Dr Akhileswaran, Chairman of Singapore Hospice Council
Associate Professor Edward Poon, Organising Chairman of the Singapore Palliative Care Conference 2014
Ladies and gentlemen
1. Good morning. I am happy to welcome all of you, especially our guests from overseas, to Singapore for a second time for this Conference.
2. Palliative care has become even more important today, in the context of our rapidly ageing population. We need to invest in developing palliative care services, as this is a critical piece in our overall efforts to provide good and affordable care.
3. Two years ago, at this same conference, I announced that the Ministry of Health had commissioned the Lien Centre for Palliative Care to develop a National Strategy for Palliative Care (NSPC) in consultation with stakeholders in the healthcare sector. An industry-led Implementation Taskforce chaired by A/Prof Pang Weng Sun and A/Prof Cynthia Goh was subsequently formed to study how to implement the recommendations of the strategy. The taskforce has since been hard at work since then, and today, I am pleased to share with you a plan of action by the Ministry of Health, to develop palliative services systematically and holistically across care sectors.
Palliative Care plan
4. MOH will invest in developing palliative care services in four main areas. First, we will enhance the quality of palliative care services, across different care settings. Second, we will invest in expanding both residential and non-residential palliative care service capacity. Third, we will implement measures to enhance the affordability of palliative care services, and finally, MOH will work with a number of community partners to promote public awareness about palliative care and end-of-life issues. Let me go into each area one of them in greater detail.
Raising quality of palliative care
5. In the area of care quality, I am happy to announce that the Implementation Taskforce has developed a set of draft National Guidelines for Palliative Care. These Guidelines articulate what we can strive for to achieve high-quality, evidence-based palliative care across the entire healthcare sector, in many different care settings including hospitals, intermediate and long-term care institutions, primary care, hospices, as well as patients’ homes. The Guidelines cover four broad domains. First, they articulate what is required for holistic, individualized and responsive patient care. Second, they articulate how patients’ caregivers and families should be supported, including in the bereavement period. Thirdly, they articulate what is required for good staff and volunteer management, in order to maintain a well-trained and professional workforce. And finally, they articulate what is required for safe care. We will be conducting a series of consultations with the palliative care sector, other healthcare professionals as well as patients and caregivers before finalising these Guidelines.
6. MOH supports these Guidelines and will work with the Singapore Hospice Council, the umbrella body for palliative care in Singapore, to promote and implement these Guidelines. As a start, the Guidelines will be used for developmental purposes, to help providers identify potential areas for improvement and gradually raise the quality of their services. MOH will partner and support the Council in reaching out to providers across the different care settings, to promote awareness of the Guidelines and to explain what they mean in terms of delivery of care in each of these settings. We will also support the Council in developing programmes and initiatives to help different care providers to meet these Guidelines, such as interpretation guides, voluntary self-assessment tools, training programmes for staff, quality improvement projects, and so on.
7. Ultimately, whether we can translate the Guidelines to good palliative care depends critically on the quality of our healthcare professionals. A recent survey by the Lien Foundation among healthcare professionals found that almost all doctors and nurses surveyed agreed that palliative care was important for those with life-threatening illnesses, but less than half of them reported being familiar with palliative care.
8. I am therefore happy to announce the launch of a new course, the Graduate Diploma in Palliative Medicine, by the Chapter of Palliative Medicine Physicians and the Division of Graduate Medical Studies, NUS. The inaugural year-long course will start in July this year. I am very encouraged that the response to the course has been very good and we already have a full class. The first cohort of doctors come from a variety of settings, including acute and community hospitals, the intermediate- and long-term care sector, as well as primary care. This is a concrete first step towards getting more clinical professionals across different settings to be trained in the relevant skills to deliver palliative care. We will need to sustain this effort so that over time, we will have a whole team of healthcare professionals who are confident and able to deliver good palliative care to their patients.
9. One of the doctors in the first cohort is Dr Melvin Goh, a general practitioner. Dr Goh shared that in his earlier years, he was never comfortable caring for dying patients and their families. But having seen first-hand the care provided by a palliative care team to his own wife after she was diagnosed with cancer, he was inspired to join the Singapore Cancer Society as a part-time doctor with their home hospice services. He said, and I quote, “my heart was prompted to be just an extra one doctor filling this gap. I wanted to be there for our patients and their caregivers when they really need our help in times of need”. Having already gone through some training in palliative care, he jumped at the opportunity to sign up for the Graduate Diploma in Palliative Medicine, to further develop his skills. I am very pleased to see GPs like Dr Goh contributing to the palliative care sector and I hope many more will follow in his footsteps.
Enhancing accessibility of palliative care
10. In the area of enhancing access to care, the Ministry of Health will significantly boost the capacity of palliative care services.
11. Many patients wish to spend the last days at home, in a familiar environment, and surrounded by loved ones. Another survey among the general public done by the Lien Foundation earlier this year showed that about eight in ten people wish to die at home, rather than in a hospital or institution.
12. MOH will resource different care providers to ramp-up home palliative care services by at least 1,000 more places by 2020, from the 5,000places today. In addition to the expansion of home palliative care services for cancer patients, we also hope to serve more patients with non-cancer diagnoses, such as end-stage organ failure. We aim to partner home care providers to expand home palliative care services for patients with end-stage organ failure, as this is a gap in our current service sector.
