06CHAPTER THOUGHTS ON THE FUTURE STATE - National Healthcare Group

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06CHAPTER THOUGHTS ON THE FUTURE STATE - National Healthcare Group
CHAPTER

                                    06
                                    THOUGHTS ON
                                    THE FUTURE STATE

115   © National Healthcare Group                      © National Healthcare Group   116
06CHAPTER THOUGHTS ON THE FUTURE STATE - National Healthcare Group
FIRST STEPS IN POPULATION HEALTH
           ASSOCIATE PROFESSOR TAI HWEI YEE, GROUP CHIEF QUALITY OFFICER, NHG
                                                                                                                                            4. Cost Control Platform                                       f. Use predictive models and health risk assessments
                                                                                                                                                                                                              that take into account situational factors, medical
                                                                                                                                              a. Achieve less than three per cent inflation yearly
                                                                                                                                                                                                              history, and prior resource utilisation to deploy
           Right from the inception of NHG as a new healthcare             In June 2009, a small group of four NHG leaders attended              for per capita cost by developing cooperative
                                                                                                                                                                                                              resources to high-risk individuals.
           cluster in 1999, population health was on the minds of          a gathering in London of 19 organisations that had                    relationships with physician groups and other
           its Senior Management. I recall the first NHG Strategic         come together to learn how to implement strategies                    healthcare organisations committed to reduce waste        g. Set and execute strategic initiatives related to
           Retreat in Sentosa then, together with about 30 to 40           and action plans to achieve “Triple Aim” as a large scale             of healthcare resources.                                     reducing inequitable variation in outcomes or
           other senior clinicians and administrators from the entities    strategy within a country or for a region. Among the 19                                                                            undesirable variation in clinical practice.
                                                                                                                                              b. Achieve lowest decile performance in the Dartmouth
           that were to make up the new NHG cluster. As a group, we        organisations, eight had already started work on five key             Atlas measures by breaking or countering incentives     In addition, we learnt how important and challenging it
           crafted the Vision, Mission Statement, and Core Values for      design concepts, and they included the UK, Scotland, and              for supply-driven care.                                 was to measure progress to achieve the “Triple Aim” at
           this new entity. Our facilitator had challenged us to look      County Jönköping, Sweden. The five key concepts were:                                                                         the population-level. Mr Henriks and Mr Nolan shared how
           beyond the mundane familiar statements and to really                                                                               c. Reward healthcare providers, hospitals, and
                                                                           1. Focus on Care for Individuals and their Families                                                                           the Vision could be best supported by building a robust
           think deeply on what, as healthcare providers, we had                                                                                 healthcare systems for their contribution in
                                                                                                                                                                                                         learning system through developing explicit theories for
           really wanted to create for the future. From this retreat,        a. For medically and socially complex patients, establish           producing better health for the population, and not
                                                                                                                                                                                                         system changes and then testing changes sequentially.
           our NHG Vision “Adding Years of Healthy Lives” to the                partnerships among individuals, families, and                    just producing more healthcare.
                                                                                                                                                                                                         They introduced the concept of “Act on the Individual
           Population of Singapore was born. Little did we know then            caregivers, including identifying a family member             d. Orient care over time - the “patient journey” -         and Learn for the Population”. The “Esther project” was
           that this Vision would eventually come to embody our                 or friend who will be supported and developed to                 targeted to the best feasible outcomes.                 an illustration of that concept.
           aspirations as a group of diverse healthcare organisations           coordinate services among multiple providers of
           to achieve what we know today as the “Triple Aim” for                care.                                                                                                                    From that early initiation to the current work of population
                                                                                                                                            5. Creating New Structures and Systems to Design and
           population health. Many international experts visited,                                                                                                                                        health, NHG has gleaned many valuable lessons from this
                                                                             b. Jointly plan and customise care at the level of                Implement Changes across Entities, Cost Control
           shared, and interacted with us over the years including                                                                                                                                       international community of experts and organisations,
                                                                                the individual.                                                Platform, and System Integration and Execution
           Dr Donald Berwick, President Emeritus and Senior Fellow,                                                                                                                                      and adapted many initiatives into our own systems and
                                                                             c. Actively learn from the patient and family to inform          a. Match capacity and demand for healthcare and social     structures. Besides that, we have also continued to be a
           Institute for Healthcare Improvement (IHI); Professor
                                                                                work for the population.                                         services across suppliers.                              part of this learning community, contributing the lessons
           Lucian Leape, Physician and Professor at Harvard School
           of Public Health; and Mr Goran Henriks, Chair Emeritus,                                                                                                                                       learned from our own local experimentation of population
                                                                             d. Enable individuals and families to better manage              b. Ensure that strategic planning and execution with all
           International Forum Programme Advisory Committee and                                                                                                                                          health. At the International Forum of Quality and Safety
                                                                                their own health.                                                suppliers including hospitals and physician practices
           Chief Executive of Learning and Innovation, Jönköping                                                                                                                                         in Healthcare in September 2018 in Melbourne, Australia,
                                                                                                                                                 are informed by the needs of the population.
           County Council, Sweden, have commented how apt our                                                                                                                                            Professor Philip Choo, Group CEO, NHG, shared our “River
                                                                           2. Redesign Primary Care Services and Structures                   c. Develop a system for on-going learning and
           Vision is in guiding our organisation in its quest for better                                                                                                                                 of Life” concept with the audience. We are truly part of
                                                                             a. Have a team for basic services that can deliver at               improvement.                                            the international community where “All Teach, All Learn”
           population health.
                                                                                least 70 per cent of the necessary medical and                d. Institute a sustainable governance and financial        is a philosophy that sustains the passion for improving
           “Triple Aim”, as a concept, was publicly articulated by IHI’s        health-related social services to the population.                                                                        and “Adding Years of Healthy Life” for our patients, our
                                                                                                                                                 structure for the “Triple Aim” system.
           Dr Berwick at a National Forum in 2007. But this has evolved                                                                                                                                  community, and our population.
           over many years, with thinkers such as Mr Thomas Nolan            b. Deliberately build an access platform for maximum             e. Efficiently customise services based on appropriate
           and Dr John Whittington. The main focus of the concept,              flexibility to provide customised healthcare for the             segmentation of the population.
           was to not only look at healthcare from the perspective of           needs of patients, families, and providers.
           improving care for an individual patient, but also to view        c. Cooperate and coordinate with other specialties,
           it from the “widest possible lens” for outcomes that would           hospitals, and community services related to health.
           impact the entire population. A challenging paradox was
           having to address, not just clinical outcomes, but also         3. Prevention and Health Promotion
           the cost of providing care and creating the best possible
           experience that care renders simultaneously.                      a. Work with the community to advocate and provide
                                                                                incentives for smoking prevention, healthy eating,
                                                                                exercise, and reduction of substance abuse.

                                                                             b. Develop multi-sector partnerships, utilise key
                                                                                stakeholder resources (worksites, schools, etc),
                                                                                and align policies to provide community-based
                                                                                support for all who wish to make health-related
                                                                                behaviour change.

                                                                             c. Integrate   healthcare      and      publicly   available
                                                                                community-level       data      utilising     Geographic
                                                                                Information System (GIS) mapping to understand the
                                                                                local context to strategically determine where and for
                                                                                whom health-related community-level prevention,
                                                                                health promotion, and disease-management support
                                                                                interventions would be most useful.

117   © National Healthcare Group                                                                                                                                                                                                                  © National Healthcare Group   118
06CHAPTER THOUGHTS ON THE FUTURE STATE - National Healthcare Group
BRIDGING LABORATORY AND LIFE FOR EFFECTIVE
           POPULATION HEALTH MANAGEMENT
           PROFESSOR LIM TOCK HAN, DEPUTY GROUP CEO (EDUCATION AND RESEARCH), NHG

