ETHOS Issue 26, Nov 2023
You wear several hats in the healthcare sector. How do your different roles help
in advancing the future of healthcare in Singapore?
I set up and am currently Chairman of the MOH Office for Healthcare Transformation (MOHT). It was established five years ago to look at more fundamental challenges to our health system, and to work on how we can facilitate and accelerate the transformation of the health system. We chose a number of critical areas in healthcare, such as primary care, where we felt major changes were needed. We focused on scaling: developing capabilities to take ideas that had been shown to be promising and cost effective, and scaling them up to the mainstream system much more quickly.
I am also Chairman of the Healthier SG Implementation Office, which was set up less than two years ago. To deliver a complex multi-stakeholder programme like Healthier SG, we needed a new structure to integrate all the different policy inputs that impinge on delivery, bringing them together in a coherent implementation plan to be carried out. For instance, what takes the most time in Healthier SG is developing the supporting IT system. But for these IT changes to be delivered in time, you first have to confirm the clinical model, clarify the financial mechanisms, and determine the data reporting requirements, and freeze these. This is what I call the policy-policy integration. Then there is the policy-operations interface, which often involves a much wider range of health family and non-health partners. The Implementation Office I chair looks after these aspects of integration, to ensure the effective rollout of the Healthier SG programme.
I also chair the Human Health and Potential Executive Committee, which oversees the biomedical sciences, research innovation and enterprise system. Many clinical improvements, or concepts such as precision public health, come out of the research lab. We need to convert these research-based approaches or products into implementable clinical and public health interventions. Being Chief Health Scientist up until September 2023 gave me the opportunity to help bring useful research ideas and applications into play: developing a system where they can be tested and validated more quickly in practice, then adopted more widely.
The different roles I play overlap, and provide opportunities to synergise between them, on the national scale.
WHY IT IS DIFFICULT TO SCALE UP IN A HEALTH SYSTEM
Healthcare innovations do not scale easily because many elements have to be brought together at the same time in order for them to be adopted widely.
You need leadership as well as a whole change management system for the professionals. Then the new technology you need to bring in must work, and must interface with the mainstream systems, with smooth data flows. Having the right payment systems and incentives are also critical, and in some cases adjustments to regulatory requirements.
Say you want to allow patients to receive hospital-level care at home: the providers and care teams need new protocols and processes to ensure care can be safely and effectively delivered. Suitable patients have to be selected. The payment system has to make financial sense for the patient, provider and payor. Regulatory issues have to be addressed to allow the innovation while protecting patient and public interests, and so on.
All this is often too complex for institutions to deal with because it requires many different parties to come together in the right environment, and enablers have to be developed so that scaling can proceed. Significant variations in practice across different providers often also hamper scaling.
On a national scale, how can the Public Service in general, especially non-health-related agencies, contribute to the goals of Healthier SG?
I think the Public Service can play a very critical role in several areas.
One area is in enabling and sustaining behaviour change. In considering behaviour, we quite often think in terms of individuals: our mental model is to educate, nag and nudge individuals, say to exercise, one person at a time. This is important, but it is hard; it would take a long time to have an impact on the whole population this way. But there are other behavioural drivers, such as environmental or cultural factors, that could have a broader impact at the population level.
Behavioural drivers, such as environmental or cultural factors, could have a broader impact at the population level.
A good example is cigarette smoking, which has perhaps seen the most successful public health intervention. Smoking is expensive because we have put taxes on it. And we have made cigarettes difficult to access, because we have all kinds of restrictions on its sale. Smoking is prohibited in most public spaces. The nett effect of these non-health measures is that it is not easy to smoke. Overall, some 90% of our people do not smoke. Over time, the cultural and social norm is to not smoke, except perhaps among certain limited groups. So a combination of these environmental changes engenders a social norm towards desirable behaviours. In fact, a few behaviours—lack of physical activity, poor diet, and smoking—contribute disproportionately to bad health outcomes, accounting for more than 40% of mortality.
Take physical activity: what can we do to promote it? We could try to persuade people to exercise, but if we make it easy—if our neighbourhoods are walkable, pleasant and safe; if there are nodes that promote interaction with others; if there is good programming and placemaking along the way to offer activities and a sense of place—then people are more likely to congregate and walk, whether for leisure or to commute. There is evidence in the literature that the more walkable your neighbourhood is, then the more people walk, and people tend to be healthier.
