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My name is william i’m , the first in clinical affairs at the school of medicine . I’m , also a geometrician practicing in national healthcare group , take part hospital . I’m going to talk to you about healthcare challenges at a societal level . Now , when you think about health , there are differe...

My name is william i’m , the first in clinical affairs at the school of medicine . I’m , also a geometrician practicing in national healthcare group , take part hospital . I’m going to talk to you about healthcare challenges at a societal level . Now , when you think about health , there are different ways of looking at it . We can look at specific diseases , for example , high blood pressure , diabetes , osteoporosis you can study their causes . What’s the effect on people ? How do we investigate them ? How do we treat them ? What are the complications ? Right and have been mitigated the effects of their complications . Examples include heart disease , cancers metabolic diseases , these examples , but we can also look at different groups of people , specific groups , what kind of disease do they get ? How do we diagnose and treat them ? For example , we can look at children , women as a group , elderly as a group , and for defined groups , it can be like in a particular environment , in particular occupations or groups from different races , for example , where there may be factors dietary factors , cultural practices and social norms so when we talk about healthcare societal level , we often think of the term population health . The institute of healthcare improvement or in the us defines population health as the health outcomes of a group of individuals , including the distribution of such outcomes within the group . And these groups may be geographical in nature . It may be a population like a nation or a community . There can be other groups like , say , a group of employees , certain ethnic groups , disabled people , prisoners or even other defined groups , so that’s , what we call population now . So when we apply this to our local context and what we are discussing today , we are talking about people living in a geographical area within singapore in particular , i’m looking at older people in the context of my talk today , but we look at groups of school children , taxi drivers , retirees or something , everything we think about when we look at these groups . What are the implications for healthcare funding ? How should the budget be allocated to meet the needs of different group ? And notice that that needs not once everybody wants everything from the government , but it’s just not possible . We need to focus on what is essential , what they need some . This lecture shows you a useful resource that you can tap on : the statistics singapore . You can just google it and go to the website and you’ll find a lot of very useful information about health statistics in singapore , including demographics are some of the common problems people face and so on , and some of the trends that we pick up on these statistics will include things like increasing numbers of elderly population . The percentage of the population sixty five and above has increased from about nine percent in twenty ten . In just a short ten years it went up to sixteen percent . All age support ratio looks at the number of people aged twenty to sixty four for every resident to sixty five and above and this fell from ten point five in nineteen ninety to seven point four and twenty ten further to four point zero in twenty twenty one . So you can see that there are fewer and fewer younger people supporting older people . The number of people living alone also increase from nine point nine percent in twenty eleven to fifteen percent in twenty twenty one . And it is not just limited to the elderly . Of course there are some younger people living alone by themselves as well . So what does increasing numbers of elderly really mean ? It can be more elderly and more people with , but it may also mean more , well elderly and the changing workforce in other words , more older people may remain in the workforce instead . It can mean longer duration of chronic diseases and more people with comorbidities with failures but if you have better disease control , you can actually have more people with chronic diseases with less disability . Over time . Changing workforces there may be more retirees and greater dependence on society for support . On the other hand , you may be able to shift the retirement age and allow more older people to remain in employment . There may be new shifts in health and social care . So we’re talking about as people grow older , should we redefine aging there are things that should be looking at solutions oriented approach rather than a problem oriented approach . So if you say that increasing numbers of elderly , is that a problem ? Right . But it can also mean more numbers of active , productive older people who can still contribute to the larger society . More elderly can also mean the need for environmental modifications to support care of the elderly . We can modify some of these environments which allow older people to continue active , meaningful and productive lives . You can think of more older people as an increasing healthcare burden , but it may also create more meaningful career opportunities for younger people , including young women . Of course , we also worry about the cost of supporting the elderly , but some older people might be able to remain economically productive in creative ways . It doesn’t always have to be work . We can be helping out in different areas , right ? We always think as being a burden to the young , but older people can also support younger people , and many older people