           The beginning of all human civilisation can be traced back        This is but the first step. Generating impressive data and   understanding of the healthcare system. Healthcare              The best designed system will only work if its people believe
           to a river or a lake, with water being a source of life. A        research studies will amount to little without tangible      professionals will be trained in knowledge management,          in its purpose. In this regard, we need to continually foster
           healthy river system – one that is robust and sustainable –       outcomes. These resources should be translated into          evidence synthesis, and in optimising the clinical network      a culture that encourages curiosity, eagerness to learn,
           is vital for the continuation of life on earth. This is similar   novel applications for clinical practice and in turn,        to provide value-driven and cost-effective care for patients.   an openness to change, and most importantly, a heart
           to the role of our healthcare system: an ecosystem that           improve patient care and safety. NHG bridges this divide     Besides practising at the top of their licences, healthcare     for the patient. Only then, will we be able to establish an
           sustains rather than depletes its resources, rich in both         by developing a strong pipeline of Clinician Scientists,     professionals should embrace improvement sciences to            ecosystem of health that is able to add many more healthy
           quality and innovation, and fluid in adapting to new              who serve as conduits between laboratory and clinical        ensure that care delivery stays ahead of the curve. A more      years to our River of Life.
           technology. This can only be achieved if we shift the             research. Together with NHG’s primary clinical training      comprehensive training programme will ensure that best
           paradigm: from ‘sick’ care to ‘health’ care.                      partner, LKCMedicine, we have jointly developed a            practices consistently permeate the workplace among
                                                                             comprehensive research career development roadmap            both healthcare professionals and administrative staff.
           Singaporeans now enjoy one of the highest life expectancies
                                                                             for our Clinician Scientists. They will help enhance NHG’s   Towards this end, NHG College has introduced a series of
           in the world. In the past three decades, our life expectancy
                                                                             research in niche areas such as metabolic diseases,          faculty development programmes to build and strengthen
           has increased by almost 10 years. Yet, with every year of
                                                                             including diabetes, infectious diseases, skin disorders,     the capabilities of our educators. These programmes
           increased longevity, we see only two-thirds of an increase in
                                                                             mental health, geriatrics, and healthy lifestyle.            include the Health Professions Educators’ Essentials
           Healthy Life Expectancy (HALE) – a measure of the quality
                                                                                                                                          (HaPEE) which is tailored to our local context, study trips
           of these additional years. We need to bridge this gap.            In tandem, medical education is expanding its horizons
                                                                                                                                          made to global organisations to learn best practices, and
                                                                             to incorporate not just clinical knowledge, but a holistic
           Traditionally, medical research and education focused on                                                                       regular faculty development workshops for staff.
           treating diseases when they occur, rather than prevention
                                                                                                                                          As compared to formulating treatment plans for the sick,
           and maintenance of health. Now, we are increasingly shifting
                                                                                                                                          devising healthcare interventions for population health
           our academic pursuits upstream to support population
                                                                                                                                          requires us to see things through wider lens. Sociology,
           health management for more value-driven outcomes.
                                                                                                                                          behavioural sciences, health economics, and medical
           To understand how to run an effective population health                                                                        technology are just as important as systems biology in
           management system is to first understand the “nuts and                                                                         providing us with new insights. We are therefore investing
           bolts” that make up the complex healthcare system. Research                                                                    in the creativity and energy of our younger generation.
           analyses how the various healthcare determinants weave                                                                         NHG is in a multi-party collaboration with tertiary
           together, and the gaps of the current system that prevent it                                                                   education institutions in Singapore to develop gaming
           from reaching its ultimate potential or goal, which is to cure                                                                 prototypes to address challenges in healthcare and to
           humanely, to relieve, to care, and to prevent, where possible.                                                                 empower self-care in patients. Termed the ‘ALIVE-POLY-
                                                                                                                                          ITE Student Internship Programme’, the gAmes for heaLth
           This is where epidemiology research comes in. We can
                                                                                                                                          InnoVations centrE (ALIVE), a collabration between NHG
           only begin to build the infrastructure of a population
                                                                                                                                          and LKCMedicine, will provide professional healthcare
           health management system if we have enough raw
                                                                                                                                          expertise to students in developing serious games
           materials to study and work with. Carefully collected and
                                                                                                                                          prototypes that may translate into user-friendly solutions
           diverse data is needed to study the trajectory of diseases,
                                                                                                                                          for better health outcomes and population wellness.
           their causes, and previously unknown risk factors, in order
           to identify the sub-populations at risk, and eventually                                                                        These key factors – exhaustive research, a fine-tuned
           design evidence-based preventive strategies and practical                                                                      education programme, and a relentless drive for
           interventions. The on-going Health for Life in Singapore                                                                       improvement and innovation – will fortify the population
           (HELIOS) Study serves this purpose. Established and led                                                                        health management infrastructure, and in turn lay the
           by Nanyang Technological University (NTU)/Lee Kong                                                                             foundation for NHG to eventually become the Academic
           Chian School of Medicine (LKCMedicine), in partnership                                                                         Health System (AHS) we aspire to be. Together with NTU,
           with NHG and Imperial College London (ICL), the                                                                                LKCMedicine, and ICL, we are working towards developing
           Study aims to mine a wide breadth of data from 10,000                                                                          a population-centred AHS with our newly formed Joint
           Singaporeans/Permanent Residents to better predict,                                                                            Strategic and Implementation Committee (JSIC). This
           prevent, and manage chronic diseases. HELIOS, which                                                                            Committee brings together Clinicians and Academia to
           is the first large-scale longitudinal health study done on                                                                     design, evaluate, and implement initiatives promoting
           Asians, will be a formidable databank for global scientists                                                                    population health.
           and doctors deepen their medical research.

