It has been said that one must look forward to face new challenges ahead. However, it is equally important to look back as well.
Singapore has changed and grown in our short 52 years as a nation. In those years, medicine has also grown and evolved. We are now ranked as one of the world's top countries for our healthcare system; leaders; providers such as doctors, nurses, pharmacists and therapists; as well as health of our people. Our pioneers have built a strong foundation.
However, we are also facing new challenges that are not unique only to Singapore, but faced by many developed countries. Two such challenges are the ageing population and rising epidemic of chronic diseases (eg, diabetes).
The new challenges
The concerns with an ageing population is not just about the number of elderly but also the systems, services and people required to care for older persons. The worry is always that with the increase in age, disability and diseases become more common.
Chronic diseases are also more common now even among the young. 12.8% of people in Singapore aged between 20 and 79 years old are estimated to have diabetes. Singapore has the second-highest proportion of diabetics among developed nations,1 after correcting for age differences between the countries. Only the US fared worse, with a percentage of 10.75.
The Ministry of Health has declared war on diabetes, with each of the political leaders at the ministry leading a different charge against this disease – one of the biggest drains on the healthcare system. In setting the battle scene, Minister for Health Mr Gan Kim Yong said the disease is already costing the country more than $1 billion a year. He also informed that of the more than 400,000 diabetics today, one in three do not even know they have the disease. Of those who do know, one in three has poor control.
Ageing is inevitable. The only cure for growing old is to die young. And it is difficult to prevent diseases like diabetes, especially in the presence of genetic predisposition. But dying of end-stage kidney disease or losing one's leg due to diabetes is certainly preventable. Strokes, heart attacks and dementia are also preventable.
Given our First World status in health service standards as well as our small geographical size, it is worrying when we read of the lack of awareness. After all, most barriers to good healthcare faced by people in other countries do not exist here. Accessibility is not an issue with hospitals and clinics situated just minutes away. Our population is also highly literate, with 97% having an average of at least ten years of schooling. Healthcare is also relatively affordable with the introduction of schemes such as the Community Health Assist Scheme, Pioneer Generation Package and MediShield Life.
So... as we celebrate our triumphs as a First World country, with a First World healthcare system and healthcare professionals, what can we do to better face new challenges ahead?
Looking back in time
I recently had the opportunity to participate in a Channel NewsAsia programme – Turn Back The Clock. The programme featured a group of five seniors who in their youth were leaders in their areas of expertise and had led active lives. With age came diseases and also losses, be it of a spouse or position in society. Gradually, many of them became dependent.
The programme "turned back the clock" and had the seniors live in a house outfitted like the 1970s. There, they lived without any helpers, so they had to cook their own meals and help each other out. They were encouraged to exercise as well, and were actively encouraged to think young and act young. There was no medical intervention, no magic pills and no magic injections.
Therapists from Mount Alvernia Hospital and I had to assess them at the beginning of the programme and again at the end of a week. We also had a psychologist from National University of Singapore assess their mental and emotional well-being.
I was sceptical when I was first approached to participate in the programme. I remember saying to the producers: "There is no way that there can be a change in function, physical or mental health after one week". How wrong I was.
Amazingly, there were visible improvements in the functional and mental abilities of these five seniors! Yes, it was only five people and it wasn't conducted as a randomised control trial with statistically significant numbers, but the results were amazing nevertheless for the five individuals and for those of us involved in the programme. I learnt three key points (the three Ps) from my involvement in this programme and also realised that the age-old principles of healthcare are truly oldies but goodies.
The person matters
William Osler once said: "It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has". He said this in the 1800s and it is as relevant today as it was then. This programme taught me the importance of knowing the patient. The programme's producers made great effort to get to know the five seniors: to understand their background, include activities that would motivate them as part of the programme, and challenge them to think and live young.