So there are many things we can do to shape the physical and built environment—including reducing noise , light and a ir po ll ution to improve sleep and promote health. We could also do more about the food environment—if we were to promote more healthy options within high density traffic areas where people pick up a meal on the way home, then they are more likely to default to healthier food options without having to actively make the choice all the time. Upon this foundation of a health-promoting environment, we could then add on other elements, such as technology, education and programming, to further enhance participation and ownership.
There are a number of initiatives to do exactly this in Singapore, such as MOHT’s Healthy Precinct programme.1 We are also looking to see how we can incorporate health as a policy outcome in our planning—the way we now think about environmental sustainability as an outcome. From the ground up, we are also validating tools to help communities to come up with health promoting programmes, in a more design-focused manner. Activating community participation will be important for sustained cultural and behavioural change.
We can shape
the physical and built environment to promote health. We could then add on other elements to enhance participation and ownership.
Indeed, artificial intelligence can be used in health not only at the level of nudging individuals, but also in helping us to design better environments; to see how foot traffic flows and assess whether our interventions are working. The use of data, collected in a trustworthy and confidential manner, can provide very useful insights.
Is data key to the future of
Data is absolutely critical. The technology already exists to collect data in all fields, but two other factors are essential.
One is public trust, which is related to how we use the data; how we are responsible stewards of data; how we demonstrate the value being created for the benefit of the community and the people through its use.
The other element is analytics. Data can be used for three main purposes:
- There is data for understanding and planning, which can be anonymised and aggregated.
- There is data for intervention, where you need sophisticated analytics to understand how and when to encourage different groups, say to exercise, and how best to continue to dynamically motivate them over time so that their behavioural change becomes sustained in the long term
- Next, there is data for monitoring results, to determine whether the interventions have worked, and whether they have reached the right groups. We know for instance that disparities in participation and outcomes are important drivers for overall outcomes at the system level in many health systems, so we want to see, for instance, more exercising among people who are not just those who are already self-motivated to do so.
One aspect of Healthier SG
is to place much greater
emphasis on personal
responsibility for health,
which is not something that
can be legislated into being.
What are some further
ways we can think about
engendering this behavioural
and paradigm shift?
We have spoken about working with individuals to facilitate long-term behavioural changes. Another way to think about this is at the provider level. The thesis of Healthier SG is that we connect residents with general practitioners (GPs) so that they have a trusted primary care doctor, who will get them to do their screenings and vaccinations on time and give them timely advice to motivate them into taking action. But we also need to make sure that the providers, the GPs, are able and enabled to play these roles.
We can do this by improving data flows, so GPs can work better with their residents and patients: they can more easily identify who has not taken their shots or gone for screenings and so on, and then nudge them in a timely manner. We will also want to provide training and streamline processes to make it easier for the providers to carry out these interventions. We can also extend this to many more providers—such as to community-based services, or to organisations and initiatives helping residents to age well in place—enabling all of them to work more effectively in encouraging their clients to adopt healthier behaviours.
All this will take time, and different players are at different levels of readiness. So we need to do this in phases. We are starting in Healthier SG by looking at common health conditions like diabetes, high blood pressure, and basic preventative measures such as vaccinations, screening and weight management. We are creating platforms to make it simpler to perform these basic interventions, such as streamlined care protocols and IT and data systems to help the GPs do these things efficiently. This lays a foundation and ensures the system is robust before moving on to the next set of reforms. It also gives us more time to build up systems and learn reiteratively with each new tranche of measures.
Activating community participation will be important for sustained cultural and behavioural change.
You work at the frontier
of health technology and
other advances. What are
some opportunities that lie
ahead for transforming
public health, and how might
these build on Healthier SG?
Healthier SG lays an important foundation. We are developing a more integrated and effective delivery model, upon which we can then implement elements of the healthcare of the future.
I think precision medicine, and especially precision public health, will become much more salient. The data revolution will enable us to identify groups who have a higher susceptibility to important diseases, allowing us to intervene early. We should be able to target high-burden diseases in a more effective and efficient way: rather than trying to screen everyone, we target high-risk groups. A GP for example may have a patient whose family member had a heart attack at a young age. The patient and his family can be advised to undergo screening for genetic mutations that could predispose them to early heart attacks. By screening the whole family, we can identify and treat those who need it very early in a targeted way. With many conditions, including cancers, this could change the trajectory of the condition for both the affected individuals and the population.
Precision public health could also be applied to engage individuals for behaviour change, or more personalised intervention, using data specific to them. For instance, wearables, which can continually monitor a patient, could also be used to titrate medication, while measuring side effects continuously. In future there will be more conditions that we will be able to predict and monitor using digital technologies—including behavioural aspects that have been difficult to measure in the past.
