The holy grail of eldercare in Singapore

Associate Professor Chin Jing Jih is director of the Institute of Geriatrics and Active Ageing and divisional chairman (Integrative and Community Care) at Tan Tock Seng Hospital.

What was your reaction to the Pioneer Generation Package?

It is a quantum that is large enough to be impactful. It was fairly comprehensive in that it looked at Medisave, MediShield Life, and SOC (specialist outpatient clinics). Many seniors in the pioneer group are concerned they will be a burden to their family. Psychologically, the package has the great effect of giving the comfort that there is a lot of backup.

What are the top misconceptions people have about the elderly's health-care needs?

A lot of times, people think that seniors are too old to benefit from any health-care intervention.

The other misconception is that the elderly are illiterate and cannot understand what's happening, so they are left out of decisions. That is a kind of ageism which sidelines old people, and because of that, they are not offered the appropriate treatment.

We should try our best to involve them. You are then able to include them in setting the goals they desire for that phase of their life and see what's appropriate.

The seniors also need to know that they are able to make that decision. One key thing of this Pioneer Generation Package is, if I'm an old person and the doctor offers me a treatment, in the past, I would look at my children and wonder, can they afford it? Am I going to burden them? At least now, I don't have to turn my head, I can think whether this outcome is something I want.

The package has three main components. Is this sufficient and were there other areas you wished could have been covered?

Covering these three areas is fairly comprehensive. The question is what to include or exclude subsequently. For example, as a person ages, besides health care, psychological and social care is important. We can look gradually at how some funding schemes can be opened up slightly to include such things, because we should also realise the three systems are interdependent. We should look at which area of spending is most cost effective and gives the best outcomes in health.

In your opinion, which area of spending would that be?

There is still a lot of preventive care that can be done in, for example, vaccination, sponsoring elders to see the dietitian to get advice on what to eat, and also control of their chronic diseases. One important thing is to recognise that all those who qualify for this pioneer package are not all the same. They may be at different ages, different stages of their disease and have different needs. As our seniors age, they may use different parts of the package more. What is important is for that utilisation to be driven by sound medical decisions and advice, and also to focus on quality of life rather than just quantity of life.

Is the system flexible enough to allow for this differentiated use?

Many of these changes are already taking place at the Ministry of Health. They are constantly engaging clinicians on innovations. For instance, I think it's a matter of time before we may either allow the use of Medisave for home care or follow some countries where, if you are able to shorten your hospital stay by going home earlier, the savings can be ported over for either community or home care.

The package places all the pioneers on MediShield Life. Is the national medical insurance scheme the right approach when it comes to health-care financing?

Having a national health insurance model is a very powerful statement. It says that this whole nation has a certain solidarity and compact between the healthy and unhealthy, those who can afford and those who can't afford.

Some are concerned that by putting a lot of elderly on MediShield Life, it would lead to increased risk and the young will pay more premiums. That is a possibility. But the safeguard against that is for the utilisation to be driven by sound medical judgment based on transparency of data, good ethics and professionalism in patients' best interest.

There's an ongoing debate over doctors who charge patients high prices or for unnecessary treatments since insurance will cover the bill, which may then lead to insurers raising premiums.

That's why I said professionalism and ethics are important. The way to counter this is transparency of data. You can see what everybody is charging and is it fair. And there has got to be checks and balances. You have to strike a balance between trust and yet there must be some check and balance to ensure that those who are not trustworthy cannot abuse the system. This is the new challenge in health-care financing.

With the emphasis on subsidies for SOCs in this Budget, there is a worry that it will overload the SOCs as patients may now want to go directly to them instead of GPs or polyclinics.

With my patients, I actually have to persuade them to undergo some tests. I don't see them coming to say, I want this test, I want that test. That's not the behaviour of our seniors - and full credit to them. Let's not forget that they are older than us, wiser, and have a perspective of what constitutes quality of life. Quality of life is not going to the hospital every day and demanding for tests to find out whether you have a condition. In fact, what many of them want is the assurance that if they follow a certain treatment plan, their risk of having to be institutionalised is lower. That is really the dream of the majority of our elderly. They want to age at home, they don't want to end up in an institution, in a hospital, they don't want to be a frequent visitor of clinics. So I'm not worried that it will lead to a buffet syndrome of sorts.