119   © National Healthcare Group                                                                                                                                                                                                                    © National Healthcare Group   120
06CHAPTER THOUGHTS ON THE FUTURE STATE - National Healthcare Group
TRANSFORMING PRIMARY CARE:
           A FUTURE STATE WISHLIST                                                                                                       1. Fulfil the Tenets of Primary Care                          To achieve these strategic goals, several system-level
           ASSOCIATE PROFESSOR CHONG PHUI-NAH, CEO, NATIONAL HEALTHCARE GROUP POLYCLINICS                                                                                                              enablers will be crucial for NHGP. Integration of care across
                                                                                                                                         Together with our GP and hospital partners in the
           AND PRIMARY CARE                                                                                                                                                                            the various care settings will need to be further supported.
                                                                                                                                         region, we continue to pursue innovative and scalable
                                                                                                                                                                                                       We hope that with the Next Generation Electronic Medical
                                                                                                                                         ways to improve accessibility, comprehensiveness, and
                                                                                                                                                                                                       Record (NGEMR) coming onstream in 2020, the flow of
                                                                                                                                         coordination of care.
           Primary Care Vision 2025: A world-class, relationship-based Primary Care ecosystem. This is the future of Primary Care in                                                                   information for patient care across public health institutions
           the Central Region as envisioned by National Healthcare Group Polyclinics (NHGP) in early 2015 when we asked ourselves                                                                      will improve, enabling the development and sustaining
                                                                                                                                         2. Optimise Population Health                                 of holistic integrated patient care plans. This is especially
           what we would like to move towards to and build over the next decade. Five strategic objectives were identified:
                                                                                                                                         We seek to gain a deeper understanding of the population      important for chronic care management. Patients should
                                                                                                                                         under our care, as well as strengthen partnerships with       own and have access to their care plans which enhance
           1. New Care Delivery Model                                     3. Patient Engagement and Activation
                                                                                                                                         the community to enhance primary and secondary care           communication and goal-setting between patients and
           Since then, NHGP has remodelled the way it delivers care       To truly engage and activate our patients, we recognise        prevention.                                                   care providers, to monitor each patient’s progress.
           across all its polyclinics. Its patient empanelment teamlet    the importance of developing a health literate workforce
                                                                                                                                                                                                       Technology advances are changing the way in which our
           care model has brought about improved clinical outcomes,       as an essential first step since our staff can be our health   3. Activate Patients, Family, and Caregivers
                                                                                                                                                                                                       society communicates, obtains, and shares knowledge.
           reduced diabetes and hypertension-related emergency            ambassadors. NHGP seeks to understand the gaps,
                                                                                                                                         Patients remain our first priority in our ecosystem. They     Primary Care will need to adopt and adapt to new
           visits, and increased patients’ uptake of primary and          identify ways and has put in place training to raise health
                                                                                                                                         are key ‘players’ in our empanelment teamlet care model,      technology, and manage the accompanying risks, to stay
           secondary preventive health screening.                         literacy among all levels of staff.
                                                                                                                                         and more will be done to activate them and their families     relevant to how our patients live and work. Virtual access
                                                                                                                                         to make and sustain behavioural changes for better self-      to care to complement clinic visits, technology-enabled
           2. Expansion of Primary Care Capacity                          4. Staff Engagement and Development
                                                                                                                                         care and good health.                                         self-monitoring, and patient education and engagement
                                                                          5. Stewardship and Setting Standards
           Over the past four years, NHGP has also established                                                                                                                                         through mobile platforms are examples of how we are
           patient    right-siting   collaborations  with    General      As NHGP transforms Primary Care, it is important to ensure     4. Research and Innovate                                      harnessing technology as part of care transformation.
           Practitioners (GPs), and successfully handed over three        that our people are committed to the highest standards                                                                       Machine-learning and Artificial Intelligence (AI) are also
                                                                                                                                         To drive our transformational efforts, we will invest more
           Family Medicine Clinics (FMCs) set up with selected GP         of ethical conduct, and exercise collective responsibility                                                                   providing us with opportunities to do more and better,
                                                                                                                                         in developing a culture of innovation and Primary Care
           partners while continuing to jointly oversee the clinics’      for the resources to provide care to our patients and the                                                                    in view of increasing healthcare demand and a shrinking
                                                                                                                                         research, with the aim of scaling and spreading successful
           clinical governance. In line with the Ministry of Health’s     population. There are staff development projects such                                                                        workforce. Primary Care providers will need to partner
                                                                                                                                         proof-of-concepts across our Primary Care ecosystem.
           (MOH) support of GPs to deliver holistic chronic care          as job redesign for operations staff and training on how                                                                     technology providers to contextualise the know-how, and
                                                                                                                                         Staff and partners will be encouraged to experiment with
           through the Primary Care Networks (PCNs), NHGP is              to work better as teamlets. We have also continued to                                                                        develop effective and sustainable solutions which meet
                                                                                                                                         new ideas to enable our patients to live well.
           leading the Central-North PCN. Some 30 GP clinics now          improve the quality of our care and service delivery.                                                                        our patients’ needs. Regulatory sandboxes which allow for
           work closely with NHGP and NHG Institutions through this                                                                                                                                    experimentation and collaboration in new ways to deliver
                                                                                                                                         5. Lead in Clinician Training
           network to serve residents in the Northern and Central                                                                                                                                      care will be necessary.
           regions of Singapore.                                                                                                         Clinician training must focus on the future, and we aim to
                                                                                                                                                                                                       The future state of Primary Care will continue to be
                                                                                                                                         provide our clinicians with the skills to manage conditions
                                                                                                                                                                                                       dependent on the building of strong relationships
                                                                                                                                         such as Frailty and mental health within Primary Care,
                                                                                                                                                                                                       between the patient and provider, and provider-provider
                                                                                                                                         more so with an ageing population.
                                                                                                                                                                                                       partnerships. While MOH reviews Singapore’s healthcare
           THE FUTURE AHEAD                                                                                                              6. Develop High-Performing Staff                              financing model, NHGP and our partners continue to
                                                                                                                                         and Providers                                                 work closely and leverage on key enablers to improve our
                                                                                                                                                                                                       quality and integration of care.
           In 2017, Health Minister Mr Gan Kim Yong shared MOH’s          This ecosystem, comprising NHGP and GPs in our
                                                                                                                                         Emphasis will be placed on attracting, developing and
           Three Beyonds strategy – Beyond Hospital to Community,         region, is underpinned by a strong spirit of cooperation                                                                     Primary Care is the cornerstone of a sustainable healthcare
                                                                                                                                         retaining high-performing staff in NHGP, and over time to
           Beyond Healthcare to Health, and Beyond Quality to Value       and knowledge-sharing, enabled by supportive funding,                                                                        system. The success of NHG’s Primary Care Transformation
                                                                                                                                         also raise the capability and standard of our Primary Care
           – for a sustainable healthcare system. This strategy further   technological and physical infrastructure.                                                                                   will be a key determinant of whether the River of Life is a
                                                                                                                                         ecosystem providers collectively. This is done through
           bolsters our Primary Care Vision 2025, by bringing the axis                                                                                                                                 powerful, yet calm life-changing force.
                                                                          In late 2018, we reviewed and updated our strategic            on-going sharing and knowledge exchange, learning, and
           of care to the primary and community levels, and closer to
                                                                          approaches to ensure that we are on track to achieve           development.
           the patient and population. The push for our Primary Care
                                                                          Vision 2025. With a focus on ensuring future-readiness and
           Transformation is gaining impetus as we continue to build
                                                                          an emphasis on partnership with the rest of the Primary
           on our Vision of a world-class, relationship-based Primary
                                                                          Care ecosystem, we have distilled six strategic goals and
           Care ecosystem for the Central Region of Singapore.
                                                                          are developing corresponding strategies to achieve them.

121   © National Healthcare Group                                                                                                                                                                                                                  © National Healthcare Group   122
06CHAPTER THOUGHTS ON THE FUTURE STATE - National Healthcare Group
MAINSTREAMING MENTAL HEALTH AND WELL-BEING
           PROFESSOR CHUA HONG CHOON, DEPUTY GROUP CEO (CLINICAL), NHG;
           CEO, INSTITUTE OF MENTAL HEALTH
                                                                                                                                         TAKING CHARGE                                                   FOCUSING ON JOY IN WORK
           One in seven adults in Singapore has experienced a mood,
           anxiety, or alcohol use disorder in their lifetime. This was   A HOLISTIC APPROACH                                            Central to this concept of Living Well, even with illness, is   This focus on personal health and well-being is something

                                                                          TO HEALTH -
                                                                                                                                         the ‘ownership’ of health — empowering and motivating           that can help us as healthcare workers too. We all know
           one of the key findings from the Singapore Mental Health                                                                      individuals to take charge of their health. One of the          that delivering high quality healthcare can be extremely
           Study (SMHS) 2016 led by the Institute of Mental Health
           (IMH). The nation-wide epidemiological study looked            NO HEALTH WITHOUT                                              ways we are looking to do this in NHG is by incorporating       challenging, and that healthcare professionals are facing

                                                                          MENTAL HEALTH
                                                                                                                                         health coaching as an adjunct to treatment. In fact, we         increasing stress and burnout, not just in Singapore but
           at the prevalence of common mental disorders in the                                                                           are already doing this to some extent. Often when we see        worldwide. Stress and burnout in healthcare workers
           Singapore resident population aged 18 years and above,                                                                        patients, we advise them to make lifestyle changes that         adversely affect the quality of care we provide to our
           their associated factors, as well as the population’s help-                                                                   will help to improve their health outcomes and quality          patients. It can lead to lower levels of staff engagement
                                                                          Often when we talk about health, we tend to overlook
           seeking behaviour. It was also one of the few studies                                                                         of life. Long-term lifestyle change is perhaps the most         and productivity, and higher staff turnover. How do
                                                                          mental health or see it as separate from physical health.
           worldwide that made a deliberate attempt to track the                                                                         important factor to sustain improvement, especially in          we deal with this challenge? One way, the Institute of
                                                                          The two, however, are inextricably linked. Studies show
           mental health status of a country over a period of time.                                                                      the management of chronic conditions such as diabetes           Healthcare Improvement in the United States says, is for
                                                                          that people with schizophrenia, bipolar disorder, and
           Compared with the first SMHS in 2010, we found that                                                                           and hypertension as well as certain mental health issues.       the healthcare workforce to reclaim the “Joy in Work”
                                                                          major depressive disorder (MDD) are more likely to also
           the prevalence of mental illness had increased, and that                                                                      It is also often perceived as extremely daunting, to have       that has led many to embark on a career in healthcare
                                                                          experience chronic conditions such as diabetes and heart
           younger people, aged 18 to 34, emerged as the group                                                                           to make changes to diet, exercise, and sleep, which have        in the first place. We need to re-focus on the meaning
                                                                          disease, and have reduced life expectancy of between 15
           more vulnerable to mental health issues.                                                                                      become lifelong habits. Health coaching focuses on this         of our work, to see how every minute of the day at work
                                                                          and 20 years compared to the general population. These
           While the SMHS 2016 showed that those who sought help          are common mental disorders; MDD is in fact the most           often difficult aspect of chronic disease management;           directly contributes to our personal goal of giving care to
           for mental health issues were doing so sooner compared         common mental disorder in Singapore, with one in 16            the aim is to work with patients to draw out their              people in need. We should improve the communication
           with SMHS 2010, more than 75 per cent of people with a         people having experienced it at some point in their life.      self-motivation to make long-term changes and adopt             we have with our colleagues, stop doing things that are
           mental disorder were not seeking any professional help                                                                        health-supporting habits that will help them to achieve         not meaningful, and help each other so we do not feel
                                                                          Conversely, people with chronic physical conditions have
           for their problems. Why is this happening in a modern,                                                                        their personal goals.                                           alone and unsupported. I believe this is the way forward,
                                                                          a higher risk of developing mental health problems, like
           developed country with a well-educated population?                                                                                                                                            and at the heart of this concept is to find meaning in what
                                                                          depression and anxiety, than the general population. If        For instance, an elderly man with poorly controlled
           We think that this could be due partly to the inability                                                                                                                                       we do and what brings us joy in our work.
                                                                          we compare two individuals who have diabetes or even           hypertension and diabetes may not be motivated to
           of sufferers to recognise their distressing feelings and                                                                      reduce his salt and sugar intake just for the sake of being     I have started a workgroup to explore how we can bring
                                                                          cancer, research shows that the person who is mentally
           experiences as symptoms of treatable mental health                                                                            healthier, but health coaching could help this man to focus     “Joy in Work” back to all at NHG, and am working with some
                                                                          healthier tends to have better outcomes.
           conditions. The persistent societal and personal stigma                                                                       instead on being well enough to see his favourite grandson      very enthusiastic and passionate colleagues who want to
           associated with mental illness is another key reason. How      As we push ahead with a population approach to
                                                                                                                                         graduate from university, a meaningful enough reason            develop this into a movement in NHG. “Joy in Work” will be
           can we do better?                                              healthcare, an important question we have to ask
                                                                                                                                         to give up salt and sugar! Health coaching goes beyond          a participative and voluntary process involving staff at all
                                                                          ourselves is “What does it truly mean to be healthy?”
                                                                                                                                         curing individuals of their illness; it is about helping them   levels of NHG as we define what matters to us individually
                                                                          The World Health Organization (WHO) defines health
                                                                                                                                         to understand how their illness prevents them from living       and as an organisation, understand the barriers to “Joy in
                                                                          as a “state of complete physical, mental and social
                                                                                                                                         the life they want. It is about focusing on what they value     Work”, and how we can address them.
                                                                          well-being and not merely the absence of disease or
                                                                                                                                         most to serve as a catalyst for change.
                                                                          infirmity.” This widely accepted definition recognises                                                                         If we can learn to bring back “Joy in Work” among
                                                                          the interlinked nature of mental, physical and social                                                                          colleagues at all levels of NHG, I believe that we will be
                                                                          well-being; and while we have some way to go in working                                                                        poised to show the way for other organisations to create
                                                                          beyond our areas of healthcare specialties, I would very                                                                       a more positive work environment. We spend most of our
                                                                          much like to see a closing of the gaps between the three                                                                       adult life at work so it is important that our workplace is
                                                                          in our work. I hope that healthcare professionals across all                                                                   one that supports mental, physical, and social well-being.
                                                                          disciplines will see individuals holistically, and attend to
                                                                          all aspects of their health — mental, physical and social.
                                                                          I believe that this will help to change how people view
                                                                          mental illness, and in turn reduce stigma.

