Singapore’s population is ageing rapidly. Today, our elderly aged 65 years and above represents 7.2% of our population. This proportion will increase to 18.4% in 2030. In absolute numbers, this means that we will have about 800,000 aged 65 years and above in Singapore in 2030. The elderly are more likely to face more health problems as they grow older and make more demands on the health services. Moreover, after the management of acute illness, some have disabilities that require extended care in step-down facilities.

Voluntary Welfare Organisations (VWOs) are the main providers of step-down health care services for the elderly which include community hospitals (CHs), nursing homes (NHs), day rehabilitation centres and home medical and nursing services. The needs of the elderly change over time, so these services should be seamlessly integrated to allow transfer to the most appropriate service. The private sector is encouraged to complement the VWOs and provide step-down care to those who can afford and are prepared to pay for the services.

The key to a high quality step-down care by VWOs involves :-

1. getting professional staff and training the staff to provide quality service
2. integrating the step-down services, so as to provide a continuum of care for the elderly.

Smaller standalone VWO providers are likely to face a bigger challenge in upgrading their service.

To assist service providers and to streamline and improve the quality and access to health care for the elderly, Ministry of Health proposes to develop a framework of integrated health services to be put in place over the next 10 years.

Step-down health services for the elderly will be organised around 3 zones i.e. West, Central and East. Each zone would be anchored around an acute regional hospital (RHs) with a geriatric department i.e. Changi General Hospital in the East, Tan Tock Seng Hospital in the Central Zone and Alexandra Hospital in the West. RHs will provide professional leadership for the development of geriatric step-down care in each zone. They can also :-

1. provide professional staff to CHs on a rotation basis,
2. develop structured staff training programmes,
3. develop quality assurance programmes,
4. hold joint case conferences,
5. share resources like laboratory service, volunteer pool, etc.

CHs and NHs would be supported by the RHs in their respective zones.

Of the range of step-down facilities for the elderly, the CH requires the greatest professional expertise. As such, professional support by the RHs to CHs is very important. MOH will identify and designate organisations which we believe are capable and willing to run CHs. They must have competent corporate and professional governance.

There are many organisations who have the capability of running NHs. Apart from running these institutions, for seamless and integrated care, CHs and NHs with the capability and the interest should preferably provide day rehabilitation services, home medical care and home nursing care. The needs of the elderly change over time, and the range of services provided by one organisation can assure a seamless transfer of care. They should provide day rehabilitation not only to their inpatients, as they are currently doing, but also to the elderly in the community, This option encourages those who are already in NHs to be discharged back to the community as community and home-based care will be an option. NHs which are willing and able to provide the range of services specified can apply to MOH to be "approved" providers.

Not all NHs need to be providing this range of services, Those which choose to continue with the status quo can do so, without discrimination or penalty.

MOH will draw up guidelines and standards of care for the whole range of step-down services, and we will audit the "approved" providers to ensure that they fulfill their contract.

MOH will provide additional funding to the "approved" providers. This will be from the operating budget from Ministry of Finance or from the Eldercare Fund.

The goal of this framework of integrated care is to :

1. upgrade professional standards of care which MOH will set and audit,
2. have a seamless continuum of care for the elderly.

Ministry is also working on the following areas in health care for the elderly:

1. Increasing the provision of nursing home beds by private nursing home operators through the provision of land zoned for nursing home use which will have a lease of 30 years. These will be tendered out to operators. We will have the first tender announcement of the Toa Payoh site on 26 July 2000. Altogether there will be about 13 –15 sites offered over the next 10 years, This will meet our requirement of NH beds, with some 40% being provided by private operators for the more affluent elderly. We will also help existing NHs to upgrade to an acceptable standard.
2. Equipping home carers with skills for caring for the elderly through home carers' training courses to enable them to continue caring for their elderly at home. The pilot first course was conducted at Kim Seng Community Centre in January 2000.
3. Increasing the number of doctors trained in geriatric skills. The NUS and Graduate School of Medical Studies is conducting a 1 year Postgraduate Diploma Course in Geriatric Medicine.
4. Providing geriatric training for undergraduates.
5. Establishing a long-term disability insurance to assist elderly to defray the cost of long term care. We are in the process of planning a study on the prevalence of severe disability in Singapore, to enable the actuarial consultants to work out premiums and benefits of this insurance scheme. We expect to implement this scheme in 2003.
6. Setting up the Eldercare fund to provide for funding of eldercare services. This measure will not unduly tax the future generation to subsidise the elderly, as only interest income will be used, with funds being derived from budget surpluses.
7. Reviewing step-down care facilities and services for psychiatric & psychogeriatric patients and those with terminal illness, and making provision for adequate psychiatric step-down facilities, so that NHs will be freed from having to provide for psychiatric and psychogeriatric care.
8. Recognising volunteers for services rendered to the elderly. Volunteers who help to look after the elderly would in turn be looked after when they grow old and need medical attention. We will study how such a system can be developed.

Ministry will continue to monitor and review health services for the elderly to ensure that appropriate and good quality care is available for our elderly.

MINISTRY OF HEALTH