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In this Explainer, find out...
What is palliative healthcare?
What are Singapore’s plans to improve its palliative healthcare infrastructure?
Why are these improvements significant?
Introduction
Singapore’s population is ageing rapidly. As of 2024, citizens aged 65 and above comprise one-fth of the population. By 2030, it is set to rise to one-quarter of the population.¹ To allow our silver generation to age gracefully, Singapore must upgrade its infrastructure with the needs of the elderly in mind.
In this Policy Explainer, we will focus on one area of eldercare infrastructure which the Government plans to update: palliative healthcare. Its plans are outlined in the 2023 National Strategy for Palliative Care (NSPC) Report, containing recommendations to enhance palliative care for patients. However, before we delve further into the NSPC’s contents, we must first understand what palliative care is.
Understanding Palliative Care
Palliative care is defined as specialised medical care focused on providing relief from the symptoms and stress of a serious illness, thereby improving the quality of life of both patients and their families.² It is designed to be compassionate care, which addresses not just the physical symptoms of chronic or terminal illnesses, but also the associated emotional, social, and spiritual needs.
Palliative care in Singapore is not restricted to end-of-life situations. It is applicable at any stage in a serious illness and can be provided alongside curative treatments.³ It also adopts a multidisciplinary approach, incorporating the expertise of various healthcare professionals including doctors, nurses, social workers, and therapists, to offer a comprehensive support system to patients and their families.
The National Strategy for Palliative Cae
As Singapore's population ages, local demand for palliative healthcare has risen. In response, the Ministry of Health (MOH) launched the NSPC in 2023, outlining 11 recommendations to expand palliative healthcare services in Singapore over the next five to 10 years.⁴
The recommendations fall into three broad areas:
Access to Palliative Care
Quality of Palliative Care
Palliative Care Environment
Figure 1: National Strategy for Palliative Care⁵
Access to Palliative Care
Despite the growth of the palliative care sector over the past 25 years, a significant proportion of patients with life-threatening illnesses still do not receive satisfactory care. Between 2017 and 2020, only 40 per cent of soon-to-be deceased patients received specialist treatment.⁶ Moreover, the median duration of palliative care from referral to death is only 22 days, which is worryingly short.⁷ This highlights the need to improve access to palliative care, which the NSPC suggests achieving in several ways.
Increasing Palliative Care Capacity
First, the NSPC recommends increasing the supply of healthcare workers who are trained to meet palliative care needs. This will be achieved through i) projecting future demand for palliative care ii) establishing and periodically reviewing staffing needs for palliative care provision iii) creating training roadmaps for all healthcare professionals to achieve basic competency in delivering palliative care and iv) defining minimum training requirements for specialised and general palliative care providers.
Developing Sustainable Care Models
Second, the NSPC recommends implementing a generalist-led, specialist-supported palliative care model that tailors support to individuals based on their needs. Specifically, while individuals with basic needs will receive palliative care from either general palliative care providers or healthcare workers equipped with basic palliative care skills, those with complex needs will be cared for by specialised palliative care providers.
Affordability
Third, recognising that 64% of Singaporeans deem palliative services too costly, the NSPC recommends reviewing existing frameworks for financing palliative care services and financial support schemes.⁸ Such reviews will assess how financial gradients across palliative care settings can be smoothened while identifying how total and out-of-pocket costs can be reduced. Together, this will help to increase the affordability of palliative care for Singaporeans.
Quality of Palliative Care
Besides ensuring universal access to palliative care, it is also important that patients receive high standards of palliative care. This is imperative for alleviating their suffering while facing life-threatening illnesses, which as discussed above, can enhance their quality of life. Recognising this, the NSPC recommends various measures to increase the quality of palliative care.