How can the system improve to help seniors age at home?

If you look at the history of our health-care system, in the 1960s, there were a lot of successful public health initiatives that improved survival, reduced infant mortality and prolonged lifespan.

Then in the 80s and 90s, the investment was mainly in specialist care and hospitals. We sent our brightest doctors overseas to train as specialists and they were able to overcome a lot of diseases previously considered incurable. The effect is we now have an ageing population where fewer people die young, but they have chronic diseases that they carry with them.

There is a need to balance specialist care with investment and integration with primary and community care. The ultimate holy grail is: we become one system of shared accountability, where more use primary and community care and the hospital is used only when the illness is beyond the expertise of primary care. This way, the hospitals can be decongested, with beds always available during a medical emergency.

There also needs to be a relook of the whole system because seniors tend to have multiple problems. We need to recognise the importance of training generalists. In the past, medical students on a renal medicine posting may spend all their time following a specialist, looking at how to manage patients in the hospital. But they now also need exposure to what happens to these patients when they go home. How does a GP help look after a patient with chronic renal failure or pick up kidney diseases early in the community? How do the hospital, GP and community dialysis service share accountability for the patient?

Is Singapore is a good place to grow old in?

It is, but more can be done. What is good is you actually see a desire to do better. One of the most important things is whether society recognises the old as an integral part of itself, or whether they are just a used machine now no longer productive, to be tucked in a corner. The Pioneer Generation Package is a very strong statement that this Government is concerned about its old and willing to put its money where its mouth is.

That sends a great message to the young about the inter-generational compact and solidarity. In the past, you hear a lot about investing in the younger generation for the continuity of the nation. That hasn't stopped. But respecting the old and transferring resources to the next generation do not have to be mutually exclusive.

Some fear the package will tell people, "don't worry, if you're not filial, I will take over your job". I disagree; the package is not meant to substitute the duties of children in providing for the health care of their parents. On the contrary, the message is something like "even the Government is now helping, you jolly well also preserve this virtue called filial piety that is very much valued by society". It is not like some societies where young and old are competing for resources. It is a sharing of resources in the right proportion.

What was your reaction to the Pioneer Generation Package?

It is a quantum that is large enough to be impactful. It was fairly comprehensive in that it looked at Medisave, MediShield Life, and SOC (specialist outpatient clinics). Many seniors in the pioneer group are concerned they will be a burden to their family. Psychologically, the package has the great effect of giving the comfort that there is a lot of backup.

What are the top misconceptions people have about the elderly's health-care needs?

A lot of times, people think that seniors are too old to benefit from any health-care intervention.

The other misconception is that the elderly are illiterate and cannot understand what's happening, so they are left out of decisions. That is a kind of ageism which sidelines old people, and because of that, they are not offered the appropriate treatment.

We should try our best to involve them. You are then able to include them in setting the goals they desire for that phase of their life and see what's appropriate.

The seniors also need to know that they are able to make that decision. One key thing of this Pioneer Generation Package is, if I'm an old person and the doctor offers me a treatment, in the past, I would look at my children and wonder, can they afford it? Am I going to burden them? At least now, I don't have to turn my head, I can think whether this outcome is something I want.

The package has three main components. Is this sufficient and were there other areas you wished could have been covered?

Covering these three areas is fairly comprehensive. The question is what to include or exclude subsequently. For example, as a person ages, besides health care, psychological and social care is important. We can look gradually at how some funding schemes can be opened up slightly to include such things, because we should also realise the three systems are interdependent. We should look at which area of spending is most cost effective and gives the best outcomes in health.

In your opinion, which area of spending would that be?

There is still a lot of preventive care that can be done in, for example, vaccination, sponsoring elders to see the dietitian to get advice on what to eat, and also control of their chronic diseases. One important thing is to recognise that all those who qualify for this pioneer package are not all the same. They may be at different ages, different stages of their disease and have different needs. As our seniors age, they may use different parts of the package more. What is important is for that utilisation to be driven by sound medical decisions and advice, and also to focus on quality of life rather than just quantity of life.

Is the system flexible enough to allow for this differentiated use?