                                                                          We also need to look beyond illness to wellness. Being
                                                                          healthy does not only mean the absence or prevention
                                                                          of illness but rather living well, enjoying meaningful
                                                                          relationships, being productive at work, and being able
                                                                          to engage in and contribute to one’s community, even if
                                                                          one is living with illness. Modern science and medicine
                                                                          today allow persons with chronic illness to continue
                                                                          living meaningful and happy lives, and this should be no
                                                                          different for those with mental illnesses.

123   © National Healthcare Group                                                                                                                                                                                                                  © National Healthcare Group   124
06CHAPTER THOUGHTS ON THE FUTURE STATE - National Healthcare Group
BRINGING DERMATOLOGY CARE INTO THE COMMUNITY
           ASSOCIATE PROFESSOR TAN SUAT HOON, DIRECTOR, NATIONAL SKIN CENTRE
                                                                                                                                                                                                                                A FUTURE-READY WORKFORCE DRIVING DERMATOLOGICAL
           Skin diseases are one of the health problems in Singapore                                                   conditions requiring a degree of specialised care now
                                                                                                                                                                                                                                                                                         INNOVATION THROUGH
                                                                                                                                                                                                                                community and broad-based care, dermatology should RESEARCH
                                                                                                                                                                                                                                In preparing our future physicians for the shift to more
           that cause the most disability. In terms of Years of “healthy                                               have the option of being treated closer to home through
           life” Lost to Disability (YLD), skin and subcutaneous                                                       Tele-DERM, an e-consult service that enables Family                                                      be taught to all medical students. It should no longer be
           diseases have been ranked as the fifth leading cause of                                                     Physicians at polyclinics to discuss skin care cases and                                                 an elective and its training curriculum should be uniform,     Strong clinical care and a vigorous teaching culture need
           non-fatal burden in Singapore1.                                                                             treatment options with NSC dermatologists promptly.                                                      so that all medical students get to see the common and         to be complemented with progressive research. Inter-
                                                                                                                       It reduces the need for patients to go for additional                                                    less common (but equally important) skin conditions that       institutional and inter-disciplinary collaborations are
           Eczema is the leading cause of skin health problems,
                                                                                                                       follow-up appointments at NSC, allowing them to receive                                                  they may encounter in their practice, be it in the primary     necessary to generate innovative and practical ideas that
           largely contributed by its high prevalence of 20 per cent in
                                                                                                                       dermatology care sooner and at their convenience.                                                        or specialist setting. This calls for a more innovative        can be translated into improved clinical and healthcare
           school going children and 11 per cent in adults2 3. Among the
           elderly aged 70 and above, there is a high burden of skin                                                   In serving as a tertiary centre in this hub-and-spoke                                                    approach to education so that all medical students             outcomes for the population.
           disease where eczema, ulceration, other skin conditions,                                                    model, NSC will continue to facilitate inter-cluster transfer                                            who rotate through the training centre in dermatology
                                                                                                                                                                                                                                                                                               Thus, the Skin Research Institute of Singapore (SRIS), a
           skin cancer, infections, and pruritus are key issues4 5.                                                    of patients who require complex diagnostic workup,                                                       are taught to familiarise themselves with a core list of
                                                                                                                                                                                                                                                                                               collaboration between Agency for Science, Technology
                                                                                                                       phototherapy, medical or surgical treatment. The new                                                     diagnoses. It will be an extension of what is currently done
           Taken together, what the data suggests is that skin                                                                                                                                                                                                                                 and Reseach (A*Star), Nanyang Technological University
                                                                                                                       NSC building, when opened in 2022, will have capabilities                                                for our examinations. Common modalities of treatment
           conditions affect a high proportion of the population,                                                                                                                                                                                                                              (NTU)/Lee Chong Kian School of Medicine (LKCMedicine),
                                                                                                                       for specialised allergy testing and a facility to administer                                             can be taught by both physicians and non-physicians
           estimated at 30 to 70 per cent of individuals, across all                                                                                                                                                                                                                           and NSC, was formed to harness the expertise and
                                                                                                                       general anaesthesia, opening up opportunities for                                                        interactively, and this is what NSC has introduced.
           cultures and ages.                                                                                                                                                                                                                                                                  experience of scientists, engineers, and clinicians, to
                                                                                                                       dermato-surgical procedures for paediatric patients and                                                  The dermatology training programme should evolve               discover new treatments for some of the diseases that
                                                                                                                       other more complicated dermato-surgical procedures.                                                      to a standardised national training programme where a          cause the most disability in Singapore. Such inter-
           QUALITY DERMATOLOGY                                                                                         Team-based care for the management of chronic skin
                                                                                                                       diseases will be the norm. While physician-led, such
                                                                                                                                                                                                                                trainee goes through different care settings. This includes    disciplinary collaboration not only promotes industry

