Youth Voices: Strengthening Healthcare In An Ageing Singapore

Youth Voices: Strengthening Healthcare In An Ageing Singapore

The 3rd session of Youth Voices, held on 17 February 2019, focused on the topic ‘Strengthening Healthcare in an Ageing Singapore’. Moderated by former NCMP Gerald Giam, the session’s panelists included:

  • Chief Executive Officer (Immediate and Long-Term Care): Dr Kenny Tan
  • Healthcare Consultant and Author: Dr Jeremy Lim
  • Deputy Director (Healthcare Charity Sector): Mr Kenneth Foo

*Disclaimer: Dr Tan and Dr Lim had agreed to be part of the panel in their personal capacities. Kenneth, while being a member of the WP, shared his personal views based on his own experience in the healthcare-related industry.

Sustaining Healthcare for an Ageing Population
A panelist sparked off discussions on challenges brought about by Singapore’s ageing population, which in turn was addressed by plans introduced by government-initiated committees. References were made to Minister of Health Gan Kim Yong’s speech during the Parliamentary Debate on the Eldershield Review Committee Report dated 10 July 2018, where the ‘3 Beyonds’ philosophy was introduced to ‘keep healthcare in Singapore good and affordable into the future’ (https://www.straitstimes.com/singapore/health/the-3-beyonds-singapores-strategy-to-sustain-quality-healthcare-as-demand-rises):

  1. Beyond Healthcare to Health
  2. Beyond Hospital to Community
  3. Beyond Quality to Value

A low trust and complex system
While one panelist acknowledged the government’s efforts, he argued that the system appeared to be built upon a low level of trust, leading to undesired outcomes such as high administrative costs.
Referencing to the recent CHAS subsidy miscalculation incident, the panelist felt that the occurrence of the incident was not surprising. What was even more surprising, he felt, was that the individuals receiving the subsidy and the service provider involved were not aware of the miscalculation. He argued that this incident was evidence of a highly complicated system.
Coupled with the government’s aversion to giving out money to those who they felt were undeserving, a large proportion of the population do not know how much subsidy they would be receiving and this tends to raise anxiety among Singaporeans.
The panelist then contrasted this with the National Health Service (NHS) in the United Kingdom (UK), where the citizenry had to pay a fixed fee after treatment. The NHS system was easy to understand and gave peace of mind to individuals, though the UK and Singapore system each have their own advantages and disadvantages.

“Wait-and-See” Approach to Healthcare
Another panelist shared that, from his experience, Singapore tended to be more conservative and adopt a “wait-and-see” approach when implementing new ideas, due to a possible inherent fear to try something novel.  He expressed the view that while the current framework appeared to be well set-up, it also felt ‘cooped-up’ and the desired outcomes did not resonate on the ground. This may be a big hurdle to fulfilling the goals centered around the aforementioned ‘3-Beyonds’ philosophy.

Creating Communities or Communes?
One panelist reflected on two areas affecting healthcare service operations: manpower and money. He found that resources to address the needs of the ageing population have seemed to increase recently, notably on building tertiary healthcare capacity as well as infrastructure such as nursing homes and turnkey projects such as Kampung Admiralty. In regards to the latter, the elderly would be able to live in a curated urban landscape whilst taking advantage of healthcare services under one roof. The panelist noted, however, that a conundrum had arisen; creating community versus creating communes. It was also mentioned later in the session that despite the provision of such infrastructure, only a portion of the elderly would be able to benefit from it as it all boils down to affordability.

Questions to the panelists on this conundrum were raised from the floor. One of the panelists acknowledged that while the provision of quality care was not in doubt, its distribution and integration was uneven, and exacerbated by the regrouping of healthcare clusters over the past decade.
Another panelist suggested that Singapore’s healthcare model as a whole was in need of a review due to its heavy reliance on bureaucracy. It was agreed upon by the panel that the system is likened to ‘a dam with a few holes’, where tweaks to the system would be patching these holes, which in turn adds more layers and adds complexity to an already complex system. Building on the analogy, one panelist called for a new dam to be built, i.e. an entirely new system. Once completed, we could make a slow transition to it and once that was done, tear the old dam down. While this new system could be made simpler to the benefit of the population, the allocation of trust and responsibility placed on Singapore citizens has to be measured carefully, in order to minimise the possibility of loopholes which could be exploited.

Q&A

One panelist kickstarted the Q&A session on the premise of healthcare costs being a growing concern, especially with the shrinking old-age dependency ratio (ODR) in Singapore, coupled with growing healthcare costs based on feedback from the ground.
Another panelist raised 2 points: that the perception of value is very personal, and the issue of tiering of subsidies. For the latter, the existing tiers would lead to undesired outcomes where minimal increases in pay could lead to a drastic drop in subsidies. Arbitrary tiering could provide relief, where healthcare institutions set up by charities could play a greater role by stepping in and maintaining service rates as low as possible, but he acknowledged that expectations may be difficult to manage.

