SPEECH BY SENIOR MINISTER GOH CHOK TONG AT THE 10TH ANNIVERSARY GALA DINNER OF THE NATIONAL HEART CENTRE, 30 MARCH 2008, 8.00PM AT THE RITZ-CARLTON, MILLENIA SINGAPORE
Ladies and Gentlemen
1 It gives me great pleasure to celebrate the 10th anniversary of the National Heart Centre (NHC) with you this evening. When it comes to matters of the heart, the National Heart Centre knows them best – it has mended many a broken heart.
2 NHC has earned its reputation as a leading heart centre in the region. It participates in worldwide trials and performs many procedures that are first-in-the-region, for example, the ventricular assist device implantation and the drug-eluting stent implantation. We were right to build up a critical mass of expertise in one institution to raise standards of cardiac care.
Challenges still abound
3 As NHC celebrates its achievements, it is also timely to reflect on the changing face of medicine and the challenges of the future. Here I want to take a holistic approach, more like a family doctor than a specialist. I shall limit myself to three observations.
Changing disease patterns
4 First, as new disease patterns emerge, our healthcare must adjust accordingly. Fifty years ago, communicable diseases and diseases of early infancy were major killers. So our average life span was 61 years. Now with better public health and advances in medicine, our average life span has gone up to 80 years and the leading killer diseases are cancer and heart disease. Looking into the future, we can expect far larger volumes of chronic diseases such as diabetes. I think we also need to pay more attention to mental illness including depression and anxiety because life will become even more fast-paced. We also have to cope with a sharp rise of illnesses associated with an ageing population, like Alzheimer’s.
Rising aspirations of populace
5 Second, as Singapore becomes a developed, cosmopolitan, global city, our healthcare standards must keep up with the rising aspirations of our populace, not just for ourselves, but also for the international talent which we want to attract to work and sink roots in Singapore.
Global shortage of talent
6 Third, good quality healthcare manpower is in short supply globally. Many developed nations are recruiting healthcare personnel from outside to meet their domestic demands. Add to this the new demand from new players in the Middle East. They have ambition to build up world-class healthcare cities. They do not have enough healthcare personnel of their own but they have more than enough money to buy them from outside. We are good pickings. However, I do not expect an exodus of our healthcare personnel to the Middle East. I think most Singaporeans would equate working in the Middle East as hardship postings. More worrying is the loss of our own bright students who have gone overseas to study medicine because NUS could not accommodate so many of them. There is a risk of their not coming back. We have to find ways to attract them back.
No straightforward answers
7 How should Singapore respond to these challenges? At the national level, new diseases, higher aspirations and shortage of talent all translate to rising medical cost. But spending more alone is not the answer. The US, for example, spends 16% of their GDP on healthcare, more than four times the rate we spend. Yet, some 40 million poor Americans, or 10 percent of their population, do not have proper access to healthcare because they do not have insurance.
8 Any increase in expenditure on healthcare will have to come directly from the consumers’ pockets or indirectly through the taxes they pay. So we should strive to build an affordable and accessible healthcare system, premised not on high taxes and subsidies, but on high productivity and low wastage.
Evolving healthcare system to meet the challenges
9 Here, the Ministry of Health (MOH) is confronted by some fundamental questions:
(a) How do we encourage our healthcare clusters to continue to raise standards in hospitals, without attracting even more patients who are better seen at primary and step-down care sectors?
(b) How do we create the right structures to harness the benefits of competition between our healthcare institutions and yet instil the instincts of collaboration?
(c) How do we retain a core of public sector healthcare talent even as we promote Singapore as a medical hub to service wealthy patients from abroad?
10 These are questions that Minister Khaw Boon Wan and his team of policy makers are addressing. Boon Wan has a most difficult and politically delicate job. He has to decide in a hard-headed way what works, what makes economic sense, what is sustainable, and convince a cost-conscious population to take his medicine. Watching him, I can say with full confidence that he will deliver a better healthcare system for the benefit of all Singaporeans. He is insightful, practical, and compassionate. I consider him the best Health Minister Singapore has ever had. This evening, I would like to lend my support to three goals which he has set for MOH.
Raising level of primary and step-down care
11 The first goal is to raise the standard of care in primary and step-down care sectors to a higher level. The primary care sector needs to be empowered and equipped to take on bigger roles in areas such as the management of chronic disease, mental health and in-community ageing. The step-down care sector, such as community hospitals and nursing homes, must gain the confidence of Singaporeans as appropriate places for them to entrust the care of their elderly. Improvements here will mean lower costs for the patients. At the same time, it will free up resources in our secondary or regional hospitals to provide higher value services. Healthcare practitioners refer to this as “right-siting” of care.