           CARE FOR THE POPULATION                                                                                     multidisciplinary teams ensure patients still receive
                                                                                                                                                                                                                                Acute Hospitals which may have select subspecialty
                                                                                                                                                                                                                                capabilities geared for the community, as well as in NSC,
                                                                                                                                                                                                                                                                                               partnerships but actualise translational research outcomes
                                                                                                                                                                                                                                                                                               and commercial applications for better population
                                                                                                                       good care from other healthcare professionals during                                                     which is a tertiary specialty centre with the full range of    health outcomes and quality of life. Its skin research and
           In people affected by chronic skin diseases such as                                                         home visits. Frail patients, in particular, will benefit from                                            subspecialties. Medical students will therefore undergo        innovation will also contribute to the global skin research
           eczema and psoriasis, most hope to still enjoy quality                                                      home-based care provided by Community Nurses from                                                        a well-rounded training programme with exposure to             community and help improve patient care.
           living with good control (if not cure) of the condition. In                                                 NSC or by care teams formed in collaboration with the                                                    different work environments; this will broaden their scope
           Singapore where accessible healthcare is the norm, this                                                     Home Nursing Foundation (HNF).                                                                                                                                          Much effort has also been devoted to building a nurturing
                                                                                                                                                                                                                                of career opportunities, giving them more options based
           notion is compounded with demands for quick and direct                                                                                                                                                                                                                              environment in which innovative ideas can flourish and
                                                                                                                                                                                                                                on their professional aspirations and culture fit.
           specialist care and a shorter waiting time to see a doctor.                                                                                                                                                                                                                         take shape. Budding research talent can be cultivated
                                                                                                                                                                                                                                This model of education will also ensure continual training    through joint research collaborations and formal
           However, there are challenges to this. In an era of expensive                                                                                                                                                        for physicians in areas that are core to critical service.     appointments with NTU/LKCMedicine and NSC, and
           biologic drugs, selecting the most appropriate treatment                                                                                                                                                             In line with the shift towards broad-based generalist          through a harmonised governance framework for the
           will incur high cost for both the healthcare system and the                                                                                                                                                          specialists in the hospital setting, dermatology rotations     NHG cluster. Grants from the National Medical Research
           patient. There are also aspects of psycho-social care that                                                                                                                                                           should be made compulsory for Internal Medicine trainees,      Council (NMRC), NHG, and LKCMedicine will help to
           impact the clinical outcome of the condition which cannot                                                                                                                                                            either at the junior or senior residency level. This should    develop research talents and advance their research work,
           be completely addressed by medication, and which goes                                                                                                                                                                also apply to Family Medicine trainees at the Primary          increasingly through the PhD route. Centre grants from
           beyond traditional delivery by the physician.                                                                                                                                                                        Care level. The teaching faculty will therefore need to        NMRC are still critical to ensure core research manpower
           In Singapore, access to good quality dermatology care                                                                                                                                                                develop training curriculums tailored for specific groups      and infrastructure support. Competitive programme
           therefore requires the effective use of health resources.                                                                                                                                                            – undergraduate, postgraduate non-dermatologist,               grants need to be secured based on where the most value
                                                                                                                                                                                                                                post graduate dermatology specialists, and in addition,        can be gained, rather than as an all-inclusive grant.
                                                                                                                                                                                                                                training courses for GPs and postgraduate dermatology
           MAKING DERMATOLOGY                                                                                                                                                                                                   fellowships to meet national and regional needs. The
                                                                                                                                                                                                                                                                                               As we move towards an era where community-based
                                                                                                                                                                                                                                                                                               care will become the gold standard in population health
           CARE ACCESSIBLE TO THE                                                                                                                                                                                               nursing and pharmacy training curriculum will need to be
                                                                                                                                                                                                                                developed in tandem so that our healthcare professionals
                                                                                                                                                                                                                                                                                               management, specialist dermatology care should similarly

           POPULATION                                                                                                                                                                                                           are empowered to practise at the top of their licence to
                                                                                                                                                                                                                                                                                               strive to become wholly accessible and cost-effective. This
                                                                                                                                                                                                                                                                                               can be achieved through providing multidisciplinary care,
                                                                                                                                                                                                                                support team-based care for the future.
                                                                                                                                                                                                                                                                                               an education model that upskills Primary Care providers
           Since a great deal of dermatological care can be delivered                                                                                                                                                                                                                          and translational cutting-edge research. Together, we will
           at the Primary Care level, our efforts to shift care from the                                                                                                                                                                                                                       be able to improve the overall skin health of our population.
           hospital to the community must continue to be encourged.

           To ensure seamless integrated care at this level, the National
           Skin Centre (NSC) will continue to be the hub for polyclinics
           and General Practitioner (GP) network. Patients with skin
           1
            GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. “Global, Regional, and National Incidence, Prevalence, and Years Lived with Disability for 328 Diseases and Injuries for 195 Countries,
           1990–2016: A Systematic Analysis for the Global Burden of Disease Study 2016.” Lancet 390, no. 10100 (2017): 1211-259.
           2
            Tay, Y-K., K-H. Kong, L. Khoo, C-L. Goh, and Y-C. Giam. “The Prevalence and Descriptive Epidemiology of Atopic Dermatitis in Singapore School Children.” British Journal of Dermatology 146, no. 1 (2002): 101-
           06. doi:10.1046/j.1365-2133.2002.04566.x.
           3
            Cheok, S., F. Yee, J.y. Song Ma, R. Leow, M.s.l. Ho, Y.w. Yew, Y.k. Tay, S.a. Rebello, N. Luo, and M.j.a. Koh. “Prevalence and Descriptive Epidemiology of Atopic Dermatitis and Its Impact on Quality of Life in
           Singapore.” British Journal of Dermatology 178, no. 1 (2017): 276-77. doi:10.1111/bjd.15587.
           4
             Yap, KB, MG Siew, and CL Goh. “Pattern of Skin Diseases in the Elderly Seen at the National Skin Centre (Singapore) 1990.” Singapore Medical Journal 35, no. 2 (1994): 147-50.
           5
            Hay, Roderick J., Nicole E. Johns, Hywel C. Williams, Ian W. Bolliger, Robert P. Dellavalle, David J. Margolis, Robin Marks, Luigi Naldi, Martin A. Weinstock, Sarah K. Wulf, Catherine Michaud, Christopher J.l.
           Murray, and Mohsen Naghavi. “The Global Burden of Skin Disease in 2010: An Analysis of the Prevalence and Impact of Skin Conditions.” Journal of Investigative Dermatology 134, no. 6 (2014): 1527-534.
           doi:10.1038/jid.2013.446.

125   © National Healthcare Group                                                                                                                                                                                                                                                                                                         © National Healthcare Group   126
06CHAPTER THOUGHTS ON THE FUTURE STATE - National Healthcare Group
BUILDING A FUTURE-READY NURSING WORKFORCE                                                                                        To achieve the goals articulated by WoW, more than
                                                                                                                                            50 innovative ideas across the care spectrum have
                                                                                                                                                                                                                         10% Productivity by year 2020

           MR YONG KENG KWANG, DEPUTY CHAIRMAN, NURSING COUNCIL, NHG;                                                                       been generated and evaluated, and five key areas for
           CHIEF NURSE, TAN TOCK SENG HOSPITAL                                                                                              productivity improvement have also been identified. The
                                                                                                                                            potential productivity gains for each area – Clinical Care,                     Percentage               Clinical care
                                                                                                                                            Hygiene Care, Patient Self-Services, Support Services,                                                   (3%)
                                                                                                                                            and Administration Support – have been estimated, and                                                    Hygiene care
           An ageing population. A higher chronic disease burden. An older and shrinking workforce. Evolving demands and
                                                                                                                                            collectively, they make up the 10 per cent productivity                                                  (2%)
           expectations of patients and the population.
                                                                                                                                            target set for 2020 in the FNCRC report.                                                                 Patient self-services
           These converging factors have made it imperative for Singapore to make fundamental shifts in how and where healthcare                                                                                                10%                  (1%)
                                                                                                                                            Many initiatives under WoW are work-in-progress, with                           Productivity
           is delivered to Singaporeans. The new approach is to promote good health throughout life, with emphasis on preventive                                                                                                                     Support services
                                                                                                                                            timelines for their implementation and the actualisation of
           care, and on continuing care at home and in the community. This transformation entails investing in people working in                                                                                                                     (3%)
                                                                                                                                            productivity gains estimated to be between one and three
           healthcare, and to prepare them with future skills so that they can continue to deliver the best and safe care regardless                                                                                                                 Administration
                                                                                                                                            years, and three and five years, respectively. Technology                                                support
           of care setting.
                                                                                                                                            and robotics can play a significant role in achieving a                                                  (1%)
           Nursing staff make up 44 per cent of the overall healthcare manpower in public general hospitals, of which 54 per cent and       greater margin of productivity improvement, and they are
           nine per cent are in the general wards and Specialist Outpatient Clinics (SOCs), respectively. With nursing at the core of the   being adopted in tandem with our continual review and
           healthcare workforce, it is being reshaped and redesigned to effectively support our Care Transformation.                        redesign of best nursing practices and care models.
           Established in May 2017, the NHG Nursing Executive Council seeks to drive and devise measures at system-level, and to
           harmonise best practices aligned to the new strategic thrusts identified by the Ministry of Health (MOH) Future Nursing          Competency: To practise at top of the                               Community: To engage the public
           Career Review Committee (FNCRC). They comprise the ‘three Cs’ – Care, Competency, and Community. The Council                     Licence, provide direct patient care and                            in healthy living, active ageing, and
           has since developed a blueprint to guide the Nursing Transformation efforts of NHG.                                              implement role redesign                                             continuous learning
                                                                                                                                            For nurses to take on expanded roles, the broadening and            As NHG works with our population to change the role