Increasing Support for Caregivers
First, the NSPC recommends providing greater psycho-social-spiritual support to caregivers. Specifically, it recommends measures such as i) enhancing respite care provision services to alleviate stresses experienced by caregivers and ii) exploring ways to improve workplace support for caregivers, such as by expanding leave provisions for caregivers.⁹
This emphasis on caregivers may come as a surprise, since the focus, after all, is on improving the quality of palliative care to patients. Yet, it is not unfounded. Caregivers play a key role in ensuring patients’ physical and emotional well-being. In doing so, they are subject to insurmountable stress, having to prepare patients and their loved ones’ for imminent death while coping with personal grief and bereavement. This puts caregivers at significant risk of depression — a 2022 study highlights that 40 per cent of caregivers of palliative patients were found to be at risk — preventing them from playing their roles effectively.¹⁰
Monitoring the Quality of Palliative Care
Second, the NSPC proposes performance monitoring, to ensure high standards across all palliative care providers.¹¹ Currently, palliative care providers are evaluated through National Guidelines for Palliative Care (NGPC) self-assessments, which are optional. Although most specialised palliative care providers are involved, general palliative care providers do not participate in NGPC self-assessments. Thus, data is lacking on the quality of care provided by general palliative care providers.
As general palliative care providers are key in making palliative care accessible to the greater public, tracking their performance is important in ensuring that future patients receive quality care.¹² As such, the NSPC recommends developing policies to increase NGPC self-assessment by both general and specialised palliative care providers.¹³
For example, MOH-funded specialised care providers need to achieve minimum service requirements to receive government funding. These minimum service requirements could be updated to mandate participation in biannual NGPC self-assessments. With consistent data on quality of care, palliative care providers can understand how to improve their service in the long term.¹⁴
Palliative Care Environment
The palliative care environment is the final cornerstone of Singapore’s palliative healthcare ecosystem. In its ideal state, Singapore’s palliative care environment should offer holistic support to all palliative care stakeholders, be they palliative care professionals, caregivers, or the public. Yet, gaps in Singapore’s palliative care environment remain, necessitating corresponding strategic thrusts to address them.
Strengthening Leadership Pipelines
First, Singapore lacks an adequate palliative care leadership pipeline with exposure to community care settings. This can be attributed to the concentration of existing leaders in acute care (i.e., focusing on providing palliative care for patients with short-term, severe medical needs), which begets the training of new leaders who also specialise in acute care. Meanwhile, since there are few leaders in community care (i.e., focusing on providing palliative care for patients transitioning back to independent living), the likelihood of being trained by someone skilled in this area falls.¹⁵
In this vein, measures to enhance leadership pipelines, especially in the community care sector, are required. The NSPC recommends several ways to achieve this, including i) increasing the frequency of engagements and mentorship for junior healthcare workers and ii) setting up a framework where palliative-trained professionals are deployed to the community for exposure.¹⁶
Increasing Death and Grief Literacy
Second, death literacy (i.e., one’s understanding of end-of-life and deathcare options) and grief literacy (i.e., one’s understanding of grief, loss and measures to support grieving individuals) are lacking among the general public and healthcare professionals. In turn, both the general public and healthcare professionals are not aware of the existence or benefits of tapping on palliative care services.¹⁷ Even if they do, they may not be comfortable discussing palliative care, leading to a lack of use of such services.¹⁸
To this end, Singapore must encourage conversations on end-of-life healthcare and procedures, thereby increasing end-of-life planning, promoting palliative care uptake and changing societal views on death. The NSPC proposes several measures to achieve this. For one, community volunteers can be leveraged as advocates of palliative care, reaching out to grassroots, religious and ethnic organisations, as well as schools to raise awareness on the topic.¹⁹ Further, increasing access to death and grief-related information and providing platforms to discuss such matters can help to increase death and grief literacy.²⁰
Significance of the NSPC
Minister for Health Ong Ye Kung’s comments at the NSPC’s launch reveal the significance of the strategy refresh.²¹ Based on his remarks, we identify two main areas of focus that the Government seems to be trying to address.
Meeting Citizens’ End-of-Life Preferences
One of the assumptions when it comes to healthcare services is that healthcare should always be curative, meaning that healthcare professionals and caregivers should do whatever is in their means to treat the patient. Ironically, the patient becomes an afterthought in this process and is expected to comply with decisions made for them. This ignores the preferences of the patient, who some would argue should have the last say over decisions regarding their body and health.