12 While commonsense tells us that this is the right thing to do, getting it accepted by the public will not be an easy task. It is not just about further upgrading the capabilities of the primary and step-down care sectors, which we must do. It is also about getting the pricing, financing and subsidy system right and changing the bias against step-down and primary care. As a first step, means testing in hospitals may reduce the financial incentive for more well-off Singaporeans to choose to remain in B2/C wards instead of moving on to a community hospital. Beyond pricing, we need to change Singaporeans’ mindset so that they feel comfortable going to their primary care physicians as a first line of healthcare and to return to them for follow up treatment after their acute episodes in the hospitals. We have to succeed in this goal of raising standards in primary and step-down care sectors and right-siting care to keep costs down for the individual and the taxpayers.
Improving clinical outcomes through competition
13 The second goal is to get our institutions to benchmark themselves and compete to improve clinical quality. However, as management guru Michael Porter observed, competition has to be done at the right levels. Institutions should compete on the quality of clinical outcomes and the pace of new, cost-effective innovation that improves patient care, instead of competing on parameters such as revenues, profits and the earnings of doctors. For this to succeed, we need common quality performance measures and systematic collection of clinical quality data. To encourage this, MOH is developing a national performance measurement framework that would allow hospitals to compare how well their specialties fare not only in relation to other hospitals here, but also leading medical institutions elsewhere. For example, the outcomes of cardiac surgeries in NHC and NUH have already been published. We should extend these efforts further, to include other procedures and specialties. Here, I want to emphasise the importance of including our private sector hospitals in this exercise. They are an inherent part of the country’s healthcare system and not a regime separate from it. But above all, we need a change in hospital culture that emphasises continual review of clinical quality, at the aggregated hospital level and right down to the performance of individual doctors.
Preserving public service ethos
14 The third goal is to ensure that our public sector institutions continue to preserve its public service ethos and retain a fair share of top healthcare talent. As we grow our medical hub, the lure of higher salaries and different working conditions outside the public sector will become more tempting. So we must find ways to preserve a core of outstanding healthcare professionals in the public sector. If we lose this fount of leadership, training for the next generation of doctors and healthcare professionals will suffer, and so will our medical hub ambition.
15 Over the years, many of our healthcare professionals have chosen to forgo prospects of a higher income and stayed on to serve subsidised patients, and to lead and teach the next generation of doctors. We will make it easier for them to stay by keeping salaries competitive in the public sector. Beyond remuneration, we must offer a value proposition that encourages them to stay. This will include a conducive environment to participate in medical research for those with such inclination and talent. For those who mentor our next generation of doctors and help shape the future of our healthcare system, we must recognise and honour them for their contributions.
16 At this dinner tonight, I am glad to see that we have many prominent cardiologists and cardiac surgeons who have opted to remain in the public sector, or who have continued to contribute to the development of the specialty as visiting consultants or as directors of various clinical programmes. We appreciate your services and contributions to our healthcare sector.
Concluding remarks
17 Designing and running a good healthcare system is much tougher than urban planning or running our transport system. We have to constantly balance between quality, accessibility and cost, and tailor our policy responses as demands and expectations change. No country has found the perfect model. Hong Kong has tried to improve integration of step-down care by taking back ownership of the step-down care institutions. The UK National Health System, by using GPs as the gatekeeper, has managed to achieve better care coordination. But both approaches involve nationalising the healthcare system which brings with it other issues such as inefficiency, abuse and waste. The US is the leader in terms of tertiary and quaternary care but this has come at a very high cost and diluted attention to basic healthcare.
18 We have been relatively successful. Our key health indicators are comparable with those of developed countries, yet we have managed to keep our expenditure on healthcare to below 4% of GDP, about half the rate spent by most developed countries. Simply put, we are getting value for our money – a first world healthcare system at half the cost; a people-oriented system that is not wrecked by abuses, over consumption, over-servicing, and defensive medicine.
19 Going forward, Singapore will have to continue to be innovative and design our own solutions to achieve the best and most cost-effective healthcare system. As for the National Heart Centre, I wish you further success in looking after our hearts.
20 Have a pleasant evening. You deserve it.
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