           THE THREE STRATEGIC THRUSTS                                                                                                      strengthening of individual competencies is critical. This
                                                                                                                                            requires changes to how we educate and train nurses to
                                                                                                                                                                                                                of our healthcare system from one of “Provider of Care”
                                                                                                                                                                                                                to “Partner in Care”, our nurses will be expected to move
                                                                                                                                            raise their job value, and to do likewise for support care staff.   into the community to provide collaborative care that is
           Care: To enhance delivery of care and                            Increasingly, our nurses collaborate with inter-disciplinary                                                                        characterised by person-centredness, continuity of care,
                                                                                                                                            Besides role redesign, role integration by incorporating
           increase manpower productivity                                   teams to enhance patient experience, outcomes, and                                                                                  self-care, and preventive health. This means the need to
                                                                            productivity. This shift in practice involves shared learning   relevant sub-specialised roles can help raise cost
                                                                                                                                                                                                                deploy more nurses in Primary Care settings, community
           We aim to empower and enable nurses to focus more on                                                                             effectiveness and sustainability. For example, a Respiratory
                                                                            and knowledge exchange, and reframing mindsets and                                                                                  hospitals, care centres, hospices, and homes to engage our
           patient care by removing unnecessary work, improving                                                                             Specialty Nurse equipped with a wide range of skills in
                                                                            attitudes. Priority is given to augmenting care coordination,                                                                       population and enable right-siting of care.
           their work processes, and boosting productivity by 10 per                                                                        advanced respiratory care can sub-specialise in asthma
                                                                            data analytics, assistive and sensing technologies, and
           cent by 2020 and by 20 per cent by 2030. To guide our                                                                            care and also review patients with other respiratory                In January 2018, an NHG Community Nursing Committee
                                                                            quality and workflow improvements. As more of NHG
           productivity efforts across the cluster, we have adopted the                                                                     conditions, where appropriate.                                      was set up to synergise efforts in the Central, Yishun, and
                                                                            nursing manpower is allocated to inpatient settings, we
           innovation cycle approach that is based on a framework to                                                                                                                                            Woodlands Zones. Besides leveraging on shared leadership
                                                                            decided to lay the groundwork for productivity efforts in       It is important to bolster the core competencies of
           reduce waste by redesigning care and processes; cut cost                                                                                                                                             from both clinical and non-clinical expertise in the areas of
                                                                            these areas.                                                    NHG nurses across the board. Geriatric Care has been
           by using automation, IT and robotics; and increase value                                                                                                                                             clinical protocol, IT, competency, and career development
                                                                            Wards without Walls (WoW) is one such initiative. Its four      highlighted as a domain for NHG nurses to fortify their
           through job redesign, such as upskilling, substitution, and                                                                                                                                          for Community Nursing, NHG has also been actively looking
                                                                            strategic components not only guide and support nurses          knowledge and skills — Tan Tock Seng Hospital’s (TTSH)
           expansion of job roles.                                                                                                                                                                              into improving work processes, and streamlining care
                                                                            in managing care transitions in a timely, appropriate and       Geriatric Resource Nurse Training (GRN) is a potential
                                                                                                                                                                                                                delivery by our Community Nursing and Community Health
           Collectively, these efforts will lessen administrative, non-                                                                     programme for all NHG nurses involved in clinical settings.
                                                                            seamless manner across various settings, but they too                                                                               Teams. As of September 2018, we have 81 Registered Nurses
           clinical and non-essential clinical activities so that nurses                                                                    Other domains for consideration include transition care
                                                                            empower patients and their families to be actively informed                                                                         and nine Community Care Associates.
           spend their time more meaningfully on direct patient care.                                                                       and palliative care.
                                                                            and to participate in the care process. This aligns with our
                                                                            Vision for these stakeholders to take greater ownership                                                                             We will tier interventions based on needs, be it for the well,
                                                                                                                                            With the increasing prevalence of co-morbidities
           Figure 1: NHG Ward without Walls Objectives                      of their health and to live fulfilling lives, including those                                                                       pre-Frail, Frail, and for those who require complex and
                                                                                                                                            leading to more complex cases, there is a greater need
                                                                            afflicted with illness.                                                                                                             palliative care. We will partner our patients from beginning
                                                                                                                                            for nurses to be adept in multiple clinical domains.
                                                                                                                                                                                                                to end, encourage them to participate in their care plans
                                         Empowered Patient                                                                                  Hence, NHG advocates team-based competency where
                                     Supported by sensors, robotics
                                                                                                                                                                                                                and eventually, cultivate a culture of health ownership. Our
                                                                                                                                            multidisciplinary healthcare professionals work together,
                                          and infrastructure                                                                                                                                                    overall aim is to keep our population healthy, to slow down
                                                                                                                                            and combine their respective expertise and training to
                                                                                                                                                                                                                the progression of Frailty and/or pre-empt hospital admission
              Home                          Acute Hospital                          Community                                               implement more comprehensive, holistic care plans. The
                                                                                                                                                                                                                with home care, and to facilitate more Advance Care Planning
                                                                                                                                            National Healthcare Group Polyclinics (NHGP) Teamlet
                                                                                                                                                                                                                (ACP) to ensure our patients ultimately leave well.
                                                                                                                                            Care Model is a good example. Patients are assigned to a
                                                                                                                                            Care Team comprising doctors, a Care Manager who is a               The NHG Nursing Transformation Journey is daunting
               Manage Patient                  Ward                   Shared-care Approach
                                                                                                                                            nurse, and a Care Coordinator, often with positive patient          because of the multiple “moving pieces” required to fit
                Complexities                  without                 Care management with
             Use of data analytics                                     patients, families and                                               outcomes and feedback.                                              together seamlessly. Yet when successful, the outcomes
                                               Walls
                 and robotics                                          community providers                                                                                                                      to be realised from this journey will be more impactful
                                          A New Care Paradigm                                                                               Through such approaches, we hope to increase intra-cluster
                                                                                                                                                                                                                and sustainable. NHG has made good progress as
                                                                                                                                            collaboration and improve NHG’s ability to tackle the evolving
                                                                                                                                                                                                                we continue to work towards the targets under the
                                                                                                                                            healthcare challenges and seasonal/system demands.
                                                                                                                                                                                                                ‘three Cs’ strategic thrusts. We will champion innovation
                                            No Boundaries                                                                                                                                                       and collective leadership at every level to deliver integrated,
                                        Care is not defined by a
                                            physical setting                                                                                                                                                    timely, person-centred, and safe care for our patients and
                                                                                                                                                                                                                the population we serve.

127   © National Healthcare Group                                                                                                                                                                                                                           © National Healthcare Group   128
06CHAPTER THOUGHTS ON THE FUTURE STATE - National Healthcare Group
PHARMACY TRANSFORMATION FOR                                                                                                      Figure 1: The National Pharmacy Strategy

                                                                                                                                            THE NATIONAL PHARMACY STRATEGY (NPS) HAS 5
           POPULATION HEALTH                                                                                                                KEY THRUSTS THAT ALIGN TO THE KEY SHIFTS IN
           MS CHAN SOO CHUNG, EXECUTIVE DIRECTOR, NHG PHARMACY
                                                                                                                                            THE HEALTHCARE TRANSFORMATION STRATEGY
                                                                                                                                                                                                                                                                            1. Pharmaceutical Care Excellence
           CHALLENGES AND OPPORTUNITIES IN THE CHANGING                                                                                                                                                                                                                        Enhancing pharmacy services that

           HEALTHCARE LANDSCAPE                                                                                                                                                                              1
                                                                                                                                                                                                    Pharmaceutical
                                                                                                                                                                                                                                                                               bring health and value for everyone in
                                                                                                                                                                                                                                                                               our community
                                                                                                                                                                                                         Care
           Singapore’s healthcare landscape is faced with the              the role of the Pharmacy Workforce. For example, it is                                                                     Excellence
                                                                                                                                                                                                                                                                            2. Confident Pharmacy Workforce
           following long-term challenges: an ageing population            already possible to tailor the right therapy based on the
                                                                                                                                                                                                                                                                              Providing a skilled, future-ready, and
           with increasing chronic disease conditions, a declining         characteristics of a person’s genetic profile to obtain                                                                  alth
                                                                                                                                                                                                                    Mov
                                                                                                                                                                                                                       eB                                                     innovative Pharmacy Workforce
           workforce due to lower national fertility rate, rising          the best outcomes in the management of some cancers.                         5                               re
                                                                                                                                                                                             to
                                                                                                                                                                                                  He                     ey
                                                                                                                                                                                                                           on                             2
           healthcare costs, higher expectations for value-driven          With the help of pharmacogenomics, the pharmacist will

                                                                                                                                                                                                                               d
                                                                                                                                                                                    a
                                                                                                                                                 Technology                                                                                           Confident

                                                                                                                                                                                  hc

                                                                                                                                                                                                                                   Ho
                                                                                                                                                                                                                                                                            3. Redesign Supply Chain

                                                                                                                                                                               alt
                                                                                                                                                 Enablement                                                      To enable                            Pharmacy

                                                                                                                                                                                                                                     sp
           patient-centred services, rising staff expectations and         have the information to determine the likely response of

                                                                                                                                                                             He
                                                                                                                                                                                         To help and             Singaporeans
                                                                                                                                                                                                                                                      Workforce