For example, Harry was an artist and he was encouraged to take up art again, while Mdm Asmah, who is a great cook, was encouraged to cook for the others. When these five strangers came and lived together, they had to depend on each other and in doing so, became part of a community of mutual help, support and encouragement. It wasn't a one-size- fits-all approach, but knowing what sort of patient has a disease is knowing who the person is, his/her past experiences, fears and interests, and finding ways to motivate and give hope for the future.
Prevention is more than a lifestyle
Once again, William Osler said it best: "One of the first duties of the physician is to educate the masses not to take medicine." While we did have a nurse on standby during the filming, our five heroes were encouraged to be active mentally, physically and socially.
As doctors, we tell our patients to exercise and eat healthy. But that is not enough. Prevention is more than just the lifestyle; it is caring, coaching and educating to give hope even if one has chronic disease. Hope that a kidney failure can be prevented even if one has diabetes. Hope that one can lead a full life even after a stroke. After Harry had a stroke, he was unsteady and became terrified after a near fall accident while crossing the road. As a result, he withdrew and limited himself. He believed he could not carry his own art tools and go painting alone. Turn Back The Clock challenged him. He was gently encouraged to do more – and he did.
But such education takes time. Time for doctors to explain to our patients why it is important to not only take their diabetes tablets, but also to eat healthily and exercise. It also takes time for patients to understand what diabetes is, to talk to someone about their fears and concerns about medication side effects, costs and complications. Time that a busy physician and/or nurse is often unable to spare. The reality is that cost effectiveness is often confused with cost efficiency – seeing as many patients as fast as possible. That leads us to the last "P" – performance.
Measuring our performance
Healthcare systems are by necessity performance-driven. We measure infection rate, time taken for surgery, time for an appointment, time to see a patient, heart rate, ejection fraction, HbA1C, blood pressure, and the list goes on. We measure the cost to manage diseases because the reality is "no money, no talk". Yet, perhaps we need to refocus on what really matters amid our key performance indicator (KPI) measurements – the Person, Prevention and Performance. How was healthcare performance measured in the good old days?
Back in the day, care was personal and doctors could spend more time with patients. There was not only the process of number of patients seen and number of pills prescribed, but also outcomes (ie, did the patient understand? Has his health improved?).
Hospitals and healthcare services were less accessible. Money was tight and insurance was uncommon. Doctors helped their patients navigate the system and managed their whole life healthcare costs. Family physicians treated families from cradle to grave. Doctors were more than just a doctor. He or she was a family friend and a partner along life's journey. That was their KPI.
"Turning back the clock" for healthcare provision
Each patient is different. His/her understanding of the disease will determine how he/she complies with treatment, and whether he/she will take better ownership to overcome the disability and/or disease. It will also affect whether he/she will participate in preventive activities, invest in health and keep out of hospitals. Once again, this takes time and a mindset change.
Certainly, no healthcare system can afford to place each person in a house and give them a week-long health boot camp. But surely we can find other ways to personalise healthcare, promote prevention and focus on KPIs that really matter.
In some countries that perform better in chronic disease management and ageing care (eg, Japan and Scandinavian countries), systems are put in place to reach out to people in the workplace and community while they are still in good health, in addition to their First World hospitals and doctors. They are cared for in a one person-one doctor-one nurse system where healthcare professionals are incentivised to care for a person throughout his/her lifetime, both for prevention and illness, from young to the point when he/she is old and disabled.
Conclusion
Prevention is primary, secondary and tertiary. Performance is tracked over years and not in just one financial year. Financial cycles need to acknowledge that lifestyle changes take time. Health outcomes change takes time to reach out, convince, track and follow up with a person for regular screening of chronic diseases and early intervention to prevent disabling complications of chronic diseases.
Singapore is facing unprecedented challenges to our healthcare system – escalating disease prevalence, a strain on health resources, and climbing costs. It cannot be business as usual. We have done well in how we have grown as a nation and promoted good health for our people. Do new challenges require new approaches? Perhaps not. Maybe it is time for us to "turn back the clock" and relook at the way our healthcare dollar is spent and care is provided, with a focus on Person, Prevention and Performance.