Monday 30 June 2014

Higher Medisave withdrawals for palliative care from 1 Jan 2015

Easing of caps next year among changes in sector announced by Health Minister
By Salma Khalik, The Sunday Times, 29 Jun 2014

Palliative care services for the sick and dying will be ramped up significantly over the next six years as Singapore's population ages.

There will be more hospice beds, home palliative care services and a new graduate diploma course to train more doctors.

People will also be allowed to use more of their Medisave money for these services, with no withdrawal cap for those who are terminally ill.

Announcing these plans yesterday, Health Minister Gan Kim Yong described palliative care as "a critical piece in our overall efforts to provide good and appropriate care to help patients age and die in place with dignity".

Speaking at the sixth Palliative Care Conference at Singapore Polytechnic, he said the Ministry of Health will invest in developing four areas of palliative care - improving the quality of care, expanding services, ensuring affordability and raising awareness.

Today, 5,000 people receive palliative care at home each year. By 2020, at least 6,000 will be cared for this way. The number of palliative care beds will also more than double from 147 today to 360.

On top of that, community hospitals will back up hospices by having beds for patients who take a sudden turn for the worse, or have other critical needs.

Two regional health-care groups, led by Tan Tock Seng Hospital and Khoo Teck Puat Hospital, will train staff at 14 nursing homes with a total of 2,800 beds in advance care planning, geriatric care and end-of-life care.

To make sure people can afford such care, the ministry will ease the current caps on Medisave withdrawals.

From Jan 1 next year, the daily withdrawal limit for palliative care will go up from $160 to $200 and the lifetime limit for home palliative care from $1,500 to $2,500.

But for patients with terminal illness such as cancer or organ failure, this cap will be lifted and there will be no restriction on the amount they can use from their Medisave accounts.

Mr Gan said that together with the 75 per cent subsidy for hospice care and 80 per cent for home palliative care, "we hope patients and their families need not worry about palliative expenses at a difficult time".

His ministry will also change how it funds organisations providing home palliative care.

Today, what they get depends on the number of visits they make. But from next month their funding will be based on the number of patients they look after, reflecting a shift to focus on results.

"This new approach to funding will deliver a steady stream of financial resources, enabling providers to plan and deliver holistic, patient-centric services," said Mr Gan. "It will also give greater flexibility to test out new models of care for the benefit of patients."

He told reporters later that care providers will be able to remodel the way they look after patients, by calling them on the telephone to check on their condition or to give advice, or by collaborating with doctors.

Health-care advocate Jeremy Lim, one of more than 500 delegates at the half-day conference, said the change in funding signals "a very important mindset shift".

Dr Mervyn Koh, co-author of the book The Bedside Palliative Medicine Handbook, said burn-out rates for people working in home palliative care are higher in Singapore than in many other countries - they end up emotionally exhausted, feel no personal accomplishment and start treating patients as just people waiting to die.

The reason is the shortage of staff, and some of these people regularly work 60 hours a week.

Govt to step up management of healthcare costs in lead-up to MediShield Life
Society also has part to play in staying healthy and making informed decisions regarding healthcare services, Health Minister says
By Kok Xing Hui, TODAY, 28 Jun 2014

The Government says it will strengthen the management of healthcare costs in preparation for MediShield Life, since the scheme’s expanded benefits and higher claim limits could lead to over-consumption.

One way it will do so is by stepping up on monitoring claims experience, said Health Minister Gan Kim Yong today (June 28) at the opening ceremony of the Singapore Palliative Care Conference. This monitoring is something that the Government is already doing, where it examines claims that are out of the ordinary to see if the treatment provided is necessary, he said, adding that public hospitals are generally very cost-conscious.

Mr Gan also reiterated that the co-insurance and deductibles included in the public insurance scheme “will encourage our patients to make informed decisions, to make wise decisions, with regards to their care needs”.

The minister added that while MediShield Life is a major shift in our social policy to provide better coverage to all Singaporeans for life, it is important to emphasise that “the Government’s effort alone is not enough”.

“We need the whole society to come together to stay healthy, to be informed in making a decision in our healthcare needs (and) healthcare services so that overall we can manage healthcare costs for the whole society,” he said.

“This is important for us to ensure that the system will be sustainable not only for this generation but also for many generations to come.”

Mr Gan also gave his assurance that the premiums announced yesterday will remain stable for the next five years despite rising healthcare costs and that “we will hold it for as long as we can”. Such projected cost increases, he said, were taken into account when deciding on the premiums.

At the conference, the minister also detailed how the health ministry will develop palliative care services in four main areas. He said MOH will enhance the quality of palliative care services, across different care settings, invest in expanding both residential and non-residential palliative care services, implement measures to enhance the affordability of palliative care services, and work with community partners to promote public awareness about palliative care and end-of-life issues.

Getting from C to A in palliative care
Recently announced guidelines to boost care for dying patients are a good step forward, but more needs to be done.
By Janice Tai Joan Chew, The Straits Times, 31 Jul 2014

BACK in 2008, then Health Minister Khaw Boon Wan said Singapore might score an A-minus for acute care services but was probably "below C" when it came to palliative care.