can be self sufficient without relying on the young . So now we look at health issues , and we can look at it from two angles . One is the medical anger . You always think in terms of diseases . So , as you know , chronic heart and lung diseases , osteoporosis fractures arthritis neurological problems , memory loss , depression , multiple medications malignancies no cancers at all . Right ? So that’s a disease oriented approach , we can think about how diseases affect the function of older people . So cat means visual impairment right ? Heart disease may result in poor asset tolerance . They can perform , they can walk very long . You know , chronic arthritis may lead to chronic pain , affect their function , affect mobility , neurological diseases may lead to memory impairments and so they become more dependent on caregivers depression , memory defects because the behavior , sleep disturbances medications because adverse effects as well . And of course , malignancies can shorten people’s lifespan soon . Now , sometimes we use what we call functional assessment skills to look at the elderly . We think in terms of different skills , like there’s such a thing called clinical score or c . You can see that it is designed by rockwell from the us and then modifying subsequently . And number one is you are very sick , so if the series is called one , you are very fit , no problems . Number two means you are , well , three , managing well for a little bit more vulnerable . By the time you reach five , six , seven , severely free , it would be very , you know , nine million . So this kind of score helps us to look at the older person and say where the person’s score is , what kind of person he is , and it’s quite useful for research purposes as well . There are other assessment skills , like index , which looks at activities of daily living . They are also what we call iadl instrumental activities of daily living , including things that can prepare food for themselves and things like that . The amt mental test test their memory , their cognition and genius , of course , test whether there is any depression , and also that many skills are available that help us to assess older people . I’m going to talk a bit more about how we see what has happened since the nineteen eighties there was a very key report . Some of you might be interested in it . You can google it on the website , right on the report on the age of nineteen eighty four , they well know how you report , so called because the minister of health - and in that report , it actually highlighted the needs of older people in singapore , have projected the problem , that we must look at savings and government funding for aged care . So that’s a very interesting project came up . We really started alarm bells in the country to say , hey , we’re gonna do something about older people . Shortly after that came the home agent . And when we started looking at how do we regulate care homes prior to that , there was no particular rules and care homes , people can just set up your account and look after them . There were no standards of care and things like that . So this brought all that in place . About that time they realized they had a need for home . So the foundation was started . And then it was also senior students health care center for older people to go to , to have their care and rehabil takes place as well . And that period also marked the growth and rebuilding and restructuring of hospitals . So by the late nineties in singapore , we started having three areas of care . One is the hospitals , other where people who are very sick can be treated , investigated , treated and brought back to good health . Then we saw the need for intermediate care , what we call the community hospitals day rehabilitation . Many people stay at home and go for exercise and have home care , hospital care and then there are those who need long term care in the same homes . Shelter homes are still even look after themselves but need some supervision and guidance . As well as shelter homes , hospitals for the end of life care for those can remain their own homes , home care for those who need to be supported at home and home hospice came about . So all that developed in the ten , twenty years from nineteen eighties onwards . But there are challenges in managing the elderly . They tend to different disease patterns and different responses to treatment compared to the young . Older people tend to suffer more complications than younger people . People - they have very complex chronic diseases and were still in a combination of diseases . Most younger people have only one or two diseases , but the person may have heart disease , dementia urinary problems and other conditions . All look into one , and then they both physical and mental conditions , and increasingly they’re more dependent on need and care , rehabilitation care . And so we also need to look at the evolving social structures . I guess the other challenge in singapore , it’s not just medical issues , but our own changing social structures . We have fewer children for older people . Our families are getting smaller , more nuclear families , you know , less caregivers and so we depend on society to help support the elderly . And there’s some big issues with stress as well . So both in older people plus evolving social structures or contribute to challenges in the elderly . But isaacs from uk coin system . Geometric syndromes or agents of geometrics what he said was that if you go to look at older people , these are the major issues confronting them . And what’s interesting is that you can see he does not name them in terms of diseases , he does not talk about dementia it does not talk about cancer . When we talk about functioning issues , immobility for the