Currently, Singaporeans do not have the option of choosing domestic palliative care, which can affect the quality of life for patients suffering from terminal illnesses. A 2014 survey of Singaporeans’ end-of-life preferences found that, while 77 per cent of the surveyed population expressed a desire to die in their own homes, only 30 per cent were able to fulfil this desire.²² 2022 saw this number rise to 39 per cent, which indicates that there is still a significant disparity.²³
This is further supported by findings from a COMPASS (Cost of Medical Care of Patients with Advanced Serious Illness in Singapore) cohort study, which included survey data from 600 patients who were diagnosed with advanced cancer. 64 per cent of the cohort preferred to die at home but only 41 per cent were able to do so, further underscoring the disparity between the ideal and the situation on the ground.²⁴
One of the goals of the NSPC is thus to place decision-making back into the hands of the patient, allowing them to have a say in their end-of-life preferences. This also builds on the findings of the Forward SG Report.²⁵ Specifically, Chapter 5 of the report mentions the importance of “[enabling] seniors with care needs to grow old in a familiar environment”.
Labour and Manpower Concerns
Another issue related to Singapore’s ageing population is the responsibility of healthcare — specifically, Singapore’s current shortage of domestic nurses. In an article published by The Straits Times in September 2023, Singapore was projected to add close to 4,000 new nurses by the end of 2023. 60 percent of these nurses were expected to be foreigners.²⁶
Minister Ong Ye Kung made this a point at the NSPC’s announcement, citing the overwhelming demand for both local and foreign healthcare workers.²⁷ He also touted granting permanent resident (PR) status to foreign healthcare workers as a possible solution to this problem. Receiving PR status would mean that these healthcare workers can opt to stay long-term in Singapore instead of being employed on contractual, short-term work permits. They will also be incorporated into the Central Provident Fund (CPF) pension scheme that provides a safety net for retirement.²⁸
This proposed solution to the healthcare labour shortage inevitably leads to a question which has been hotly debated for the better part of the past decade: Is Singaporean society willing to absorb an influx of blue-collar foreign workers?
This debate harkens back to the Population White Paper that was put forth in 2013. In the White Paper, the Government floated the idea of incorporating 55,000 new residents annually through a combination of naturalisation and granting PR status.²⁹ The reaction to this proposal was visceral, underscored by mass rallies and the largest public protest in Singapore’s history.³⁰ Citizens continued to be concerned over the issue of immigration even after then-Prime Minister Lee Hsien Loong attempted to assuage Singaporeans that immigration numbers would be dialled down, with the issue spilling over into the 2015 general elections two years later.³¹
Singapore’s stance on foreign workers needs debating, as it has implications for Singapore’s social compact and the kind of society Singaporeans want Singapore to be. It may be easy to proclaim a general acceptance of foreigners to avoid being seen as an anti-immigration nativist. However, incorporating foreign-born workers into the social compact may also give rise to NIMBYISM (not-in-my-backyard-ism). One example stands out. In 2008, Serangoon Garden residents signed a petition to block an old school in their district from being converted into a foreign workers’ dormitory, citing vague justifications for the safety of children and the elderly in their district.³² Thus, when issues like these go from being an ideological debate to a reality of daily life, Singaporeans may suddenly find that bread-and-butter issues such as upholding their homes’ resale value take precedence.
As Singapore continues to age, the demand for specialised healthcare services, including palliative care, will only increase. To this end, a sustainable workforce solution, possibly bolstered by skilled foreign workers, becomes crucial. Therefore, the Government must engage with its citizens transparently and constructively about immigration policies. By doing so, it ensures that the development of healthcare resources aligns with the societal values and needs of Singaporeans, thus maintaining trust and cooperation in shaping a compassionate and effective national healthcare strategy.
Conclusion
It is important to remember that palliative care is an important subset of Singapore’s healthcare sector. Improving options and infrastructure for palliative care is vital for ensuring dignity in death. Despite the thorny and sensitive nature of this subject, it should not deter us from having discussions on this issue. We might even find that citizens may be more willing to discuss end-of-life concerns than we assume. To take inspiration from the tale of the grasshopper and the ant in Aesop’s Fables, failing to prepare for issues in the present will only result in problems resurfacing in future.
This Policy Explainer was written by members of MAJU. MAJU is an independent, youth-led organisation that focuses on engaging Singaporean youths in a long-term research process to guide them in jointly formulating policy ideas of their own.
By sharing our unique youth perspectives, MAJU hopes to contribute to the policymaking discourse and future of Singapore.
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