                                                                                                                                                                                                                                       ita
                                                                                                                                                                                         support                 to receive                                                   Delivering seamless, convenient,

                                                                                                                                                                       Move Beyond

                                                                                                                                                                                                                                          l to
           career aspirations due to higher education, and the impact      the patient to the drug and be able to better optimise                                                        Singaporeans
                                                                                                                                                                                         to lead
                                                                                                                                                                                                                 appropriate
                                                                                                                                                                                                                 care in the
                                                                                                                                                                                                                                                                              accessible, affordable, and safe

                                                                                                                                                                                                                                          Community
                                                                                                                                                                                         healthier lives.        community and
           of technology advancement on the future of work.                medication use and personalise the therapy. Advancement                                                                               closer to home.
                                                                                                                                                                                                                                                                              medications at every point of care
                                                                           of Precision Medicine requires better trained pharmacists
           The issues with medication are increasing, with rising
                                                                           to understand and drive the use of pharmacogenomic data
           incidences of chronic disease alongside the development                                                                                                                                To give every Singaporean                                                 4. Information Enablement
                                                                           to optimise medication therapy.                                                                                         best value, while keeping
           of more potent medicines. Medication use and outcomes                                                                                                                                     keeping our system
                                                                                                                                                                                                          sustainable.
                                                                                                                                                                                                                                                                              Empowering people to get the best
           are not optimal and medication-related hospital admission       The use of automation for inpatient and outpatient                                                        M
                                                                                                                                                                                                                                                                              out of their medications and achieve
           rates are a concern. Some of these concerns can be              medication dispensing has freed up manpower from                                     4                     ov
                                                                                                                                                                                        eB
                                                                                                                                                                                          eyo                  e
                                                                                                                                                                                                                                                      3                       care goals
                                                                                                                                                                                             nd Qu          alu
           attributed to poor communication and coordination of            the mundane work of picking and packing medication.                            Information                             ality to V                               Redesign
                                                                                                                                                          Enablement                                                                     Supply Chain
           care across different settings as patients consult multiple     The shift from a distribution function to a more patient-                                                                                                                                        5. Technology Enablement
           prescribers, raising the risk of medication errors and          focused role can now accelerate in tandem with the                                                                                                                                                 Delivering seamless and effective
           drug wastage. More needs to be done to holistically             changing models of care.                                                                                                                                                                           transition of care across all care settings
           manage concomitant conditions, systematically identify                                                                                                                                                                                                             through technology as an enabler
                                                                           In addition, the digital transformation wave of big data
           and address the medication problems faced by patients,
                                                                           analytics, machine learning, Artificial Intelligence (AI), and
           increase patients’ ownership of their health, and help them
                                                                           the Internet of Things (IoT) will change the way pharmacy
           understand the medicines they are taking.
                                                                           operates and how the public will eventually gain access to       PHARMACY TRANSFORMATION
           The advancement of medical technologies and automation          medication. It will allow analysis of trends from prescription
           brings many opportunities and will rapidly change               records, and help identify poor adherence.
                                                                                                                                            The Pharmacy Leadership in NHG also addressed the                                                                 Quality Prescribing
                                                                                                                                            challenges facing the workforce and the medication-
                                                                                                                                                                                                                                                              The pharmacist is well-placed to review the appropriateness
           NATIONAL PHARMACY STRATEGY                                                                                                       related problems experienced by patients. The Shared
                                                                                                                                            Vision of “Keeping the Population Well through Safe and
                                                                                                                                                                                                                                                              of prescriptions, monitor drug treatment, and check for
                                                                                                                                                                                                                                                              potential adverse drug reactions and drug interactions.
                                                                                                                                            Appropriate Medicine Use” was hence developed.
           The National Pharmacy Strategy (NPS), launched by the                                                                                                                                                                                              Pharmacists intervene in the choice of drug, dosing regimen,
           Ministry of Health (MOH) in 2017, outlines five key strategic                                                                    The three key priorities for change endorsed by NHG Senior                                                        and route of administration to improve medication safety,
           thrusts to transform the pharmacy landscape:                                                                                     Management were to improve the Quality of Prescribing,                                                            efficacy, and adherence. Being specifically trained in drug
                                                                                                                                            Medication Adherence, and to establish the flow of the                                                            therapy, integrating the pharmacist into the healthcare team
           1. Pharmaceutical Care Excellence                                                                                                Single Source of Truth for medication information. With                                                           will improve quality, safety, patient satisfaction and reduce
           2. Confident Pharmacy Workforce                                                                                                  MOH’s initiatives as a foundation, a Pharmacy Transformation                                                      costs. The APPRAISE workgroup’s focus is on designing
                                                                                                                                            Steering Committee (PTSC) chaired by Mrs Chew Kwee                                                                tools and curriculum to boost the competency of the
           3. Supply Chain Redesign                                                                                                         Tiang, CEO, Khoo Teck Puat Hospital (KTPH) and Yishun                                                             Pharmacy profession to conduct accurate assessment of
           4. Information Enablement                                                                                                        Health, and Associate Professor Thomas Lew, Chairman                                                              patient’s needs and optimise therapy for better outcomes.
                                                                                                                                            Medical Board, Tan Tock Seng Hospital (TTSH) and Central                                                          The workgroup also explores new practice models and
           5. Technology Enablement                                                                                                         Health, was set up to spearhead the pharmacy transformation                                                       skills (for example, motivational interviewing, and shared
           The Pharmacy Leadership Teams across Institutions have                                                                           initiatives across NHG Institutions. The PTSC reports to Dr                                                       decision-making) needed to shift the Pharmacy Workforce
           been actively involved in the planning and delivery of                                                                           Jason Cheah, Deputy Group CEO (Transformation), NHG,                                                              towards a more value-adding clinical role.
           these strategies which involve changes to drug formulary                                                                         and CEO, Woodlands Health Campus.
                                                                                                                                                                                                                                                              Currently, the data collected is being analysed to
           policies, education and training of pre-registration                                                                             Three workgroups, namely, APPRAISE, ONE-PML, and                                                                  identify the segment of patients who are at high-risk of
           pharmacists, development of advanced practitioners,                                                                              ELITE, comprising representatives from various NHG                                                                experiencing drug-related problems and who will benefit
           career and skills development of pharmacy technicians,                                                                           Institutions were formed to drive the three key thrusts of                                                        from closer monitoring and reviews. Work is also in
           development of the National Harmonised Integrated                                                                                Quality Prescribing, Medication Information Flow, and                                                             progress to develop a guide to conduct systematic patient
           Pharmacy System (NHIPS), Pharmaceutical Care Services                                                                            Patient Activation.                                                                                               assessment, medication reconciliation, medication review,
           for the community, and the formation of the Supply Chain
                                                                                                                                                                                                                                                              and develop the pharmaceutical care plan.
           Organisation – ALPS Pte Ltd.