people who are instability other people can walk around , but they tend to fall and resolve injuries . Incontinence which is an embarrassing problem for them . Older people have been intellect memory problems . Someone else added the addition of indonesia . Poor diet , poor nutrition . John subsequently talk about things like psychopenia muscle wasting cognitive impairment and the direction of aging people not wanting to eat . And these are all images of false depression delivery . So when we look at elderly , we don’t just look at diseases , but we look at the impact of the diseases on your function and managing older people . It’s not just about managing the disease , but managing some of these mobility functioning issues tend to affect them . We also need to look at care integration . There are many settings to look after older people today . We are called clinics we are conversing homes , we have got hospices and so on , right ? How do we integrate all these care settings for a patient today , with many organizations providing care , how do we bring all this together ? Right ? So there are health issues and social issues across different , multiple sectors today , with different care providers . If you come to hospital , their hospitals , they go to their doctors , their gps , they are , there are different vw organizations , private organizations as well . How do we string all of them together ? How do we integrate them together in a care order which is patient centered , recognizing that health and social outcomes are really very interdependent let me give you an example . Imagine an eight year retiree is called high blood pressure , diabetes , high class . For many years , he used to be very active , independent , right , but for the last two to three years he’s been putting on weight because he’s stopped exercising why ? Because he had pain in his knees from and his blood sugar is poor . If you socially isolate because it can’t go with friends as you used to . So what problems may we anticipate clearly , it is the issue that goes beyond the medical issues . It’s not just the diabetes . It’s not just hypertension or high cholesterol but dysfunction issues become important . It’s going to be at the risk of stroke and heart disease . From these risk factors , he’ll get diabetic complications to affect his function , including his eyes . You know , the sensory functions , pain , function , decline . It will fall to get depressed and then at the end of it , he will affect his care to be very stressful on his children and manage their own jobs , manage the younger children as well and then you have to care for it . So with these challenges in older people , we need to take a different approach . Instead of waiting for things to happen , can we take what i call it and this approach and this can . If i look at an elderly person in my clinic today , i ask myself : what are his current problems today and what might be his problems in the near future ? So i look at medical issues . What are these issues ? You know , how will the disease progress , right ? Will he decline ? What might be the side effects of the treatment that i’m giving him long term use of certain forage problems ? Then i take a step back and say , what are the functional issues like ? Those are the medical issues for his function decline , is able to continue bathing himself , washing himself , going to the toilet what about his mind of his mental political decline over time , right where you can decondition because it stays home all the time . How do i keep this house so strong ? How do i keep him active ? So , just to issue , then , the third thing i need to ask myself is : what are the social issues with every care crisis ? If tomorrow he falls and breaks a hip , who’s going to look after him ? Or do you end up emergency care , needing to put into hospital and put him straight into nursing and things like that ? Are there potential ethical issues or legal issues as well ? What if the man says : i don’t want any treatment at all ? I want to die ? How do we deal with the kind of issues ? Right ? And what about issues of sexual and other abuse is not very common in singapore , but it does happen , and sometimes it’s not deliberate we always think of elder abuse as young people being vicious and treating with people . Sometimes you can help people because the young people are frustrated we can , so they scold them or their relatives , but they’re just so frustrated managing people mistaken that this is a treatment . Then you can give the stress we need to look at . So looking at the older people , we must go beyond the medical issues to the functional issues as well as to psychosocial issues and family matters as well . So a team approach is often needed right so you may have specialists like you have your and contact specialists and specialists looking after them . You need a family physicians to care , but you also need nurses clinicians and advanced practitioners sometimes have more certain aspects right pharmacies to help solve the multiple drugs they are on , social workers to look at some of the issues , sometimes the psychologists as well . And then we’ve got the therapies to the physios the right , sometimes even the pros the prosthetic devices and authorities are going to explain differences here . Speech therapists speech difficulties , dietitians at the end of , it is so complex , when you can , to match the entire system . So i can see , looking at the elderly has now become very complex . No longer one healthcare worker , one patient is multiple health care workers , hopefully in a coordinated team managing an elderly person in the context of his family and his environment as well . And of course , the family and caregivers must be involved too . You know this