Integrate now, create health: perspectives from Singapore

Abstract

Population ageing is arguably humanity's greatest challenge in the 21st century. The magnitude of this phenomenon, compounded by the increasing burden of chronic illnesses and the question of longevity and quality of life, will undoubtedly create health, economic and social demands on all developed and developing countries [1]. In Singapore, the government has created a multi-agency effort, led by a senior statesman, comprising of different public and non-governmental agencies representing social welfare, health, transport, housing, and infrastructure. This is a concerted effort to coordinate amongst various parties to manage what has been aptly termed as the ‘silver tsunami’. Singapore is the second most rapidly ageing population in the world today, due mainly to two key factors—the rapidly declining total fertility rate, and the increasing life expectancy at birth. While the population is still generally young now (8.5% are over 65 years old), the proportion of elderly is set to almost triple within the next 25 years. The impending silver tsunami has forced our healthcare system to reorganise how we deliver care. With the ageing profile, increasing acuity and greater frailty of our patients, more will require a longer period of care to recover. Many will need continued rehabilitation, some will need some level of transitional care support at home and others may need convalescence in nursing homes and other aged care facilities. Hence, our care delivery system is undergoing a massive restructuring, moving from ‘silo or compartmentalised episodic care’ to a more integrated approach by forming regional health systems, whereby an acute general hospital is linked to a community rehabilitation hospital supported by a network of primary care providers, community home care teams and day rehabilitation centers as partners. The importance for close coordination and effective collaboration between the acute hospitals and their clinical partners in the community becomes more urgent so that patients can transition seamlessly from one provider and setting to another. Underpinning the restructuring is an electronic health record system that is being developed nationally. This virtual and longitudinal health record will be accessible to all authorised medical practitioners at our hospitals and primary care centres, and eventually extending to the community care sector. It will allow for more effective treatment and monitoring of patients, who may receive a spectrum of healthcare services from different providers. The notion of integrated regional health systems is certainly not a new concept nor model, but few countries or health systems have managed to successfully implement this. Some of the examples that have been often mentioned in the literature (e.g. Jonkoping in Sweden, Geisinger and Kaiser Permanente in the US, etc.) are exceptions rather than the rule. A key consideration is the political and social milieu within which the health care system operates, the financing system and the presence of real leadership to drive the change and integration that is necessary. Singapore has the advantage of being a very small nation of some 5 million residents. It also has the advantage of having a relatively high penetration of the use of technology by individuals and in the homes. Such infrastructure has played a key role in fostering integration of care at a faster pace. In addition, Singapore's healthcare system is underpinned on a unique philosophy of individual responsibility, coupled with a national system of individual health savings accounts and co-payment. In this regard, health policy has managed to influence individual behaviour towards maintaining healthy and avoiding unnecessary healthcare utilisation. Today, Singapore's healthcare expenditure as a percentage of GDP is 4.5% [2]. Despite this, however, the challenge still remains as the population ages and chronic diseases such as diabetes, hypertension and stroke increase in prevalence. In 2009, the Singapore's Ministry of Health gave the mandate to the Agency for Integrated Care (AIC) [3] to oversee, coordinate and facilitate all efforts in care integration. It is recognized that in order to continue providing affordable, quality healthcare, health systems have to be restructured in such a manner that enhance efficiency and reduce fragmentation, with integration as a key reform driver [4]. AIC is now tasked with performing the role of a ‘national care integrator’. Part of AICs strategic thrusts is to develop the capacity and quality of primary care and community care, and connecting the various healthcare providers for better health outcomes. As part of our strategic effort in integration, the AIC will also be implementing a new national care assessment framework for more accurate and consistent identification of individual needs for community and continuing care. This will be fully implemented by the end of 2011. As our healthcare system evolves and becomes more integrated in the coming years, a great deal still remains to be done to improve the cost-effectiveness and efficiency of delivering care and to improve the overall health of the population. A number of ambitious frameworks have since been developed which are worth studying—one of which is the Institute for Healthcare Improvement (IHI) Triple Aim—which provides working models and principles for better and more efficient care, keeping costs affordable and keeping populations healthy. This is a model which the Singapore healthcare system is working towards. As many more integration initiatives will take off in the next few years across many countries, we are pleased to organise the Inaugural Asian Conference on Integrated Care in Singapore from 25 to 26 February 2011. This is a collaboration between AIC and the International Network of Integrated Care (INIC), and participants can expect to hear from prominent experts from the USA, Europe and Australia, as well as our fellow colleagues from the Asia Pacific Region involved in care integration initiatives. We hope to welcome you in Singapore in February next year!