Beyond Pioneer and Merdeka Generation Schemes
Another panelist noted the gap between the upper and lower socio-economic segments of the population (in terms of income), where the former usually has access to insurance, and the latter benefits from the government via subsidies and supplementary assistance schemes such as CHAS. However, those in the middle are the ones feeling the most pressure as they do not meet the criteria to qualify for certain subsidies such as CHAS, Pioneer and the upcoming Merdeka Generation schemes. It was suggested that an all-encompassing scheme for the entire population should be formulated, instead of the current patchwork of cohort-specific and means-tested schemes.

Rising Healthcare Costs
In most healthcare systems, the bulk of the cost comes from labour. One addressable issue at the moment would be simplifying the system whenever possible to generate reduced administrative costs. Next would have to come taking steps towards striking a better balance between the financial risk to be borne by the population and the goal of fiscally sustainable yet effective state healthcare spending.

Paternalism, Partnership and Participation
A question was raised in regards to responsibility borne by the government which, it was argued, should be greater in Singapore’s context given how much our governmental leaders are being paid.
A panelist raised the concept of the 3Ps of healthcare philosophy: ‘Paternalism’, ‘Partnership’ and ‘Participation’. He expressed that the first philosophy was becoming archaic, and could become an Achilles heel, given the public appetite for a greater government role in healthcare. A shift towards partnership and participation would be ideal.
The view that the population appears to be more burdened was raised by an elderly participant, and she felt that out-of-pocket expenses i.e. on medicine, consultations etc., seem to be quite high.

A point on Kampung Admiralty was briefly raised as well as an opinion that we ought not to simply “medicalize” elder-care.

Pay More Taxes for More Healthcare?
In some European countries (i.e. Finland, Norway), citizens pay more taxes since young, knowing that it would benefit them in the long run with heavily-subsidised healthcare, as well as benefit the current elder generation. The panelists agreed that to bring such a concept to Singaporeans now required the political will to change the way Singaporeans view how healthcare should be provided.

Hopes for Singapore’s healthcare system
“What is one key feature of other healthcare systems would you like to see adopted here in Singapore?” a participant asked. One panelist reiterated his view that more trust should be placed on Singaporeans. He said that the prevalence of data should be taken advantage of to ‘identify the rotten apples early so that the good apples would be able to benefit more’. In addition, a systemic change would be required in heightening support towards those who can be treated and those who cannot be healed (i.e. terminal illnesses).
Another panelist raised Japan as an example, where pride and culture take centre-stage. This cannot be legislated and is something which Singaporeans have to collectively own. The transformation of Singapore’s healthcare system has to be a multi-ministry effort, beginning from education. Our educational institutions are responsible for inculcating values in our future generations, in order to bring about changing attitudes towards the level of responsibility which should be taken by Singaporeans towards healthcare.
On a side note, one panelist indicated that CHAS may in fact introduce stigma within the population, due to tiering of subsidies by income.

Breakout sessions
Youth Voices attendees were given the opportunity to share their views with panellists who moderated their breakout group. Highlights from these discussions include the following:

  • What’s the level of trust given to doctors from the public and the private sectors in regards to dispensing particular drugs?
    • Medication with higher efficacy may not be subsidised and this potentially limits the doctor’s discretion, though widening the degree of discretion also opens the door to sharp cost increases.
  • Would we rather pay more taxes to subsidise healthcare in the future, or stick with lower taxes and focus on prevention, screening for early detection and healthy lifestyle pursuits?
  • It appears that there are quite a number of pilot schemes in healthcare. But has the data generated been of use to academics, healthcare experts and civil society bodies who can play a part in designing healthcare policies?
  • Quality of care could have been compromised by the KPI-driven attitudes of healthcare professionals. One participant opined that those trained overseas are perceived to be more care-driven than those trained locally.

Closing statements
The session was brought to a close with a few statements on mindset; the need for changes to Singapore’s healthcare system to cope with trends like aging; and the need to reign in expenditure growth.
It was mentioned that caregiving is not entirely influenced by financial capability, as mindset, perception of care, communication and coordination play a part. The frequent reorganisation of healthcare clusters show that there could be an inherent lack of coordination in the system. It was also recognised that the attitudes of the population towards healthcare will play a key role in deterring how the system evolves. In future, the government’s role may need to focus more on creating an enabling environment for patients, healthcare providers, insurers and state financers to engage with one another.

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