13. Some patients on home palliative care may still require care in inpatient facilities to stabilise their condition when their illnesses take a turn for the worse. MOH will work with care providers to increase the number of inpatient palliative care beds from 147 today to 360 beds by 2020. MOH had earlier supported Dover Park Hospice in increasing its bed numbers, and will also be supporting Assisi Hospice in expanding its capacity by 50 beds when it moves to its new building by end-2016.
14. MOH will also be developing beds in community hospitals to cater for patients on palliative care. Community hospitals can supplement our inpatient hospices, and support our home palliative care services as well as nursing homes, by providing short periods of care to patients who have acute needs or exacerbations, before helping them to return home.
15. Our Regional Health Systems will also be supporting nursing homes in advance care planning and end-of-life care, such that their elderly residents can be well cared for towards the end-of-life according to their wishes. As a start, two Regional Health Systems, the National Healthcare Group and Alexandra Health System, have been resourced to upskill 14 nursing homes, with a total of about 2,800 beds, in Advance Care Planning, geriatric care, and end-of-life care. In particular, Khoo Teck Puat Hospital will be embarking on an innovative tele-health system linking the hospital up with nursing homes in the northern region of Singapore. Through this system, the KTPH geriatric team can provide consultation services and training to nursing home staff, and even hold multi-disciplinary case conferences and audits.
Ensuring the affordability of palliative care
16. The Lien Foundation survey among the general public also found most respondents were concerned about the costs of palliative care. On this front, MOH will do more to ensure that providers are well-resourced to provide the quality care that we are aiming for, and that palliative care services always remain affordable for our patients.
17. From 1 Jan 2015, MOH will allow more Medisave to be used for palliative care to help reduce patients’ cash payment. Currently, patients can use $160 per day from their Medisave to pay for their stay at inpatient hospices. MOH will raise the Medisave withdrawal limit to $200 per day. This, together with up to 75% subsidy for inpatient hospice services, will help address concerns about affordability.
18. MOH will also increase the lifetime limit for Medisave use, whether for patients or their family members, from $1,500 to $2,500 to pay for home palliative care. In fact, for patients with terminal illness such as cancer or end stage organ failure, MOH will allow patients unlimited use of their own Medisave for home palliative care. Together with subsidies of up to 80%, we hope patients and their families need not worry about palliative expenses at a difficult time.
19. MOH will also improve funding for home palliative care providers. Currently, providers are funded based on the number of visits made to patients. I think we should shift our focus, not so much on the number of visits, but on the outcomes. From 1 July this year therefore, MOH will provide home palliative care providers with increased funding, based on a fixed amount of funding for every patient under their care each month. This new approach to funding will deliver a more predictable stream of financial resources, enabling providers to plan and deliver more holistic, patient-centric services. More importantly, it will also give greater flexibility to test out new models of care for the benefit of our patients.
20. Finally and perhaps most importantly, MOH will be working with various community partners to multiply public education efforts. We want to outreach to more people so that they will be aware of palliative care services available towards the end-of-life, and the importance of Advance Care Planning. We want them to know that it is alright to talk about issues surrounding death, and that it is important to know the care options that they have at the end-of-life.
21. I would like to commend the good work thus far of organisations like the Singapore Hospice Council and the Lien Foundation, who have been actively championing public awareness of palliative care and end-of-life issues. In May this year, the Lien Foundation organised a series of roadshows with getai performances called “Die Die Must Say” in locations across Singapore, to encourage discussions about death and dying. It was very well-received by the public and sparked a lively discussion in the media about a “good death”. I understand that both SHC and Lien Foundation have more events planned for the later part of this year, and MOH hopes to work with them on more such community outreach efforts.
22. On its part, the Agency for Integrated Care (AIC) will be working with several VWOs to raise awareness of Advance Care Planning in the community. Advance Care Planning, or ACP, is a series of conversations between trained facilitators, individuals and their family members about the individuals’ preferences for care towards their end-of-life, and what a “good death” means to them. It is an important part of ageing well and planning ahead, along with other aspects like making a will and signing a Lasting Power of Attorney. AIC aims to reach out to around 1,500 seniors in the community through workshops and outreach events, and enable interested seniors to have these important conversations. For example, Sheng Hong Lifepoint is one of AIC’s partners who will reach out to seniors in the Chinatown area. AIC supports these VWOs by training their staff in ACP facilitation, and also equipping selected staff and volunteers to be ACP Advocates who can share about ACP with their friends and their loved ones. AIC aims to train at least 150 of such facilitators and advocates among the VWOs, over the next three years.
23. In short, following the establishment of the National Strategy for Palliative Care, we have set out a concrete plan to work towards enhance the quality, accessibility and affordability of palliative care. This is a multi-year effort, and we will continue to review our policies and make improvements, in partnership and consultation with stakeholders in the sector. In line with this year’s theme, we will continue to build bridges between the government, healthcare institutions, palliative care professionals, voluntary welfare organisations, and academics and researchers, to enhance palliative care in Singapore. I look forward to many more fruitful partnerships with you.
24. Before I end today, I would like to pay tribute to all the palliative care professionals gathered here, for your tireless devotion to patients and their families, despite the heavy physical and emotional demands of your work. You have touched the lives of many, and it is because of you that palliative care is what it is today in Singapore. Thank you once again.
25. Finally, I would like to congratulate SHC on its successful bid to host 2017 Asia Pacific Hospice Conference. I note that this is one of the most prominent palliative care conference in the Asia-Pacific Region, and I look forward to it coming to our shores.
26. Thank you and have an fruitful conference.