue to evolve. What I know of nursing then is very different from how we know of it today, and the landscape will be even more different tomorrow. While systems, structures and policies are constantly being fine-tuned and new rules of engagement redesigned to make our healthcare system safer and better – let us still remain true to our professional ethos and moral calling. The code of ethics and professional conduct we pledge and live by must continue to be our unshakeable, firm and guiding beacon.

It has become somewhat of a practice for me with each Nurses’ Day to take stock of the development of the nursing profession. And I am gratified as CNO to see that we have made commendable strides in many areas. Indeed, it is a privilege to be a Nurse. So let’s be the best we can be. Here’s wishing every nurse Happy Nurses’ Day!

Pauline Tan
Chief Nursing Officer