                                                                                                                                            APPRAISE is the acronym for Appropriately Propagating carePlans towards the Resolution of DRPs related to Adherence, Indication, Safety and Efficacy
                                                                                                                                            ONE-PML is the acronym for One-Patient Medication List
                                                                                                                                            ELITE is the acronym for its mission: Empowering patients and/or caregivers through health Literacy, Information Technology and Education
129   © National Healthcare Group                                                                                                                                                                                                                                                                         © National Healthcare Group   130
06CHAPTER THOUGHTS ON THE FUTURE STATE - National Healthcare Group
Medication Information Flow
                                                                             SAFE MEDICATION –                                               COLLECTIVE LEADERSHIP AND COLLABORATIONS
           The risk of medication errors is the highest during
           transitions of care. This is due to multiple factors such
                                                                             ACROSS AND CONNECT                                              To facilitate systemic changes and collective ideation, the Pharmacy Transformation team has created several platforms
           as the lack of communication and coordination among                                                                               for networking, engagement, and teaming among the various healthcare professionals and other stakeholders.
           healthcare providers, patients’ difficulty in remembering         In order to address the medication challenges faced by
           instructions post-discharge, as well as confusion over            patients who seek care in multiple settings, Pharmacy           The TTSH Kaizen Office was engaged to facilitate a “Go-and-See” exercise, involving a total of 60 doctors, nurses,
           changes in medication. This is compounded by the                  Transformation at NHG has rolled out two projects —             pharmacists, administrators, and other professionals, to observe the patient flow and transitions across 20 sites including
           different incomplete sources of patients’ medication              ACROSS and CONNECT.                                             acute hospitals, polyclinics, community hospitals, Nursing Homes, General Practitioner (GP) clinics, and patient homes.
           information, which often makes the work of reconciling                                                                            Future State Mapping workshops, also involving diverse groups of stakeholders, were conducted in 2018 and 2019 to
                                                                             ACROSS (Activation, Communication and
           the Patient’s Medication List (PML) very complex and                                                                              jointly define the dream state and conceptualise proof-of-concept pilots. Through such workshops, participants had the
                                                                             Rules Of engagement for Single Source of
           time-consuming.                                                                                                                   rare opportunity to work with people across healthcare settings, understand different perspectives, and visualise the
                                                                             truth)
                                                                                                                                             end-to-end processes. Champions were also identified to spearhead the various Pharmacy Transformation initiatives.
           The ONE-PML workgroup strives to enable a seamless                The projects aim to provide safe medication across NHG
           communication of accurate, complete, and trusted                                                                                  The table below summarises the feedback from patient focus groups and Future State Map workshops conducted with
                                                                             Institutions. They redesign current workflows to prevent
           patient’s medication information across disciplines and                                                                           stakeholders, on what patients need and value about medication management.
                                                                             harm, address medication information needs, and activate
           care settings. Workshops have been held to understand             patients.
           the issues and co-create the process flow of information.                                                                         Figure 2: What Patients Need and Value
           These were attended by different stakeholders from the            1. Standardise Medication information Update, Retrieval
           acute hospitals and Nursing Homes, and proved to be very             and Flow across NHG (SMURF)
                                                                                                                                                 PATIENT ACTIVATION AND                                                               MEDICATION INFORMATION
           fruitful as participants were keen to collaborate and resolve       Targeting prescribers across all our Institutions, SMURF               ENGAGEMENT                                 HARM PREVENTION                               FLOW
           the issues they have faced for a long time.                         enables the standardisation of prescribing guidelines              Confused           Activated            Errors         Quality Prescribing            Fragmented           Holistic
           Separately, the pharmacists at the polyclinics have                 across NHG.
           implemented the process of medication reconciliation              2. Support through COmmunity & Patient Engagement                 Patient’s Value      What We Can Do       Patient’s Value       What We Can Do        Patient’s Value      What We Can Do
           targeting recently discharged patients from the acute                (SCOPE)                                                         I UNDERSTAND        Patient awareness       I expect my           Harmonised            I expect my        Communication
           hospitals. Changing the sequence of the patient’s journey                                                                                 and can          and education         medication            prescribing            healthcare        channels among
           to see the pharmacist before the doctor (instead of                 SCOPE is aimed at patients discharged from the hospital          COMMUNICATE                                therapy to be           practice           providers across       healthcare
                                                                                                                                                   information                            APPROPRIATE,                               settings to KNOW       professionals
           being the last stop), resulted in a significant reduction           in transition to the polyclinic and community. It helps to         regarding my          Effective        COST EFFECTIVE                              MY CONDITIONS
                                                                                                                                                                     communication                              Common Care                                  across care
           in the incidence of prescription errors. Through patient            assess a patient’s risks and needs, and administer relevant       medication and                          and SAFE for me                               WELL and I do
                                                                                                                                                                                                                                                               settings
                                                                                                                                                medical condition     channels with                                Plan              not have to repeat
           interviews, the pharmacists were also able to identify              assistance prior to discharge and for polyclinic follow-up.                             patient and                                                         myself
                                                                                                                                                                                          I want a SIMPLE
                                                                                                                                                 I KNOW my              caregiver         medication plan                                                    Visibility of
           many drug-related problems and resolve them. At the               3. Streamline from HOspital to Polyclinics (SHOP)                                                                                   Shared Rules
                                                                                                                                                medications and                           with less pills to    of Engagement        I am supported by    complete patient
           end of the visit, patients are given their Medication List,                                                                          UNDERSTAND                               take. Don’t OVER-                           a COORDINATED           medication
                                                                               SHOP focuses on polyclinic patients referred by the                                     Information                             among healthcare
           and benefits as well as side effects explained.                                                                                      how they work        communicated            TREAT me            professionals          CARE TEAM          information to
                                                                               hospital for further intervention at NHGP’s medication                                  in preferred
                                                                                                                                                                                                                                       across settings      all healthcare
                                                                               clinics. It streamlines the patient journey and medication          I need only                             I want to make                                                   professionals
           Patient Activation                                                                                                                     RELEVANT
                                                                                                                                                                        language,
                                                                                                                                                                     avoiding jargon     JOINT DECISIONS
                                                                                                                                                                                                                  Optimised
                                                                                                                                                                                                                                     I receive CLEAR,
                                                                               clinic work processes, such that patients with potential           information                            with my healthcare       medication          RELEVANT and
           As Singapore’s healthcare needs get more complex, the                                                                                                                                                   therapy                                  Shared Rules
                                                                               medication problems can seamlessly move to polyclinic             to be given to                               providers                                CONSISTENT
                                                                                                                                                  me in EASY          Multilingual          regarding my                             information from      of Engagement
           ability of patients to understand their medical condition,          medication clinics for further intervention.                                                                                                                               among healthcare
                                                                                                                                                 to understand      medication labels,       medication         Shared decision         all providers
           ask questions about their therapy and follow instructions                                                                              LANGUAGE             pictogram               therapy                                                      professionals
                                                                                                                                                                                                                    making
           becomes critical to their continued health. Many studies have     4. Updated medication list for Complex Care patients                                                                                                           I want
           linked low health literacy to poor health. Conversely, the more      Across Multiple Institutions (CCAMI)                            I must be HEARD        Medication             I want                                   CONTINUOUS            Streamlined
                                                                                                                                                and RESPECTED                              AFFORDABLE            All healthcare        RAPPORT with
                                                                                                                                                                      reconciliation                                                                        upstream and
           active and engaged the patients, the more they can manage                                                                            by my care team                                 care             professionals       any care team, and
                                                                               Designed for complex care patients in Specialist                                        and review                                                                            downstream
                                                                                                                                                                                                                maintain a single     not transactional
           their own health.                                                   Outpatient Clinics (SOCs) visiting multiple prescribers                                                                         source of truth for         rapport
                                                                                                                                                                                                                                                              processes
                                                                                                                                                I need consistent
           Among the patients with chronic diseases, studies have              across NHG Institutions, CCAMI helps to identify and               SUBSIDIES no         Community                                 medication list
                                                                                                                                                                        support                                                                              Common IT
                                                                               share medication lists for complex care patients, who            matter where I am
           shown that poor medication adherence is the top medication-                                                                                                                                         Harmonised drug
                                                                                                                                                                                                                                                          platforms shared
           related problem faced. The ELITE workgroup focuses on               are concurrently chronic patients of TTSH, KTPH, and                                                                                                                          across NHG
                                                                                                                                                                      Portability of                              formulary
                                                                               NHGP.                                                                                                                                                                         Institutions
           improving the pharmacy health literacy awareness among                                                                                                      subsidies

           staff, developing communication strategies to engage and                                                                                                                                                                                        Common Care
           empower patients and caregivers, and developing assessment
                                                                             CONNECT (COnnecting NHG and Nursing                                                                                                                                              Plan
           tools to identify poor medication adherence.
                                                                             Homes through rules of Engagement,
                                                                             Communications and single source of
           The workgroup organised the NHG’s Cluster Campaign                Truth)
           “Know Your Medicines, Get it Right,” held in conjunction with                                                                     For the first time in NHG, the issues with medication are being tackled on a large scale by a multidisciplinary group.
                                                                             The project works to establish and facilitate open
           Pharmacy Week in October 2018, to increase awareness about                                                                        There have been surprising discoveries, immense learning, and many intense discussions due to its complexity. As the
                                                                             communication between Nursing Homes and NHG
           the importance of creating one’s own PML. In collaboration                                                                        teams develop new prototype workflows, they are concurrently developing new capabilities including problem-solving,
                                                                             (inpatient and SOC). It ensures a platform and workflow
           with National Healthcare Group Polyclinics’s (NHGP) Patient                                                                       strategic-thinking, communication, engagement, and leadership.
                                                                             for PML creation, documentation, maintenance and flow;
           Education and Activation team, frontline pharmacy staff
                                                                             and rules of engagement and communication channels.             As one of the enablers for the River of Life Transformation Journey, we will have both the challenging and exciting task
           are being trained in health literacy concepts and effective
                                                                                                                                             of engaging and aligning with all the workstreams due to the inter-related aspects of patient care.
           communication, to strengthen their confidence in supporting
           patients and caregivers to better understand their medication
           and make decisions in managing their medications and
           conditions. A tool to identify medication adherence issues is
           currently being validated.

131   © National Healthcare Group                                                                                                                                                                                                                          © National Healthcare Group   132
06CHAPTER THOUGHTS ON THE FUTURE STATE - National Healthcare Group
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