Many of these changes are already taking place at the Ministry of Health. They are constantly engaging clinicians on innovations. For instance, I think it's a matter of time before we may either allow the use of Medisave for home care or follow some countries where, if you are able to shorten your hospital stay by going home earlier, the savings can be ported over for either community or home care.

The package places all the pioneers on MediShield Life. Is the national medical insurance scheme the right approach when it comes to health-care financing?

Having a national health insurance model is a very powerful statement. It says that this whole nation has a certain solidarity and compact between the healthy and unhealthy, those who can afford and those who can't afford.

Some are concerned that by putting a lot of elderly on MediShield Life, it would lead to increased risk and the young will pay more premiums. That is a possibility. But the safeguard against that is for the utilisation to be driven by sound medical judgment based on transparency of data, good ethics and professionalism in patients' best interest.

There's an ongoing debate over doctors who charge patients high prices or for unnecessary treatments since insurance will cover the bill, which may then lead to insurers raising premiums.

That's why I said professionalism and ethics are important. The way to counter this is transparency of data. You can see what everybody is charging and is it fair. And there has got to be checks and balances. You have to strike a balance between trust and yet there must be some check and balance to ensure that those who are not trustworthy cannot abuse the system. This is the new challenge in health-care financing.

With the emphasis on subsidies for SOCs in this Budget, there is a worry that it will overload the SOCs as patients may now want to go directly to them instead of GPs or polyclinics.

With my patients, I actually have to persuade them to undergo some tests. I don't see them coming to say, I want this test, I want that test. That's not the behaviour of our seniors - and full credit to them. Let's not forget that they are older than us, wiser, and have a perspective of what constitutes quality of life. Quality of life is not going to the hospital every day and demanding for tests to find out whether you have a condition. In fact, what many of them want is the assurance that if they follow a certain treatment plan, their risk of having to be institutionalised is lower. That is really the dream of the majority of our elderly. They want to age at home, they don't want to end up in an institution, in a hospital, they don't want to be a frequent visitor of clinics. So I'm not worried that it will lead to a buffet syndrome of sorts.

How can the system improve to help seniors age at home?

If you look at the history of our health-care system, in the 1960s, there were a lot of successful public health initiatives that improved survival, reduced infant mortality and prolonged lifespan.

Then in the 80s and 90s, the investment was mainly in specialist care and hospitals. We sent our brightest doctors overseas to train as specialists and they were able to overcome a lot of diseases previously considered incurable. The effect is we now have an ageing population where fewer people die young, but they have chronic diseases that they carry with them.

There is a need to balance specialist care with investment and integration with primary and community care. The ultimate holy grail is: we become one system of shared accountability, where more use primary and community care and the hospital is used only when the illness is beyond the expertise of primary care. This way, the hospitals can be decongested, with beds always available during a medical emergency.

There also needs to be a relook of the whole system because seniors tend to have multiple problems. We need to recognise the importance of training generalists. In the past, medical students on a renal medicine posting may spend all their time following a specialist, looking at how to manage patients in the hospital. But they now also need exposure to what happens to these patients when they go home. How does a GP help look after a patient with chronic renal failure or pick up kidney diseases early in the community? How do the hospital, GP and community dialysis service share accountability for the patient?

Is Singapore is a good place to grow old in?

It is, but more can be done. What is good is you actually see a desire to do better. One of the most important things is whether society recognises the old as an integral part of itself, or whether they are just a used machine now no longer productive, to be tucked in a corner. The Pioneer Generation Package is a very strong statement that this Government is concerned about its old and willing to put its money where its mouth is.

That sends a great message to the young about the inter-generational compact and solidarity. In the past, you hear a lot about investing in the younger generation for the continuity of the nation. That hasn't stopped. But respecting the old and transferring resources to the next generation do not have to be mutually exclusive.

Some fear the package will tell people, "don't worry, if you're not filial, I will take over your job". I disagree; the package is not meant to substitute the duties of children in providing for the health care of their parents. On the contrary, the message is something like "even the Government is now helping, you jolly well also preserve this virtue called filial piety that is very much valued by society". It is not like some societies where young and old are competing for resources. It is a sharing of resources in the right proportion.