For example, MOHT is looking into using digital tools to address mental health, which is a particularly challenging area to address. Mental health issues carry a stigma; we also need scalable solutions, because how many counsellors can we have? We need to find effective and scalable ways in which the majority with relatively minor issues, such as coping or adjustment problems, can actually help themselves. Digital mental health solutions, with human specialists offering further help when necessary, are a promising way to provide this type of support at scale.
In future there
will be more conditions that we will be able to predict and monitor using digital technologies.
One example of such tools comes from a study we recently completed with the Institute of Mental Health (IMH) involving patients with schizophrenia.2 There is no objective marker of when someone on treatment for the condition is going to get worse, and it is difficult to ascertain how patients are doing at any given point in time. MOHT worked with IMH to develop a platform to collect digital data, with the patients’ consent, through wearables and smartphones. This data was then analysed using AI. Based on these digital signals, we were able to tell the care team which patients were more likely to relapse. This is now being adopted as a mainstream service in IMH, for psychosis and for mood disorders.
While this is an example from a severe mental health condition, we are looking into how the same technology might be applied to moderate or mild disorders as well. Such digital markers could provide doctors with more objective and regular indicators, which could help ascertain if a patient is getting better or worse or might need further intervention. In time, it might also possibly facilitate self-help. If we are able to engender better awareness and better self management, then we reduce the risk of over-medicalising, where we see a therapist for any minor issue, which is neither sustainable nor helpful in the long run.
We have just been through the
COVID-19 pandemic. If Healthier
SG and its related reforms were
in place, would Singapore fare
better in a similar crisis?
The pandemic had three big lessons for the health system. First is the importance of governance—of the health system and more generally. Second is the advantage of integration. In general, health systems which were fragmented did more poorly, mainly because they could not coordinate their actions, whereas health systems with a high level of integration were better able to deliver. The third is the value of data.
If we had another major event after Healthier SG is fully implemented, we are likely to be better off in several ways:
For one thing, we will have better data flows. We have good data from the public system, but we have significant gaps from the private system, including GPs. With Healthier SG, this will be improved. We will have channels by which better and additional data could be collected if needed.
We will also have more trusted channels of communication—with residents above 40 years of age enrolled to a primary care doctor, we have a powerful means to reach out to residents, including those who tend to be more vulnerable in a pandemic.
We will also have a delivery system which can be readily mounted as the mainstream way to deliver vaccines or drugs to a large segment of the population.
We are also extending telehealth into primary care, although it will take a few years to fully roll out. An established, well-f unc tioning telehealth system would be invaluable in a crisis in which physical presence in a clinic were difficult or risky. It would also be a major advantage if extended into the community care sector: during the pandemic, many older people were socially isolated with restrictions on physical gatherings, and many services for them had to stop.
Of course, such technologies rest on established relationships that have to be regularly exercised in normal times. So it is not as if residents have to interact with someone they have never met before over a digital channel rather than face-to-face. If we had a hybrid system of both physical and digital provision, even during normal periods, we would have better options in a crisis.
As Singapore builds towards
its vision of future healthcare,
what in your view are our
most critical uncertainties?
There are a number of milestones critical to the success of Healthier SG:
- The first milestone is having enough GP clinics embrace it and come on board as partners, which means they can see that the programme is good for their patients and makes clinical and business sense to them as well. So far, with about 1,000 (out of 1,300) clinics on the programme,2 we are doing well here.
- The next milestone is the value proposition to patients: whether residents can see a clear and compelling reason to enrol in Healthier SG. Again, with over 400,000 residents enrolled in Healthier SG since July 2023,3 we are off to a good start.
- The third milestone will be critical, and that is the delivery outcomes. Whether patients stay with their enrolled GPs, whether preventative care—as indicated, for example, by screening and vaccination rates; by better control of common chronic conditions like diabetes, high blood pressure—are all trending in the right direction. That would provide good evidence that the intent of Healthier SG is being achieved.
In the further future, once we have the framework in place, we will be able to introduce precision public health, digital health and other interventions. All these will ride on the foundations that are being built today.
All of this will rest critically on public trust and support: both at the individual level, but also the sense that this is creating public good; that even if it does not benefit me directly, it is good for the health of the Singapore population as a whole. We want people to see and believe that what we are doing will result in the broader good, which means we must demonstrate and report the progress that is being made, in ways that are relatable to the general public.