It has come a long way since. The World Health Organisation and Worldwide Palliative Care Alliance this year ranked Singapore among the top 20 countries in the world for its palliative care.

Palliative care is an approach to care that improves the quality of life of patients with life-threatening illness, through minimising suffering by treating pain and other physical, emotional and spiritual problems.

Close to one in three of about 19,000 people who died here last year received such care at home or in a hospice or nursing home.

Demand for palliative care is rising as the population ages and the incidence of cancer and chronic diseases - which tend to affect older people - increases. By 2020, more than 10,000 people a year here would need palliative care.

In 2011, the Ministry of Health (MOH) commissioned the Lien Centre for Palliative Care to draw up a national strategy for palliative care, which looked at how to deliver such care in a more coordinated manner.

This was followed by an industry task force led by associate professors Pang Weng Sun and Cynthia Goh to draw up national guidelines over the past year. Last month, the guidelines were among the plans which MOH announced to enhance the quality of palliative care, expand services and ensure their affordability.

Right now, palliative care is offered at hospices like Dover Park Hospice or Assisi Hospice. Other organisations such as HCA Hospice Care tend to dying patients at home.

All restructured hospitals such as Tan Tock Seng Hospital (TTSH) and the Singapore General Hospital have their own palliative care teams and established programmes for patients. But many community hospitals and nursing homes still call in palliative care doctors on an ad hoc basis.

The guidelines spell out what hospices, hospitals and other providers are required to do in 13 different areas, from coordinating care to bereavement support for family members and the use of pain-relieving drugs.

Industry experts said the guidelines are helpful but are concerned about whether they will really make for improved palliative care on the ground.

The guidelines will make palliative care more consistent. For example, one proposed guideline requires health-care providers to have a system in place to identify people who are likely to die within the next 12 months.

Once identified, the doctor or medical team has to determine the care needed for the patient: in a community hospital or nursing home, or discharged back home, with home care nurses and palliative care doctors on standby. A care coordinator is then appointed. The patient must be told who the care coordinator is, and advised on how to reach the care provider 24/7. This is crucial because every minute counts for dying patients when they are being referred to different places to receive palliative care.

At Dover Park Hospice, 21 per cent of patients referred to it and put on wait lists died before admission, according to its 2013 annual report. About 15 per cent of the patients getting home care from HCA Hospice died within a week or less while being tended to at home.

But guidelines, no matter how rigorously developed, will not improve the quality of patient care if they are not implemented well.

"The point of every set of guidelines is professionals actually using them while on the go so as to improve patient care," said Dr Mervyn Koh, head of palliative medicine at TTSH.

Industry experts cite three possible roadblocks to the establishment of seamless palliative care.

The first is lack of trained health-care professionals.

In a recent survey by Lien Foundation of 200 doctors and 425 nurses, about six in 10 doctors and four in 10 nurses said that their basic training did not prepare them to handle patients with life-threatening diseases. "The survey gives an assessment of the critical weaknesses in our health-care system, especially in the area of professional training," said Mr Lee Poh Wah, chief executive of Lien Foundation.

Two, there is no impetus for these professionals to follow the guidelines which are not enforceable. The Ministry of Health told The Straits Times that it has no plans to tie the guidelines to licensing at the moment, though it intends to use them as a basis for training and other initiatives to raise quality of care.

"Licensing could be an option but I hope it will not be punitive, so one way in which more people can be encouraged to follow the guidelines is giving incentives such as providing more funding if people comply," said Dr Wu Huei Yaw, medical director of Dover Park Hospice.

Three, even if the health-care workers are motivated to follow guidelines conscientiously, the many sets of guidelines out there make patient care a daunting and potentially confusing task.

Take, for example, a doctor in a nursing home who is caring for a diabetic patient on palliative care. The doctor has to try to meet the patient's complex needs by grappling not only with the guidelines on palliative care, but also those for nursing homes and diabetes care as well.

To be fair to MOH, it has begun to look at these issues. For instance, there will be a new graduate diploma course to train more doctors in palliative care. But more can be done.

Students should get more basic training in palliative care. The National University of Singapore's Yong Loo Lin School of Medicine devotes only four days of its entire medical course for students to spend time in a hospice to learn more about palliative care.

Basic training is important because it is harder to later get general practitioners to attend short courses on their own time.

Ms Vanessa Yung, secretary-general of the Singapore Hospice Council, noted: "The only three-day course offered currently to familiarise doctors with the basics in palliative care has received such poor response that its last few scheduled sessions did not run, except for one session in August last year."

The guidelines should also be given more weight by awarding palliative care licences only to those who comply with them. Or the guidelines can be used as a basis for quality audits.

Singapore may be two decades behind Australia in having local standards in palliative care, but it is ahead of Canada and Scotland. The guidelines announced last month are a good step forward. However, it takes a lot more than guidelines to get Singapore from a "below C" to an A in palliative care.

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