game . Some years ago , the ministry of health reorganized the healthcare services in singapore into three classes : national university health system in the west , national healthcare group in the central and singapore health services or health services in the east and south . Industry clusters . Each cluster would have hospitals , especially centers looking after the complex cases , but they will also be community hospitals looking after people who need rehabilitation . You also have to coordinate services in region , including home care , clinicsics community services and so with three clusters , better organization and development of services , reaching out to people in the community . Now , if i look at this diagram here , it gives you an example of what’s in the customer . So the focus is the patient and his family . Hospital , medical centers , community hospitals , care centers , home care , nursing homes for some of those who need community home services , polytechnics gps as well . So the idea to integrate health and social services within each of these customers . This diagram shows all the hospitals that are existing today . With new hospitals coming up , you’ll see something blue on the top left corner will have complex , which is the new hospital is coming up . Hospital is being rebuilt at the moment , and there will be more services available . But it’s not just about hospitals , it’s also about community hospitals and other services as well . So we’re already spending on healthcare right across the whole nation in a more organized manner . Now , there are some things we need to look at in terms of healthcare . In the past , we focus a lot on development of hospitals . Ministry of health has recognized that there is a need to move beyond hospitals to the community . How do we deliver healthcare and hospitals to communicate to people in their own homes and people in the society itself ? And so how do we transform primary care ? At the same time , we need to look beyond quality to value . In the past , we always think that the most expensive medicine might be the best lesson for people . That’s not always the case . We can ask ourselves with the money we spend , what is the value that we get ? So , in other words , we focus on how we spend our healthcare dollars and how we get the best value , how to be the best out of it for the population of singapore . And then we also look at beyond healthcare to health . If we keep looking downstream and healthcare treating treating diseases and diseases , we need to look at how to promote health and prevent people getting diseases . So just a little direction and better health , better care leading towards a better life . I’m going to focus a bit more on older people now , because it’s really also my area of interest . You can look at older people and group them by age , younger , older , and then the very most . You can also look at people by their functional status . People are well and independent , people with chronic illnesses and disabilities and a very few . Now you may think that the old ones are always free , that’s not always the case . You see that you don’t even know who can be free , right ? And even all those you know can be quite independent and functioning well . Some of you may know some people who in the eighties and still walking around and still very independent at all . And yet there are also people in the sixties who are a bit down . And so green . Doesn’t always mean you’ll be free there’ll be some older people actually like this . Next slide looks at aging and disease . Right . So initially you may have a person who’s reasonably well with a person in a high blood pressure , diabetes , high cholesterol over time , you develop a stroke in the disease to consider its function . And then they thought , as the condition gets worse in the recurring strokes heart failure , infections , so it moves from being a , well , elderly person to a frail elderly person . You use the functional decline , the function declines over time . So what do we do at each step to prevent people from declining summarized into this , like what i call the auto landscape , and i’ll go to this a little bit more detail . First , i look at the four pictures of the first group of the well , elderly people are all quite well . Second group of those chronic illnesses like diabetes , high blood pressure , the problems with advanced , they have more field now you have complications from the diabetes . They never stop or something . And if the last group of those who can apply right and you can see that there are different kinds of services that are needed for each of these groups and we have different goals and each of these groups . Let me now go into each of these groups in a little bit more detail . So if you take the first group , these are older people who are still well , and we’re talking about how do we help people to eat well or healthy aging some people use a successful aging right ? And as we look at what the individual issues , yeah , some people have longevity you know , right ? There are some genetic factors affecting whether people diet , exercise , their lifestyles right ? How’s their community support services and all that , how they might influence them . So in this group are reasonably well , we look at control basic diseases that they have , and we focus a lot more on health promotion and health education , and at one time we even run programs like help for older persons in medical schools and so on , so that’s a different focus for this group . The second group are those who now have caused some diseases , right ? and they need disease management . They need to be restored back to normal as much as possible . And in older people , sometimes , besides the usual diabetes , under pressure , high cholesterol and things like that , you may also have issues and memory that for early dementia chronic pain , right , multiple medications from multiple illnesses and so on . So this group needs a lot more care , they need a lot more programs to support their illnesses and conditions and so on . At the time , what we call people with complex illnesses they now have their disease over a period of time , do not develop complications . For example , somebody under pressure might develop a heart attack on my , develop a stroke or something , right ? They are more free now . They have more problems here . Their care now needs to be different . There’s more coordination of care and cost of care also increases in this group - this is what we call the advanced care management group , for additional plans to support them . Then , finally , the last group of those with black issues , they come to the stage of their life whereby their illnesses have become more complex and the focus is no longer on curing them , no longer on controlling the disease , but really supporting them right through their last journey in line . And that’s where we need to understand a lot more about their own preferences their own inclinations what’s important to them . There’s a bit of a shift from the physical factors to more of the psychosocial factors as well in order to support older people through all this journey that causes an issue . So the ministry funds a lot of this , but some of it also self funded over the years , right ? So you have made to help you there’s also life how to support you from the ministry that funds to support those from the kangaroo some insurance savings from the show , and also for those who are really low income . Vw also support . And also , you can see , sometimes we think of older people with complex healthcare issues as working on a tightrope but there’s a lot of support to hold them as well . But when the time comes , there is support for them and there are many programs if we look at and support them . There are newer trends now . We are beginning to look at older people in different ways now . So this slide shows one of the groups in terms of dementia services , we know that the number of people dementia has been increasing . How do we create a community that supports people with dementia in their own homes ? So some of my friends have done this , can tackle different organized societies whereby they’ve got people in the community to support older people , including training shopkeepers to recognize which older person might have memory deficits how do you help them when you’re purchasing something ? How do you help them with a change ? If someone sees an older person wandering around the streets as though it’s lost , how do we have the person go back to his own home ? So , in other words , you must look at communities supporting older people in need as well , and this is where we need to move as a society . Another issue which i did mention a little bit about before , is advanced care planning . As we grow older with illnesses and is again not limited to elderly people , even younger people can get advanced illnesses as well . We should have conversations with them . What is important to them , how far do they want treatment ? So there’s a level , where we call the general advanced care planning discussions , where we have an understanding of what people’s preferences and so on . As the disease becomes more complex . And maybe these specific discussions , for example , somebody with kidney dial , when do we say we stop ? Do you say we keep on going on forever and ever ? Certainly yes , if a person is still doing well , but we should continue , a person develop additional complications . When we say we start to withdraw , so that’s why we call these specific advanced care plans . And then you have what we call a preferred plan of care and people you so say , take a person who’s got very complex illnesses reaching the end of life , should he have continued treatment in hospital , should be placed on ventilators should be put into intensive care . When do we say we let a person make a decision and say , what would you like for yourself ? So these are important conversations that we want to document this advance care plan where they need not be restricted . People can change their minds when the time comes is perfectly fine , but then these patients , the healthcare workers and their families have an understanding of their preferences and we know how to plan care for them . Now , i’ve finished most of my talk , but you may want to have some references that you want to go back and look at . There are a few very key publications that which has put up . What is this on the left ? Cities caring for our people really looks at how singapore has evolved over the years . The healthcare system , which can look a bit more detail into our current healthcare system , what the issues are . And you can look this up on the internet as well , available . I will look through it and give you a better idea as well . Then there are some community publications as well , which are useful . They talk about how support systems for older people and people , just one building and other communities in singapore . The foundation gave a very good summary of some of the services for older people as well . I’ll give you a summary of what some of the challenges faced by older people today , both in terms of health care as well in terms of their functional and social issues . I’m sure , from whatever organization you are from , you may be able to think of some creative ways of supporting our older people . You might be , you might have good ideas , you have other ways of doing things that might be helpful to them as well . Thank you very much for the session .