Getting the balance right in healthcare planning
This was not a great year for healthcare. From an infectious diseases point of view, 2015 could even be described as healthcare’s annus horribilis, with Group B streptococcus and hepatitis C making headlines for the wrong reasons.
Singapore’s stellar reputation in healthcare took a hard knock with the Independent Review Committee’s investigation into the hepatitis C outbreak at the Singapore General Hospital (SGH), pointing to “lapses” and “gaps” in infection-control practices.
The silver lining lies in how national attention is now firmly focused on infection-control measures in healthcare institutions and disease surveillance, and we can expect Singapore to bounce back stronger. Minister of State (Health) Chee Hong Tat is leading a taskforce to strengthen outbreak detection and response, and his team is expected to complete its work by the middle of next year.
While infections dominated the headlines in 2015, how Singapore deals with two other I’s — infrastructure and ideology — in the long term will be even more significant for the healthcare sector.
INFRASTRUCTURE SHORTFALL — CLOSING THE GAP
Singapore has conceded errors in health planning with consequent infrastructure shortfalls, and 2015 saw this gap narrowed with the opening of the Ng Teng Fong General Hospital, Jurong Community Hospital and Yishun Community Hospital.
By adding almost 900 beds thus far, high demand for in-patient care has been met somewhat. The rapid filling up of the hospitals is sobering, though, reinforcing an old adage that “a bed built is a bed filled”.
While Singapore continues to beef up hospital-bed capacity, there is a greater need to transform our model of care to one that is prevention- and health-focused, with a heavy emphasis on home- and community-based services.
This does not require “hard” infrastructure such as beds or big buildings, but it does need “soft” infrastructure such as cheap or free data connectivity, the right people with the right skills, enlightened and enabling regulations, as well as clever systems of organising and financing to accelerate this necessary transformation. Healthcare should hitch its wagon onto larger national imperatives.
For example, the Smart Nation initiative has emphasised healthy living and elder care as key focus areas and hopefully Singapore can lead the world in redesigning new health and healthcare models for the next 50 years.
Prime Minister Lee Hsien Loong, in launching the Smart Nation initiative, singled out telemedicine for bringing healthcare to homes, saying: “From the hospital we can connect up and you can talk and find out what is happening, and give advice, and monitor and treat the patient.” Many more examples need to be brought to life in Singapore and rendered mainstream.
Rethinking ideologies
The government’s leftward shift has been well documented and the budget for social services and development has increased by 16 per cent to S$32.1 billion in financial year 2015, compared with S$27.6 billion in the previous financial year.
In healthcare, the manifestations of this largesse have been profound, with the Pioneer Generation Package taking centre stage last year, and MediShield Life enjoying the spotlight this year.
The increase in social spending is part of a strategic shift in the approach of nation building, as reiterated by Health Minister Gan Kim Yong during the parliamentary debates on MediShield Life last year.
“The idea of MediShield Life goes beyond healthcare and insurance. It is a reflection of the kind of society we want to build: A more inclusive society ... and a more caring society,” he said.
Most Singaporeans applaud this leftward shift, but the evolution will not be smooth, as the government’s stance on Jade Circle, a nursing home’s initiative to create a home-like environment comprising single or twin rooms for dementia patients, demonstrates.
The medical rationale was that dementia patients benefited from the additional privacy and ownership with less disorientation.
Despite this, the Ministry of Health (MOH) declined to provide operational funding for residents in single or twin rooms, central to Jade Circle’s model, stating: “As a matter of policy, it will be difficult for the MOH to provide ongoing subsidies for patients staying in wards that are designed to proxy private or A-class ward configurations such as single or double-bedded rooms only.”
In a subsequent Facebook post, Minister of State (Health) Dr Lam Pin Min defended the MOH position on single and twin rooms, saying the MOH needed to be “more cautious” and explaining that “such parameters may be hard to scale or to be financially sustainable, if applied to the rest of the aged care sector”.
This episode underscores a larger and more fundamental divergence on what is considered medically necessary and what is considered a luxury or a frill and, therefore, what degree of creature comforts would be appropriate for residents to be funded by government subsidies.
Preconceived biases around what subsidised patients deserve are in the forefront in Jade Circle.
But instead of pussyfooting on what public funds can or cannot be spent on, we should strive to get the science right first.
We can use scientific data and future projecting models to empirically evaluate the costs and benefits of various innovations, before deciding what makes sense for Singapore in our unique socio-cultural setting.
It is thus heartening that the government is establishing a new Agency for Care Effectiveness. This agency would define clinical care standards — that is, determine what is medically necessary and hence appropriate for government funding — versus what are frills, which taxpayers’ dollars should not reasonably be used for.
Coupled with increasing sophistication in health economics, it could be a lynchpin of health-policy decision-making in the years to come.
Another positive sign emerged this week with the confirmation that the task force headed by Mr Chee plans to look into better use of data analytics to improve the detection of potential outbreaks of infectious diseases. The current system “depends too heavily on human judgment to process large amounts of information and decide whether the risks are significant enough for escalation and further investigation”, Mr Chee noted.
Healthcare is and will always be characterised by potentially infinite demand and finite resources. Hard choices will have to be regularly made with very human consequences.
As we move into 2016 with clear government and societal commitments to do more in healthcare, whether in infectious disease control, infrastructure or new models of care, we must do even better — through decisions and actions under-girded by evidence and data, emboldened by conviction and warmed with compassion.
ABOUT THE AUTHOR:
Dr Jeremy Lim is head of the health and life sciences practice for the Asia-Pacific for Oliver Wyman, the global consultancy. He is the author of Myth Or Magic: The Singapore Healthcare System.
