Irene Quay Siew Ching
Singapore
“Regardless of how much funding our Government pours in to subsidise drug treatments and improve access to medication, a patient's treatment cannot be optimised if he or she does not swallow a pill that is tailored to their needs.”
“Thank you, Chairman. Senior Minister of State Lam shared about this national antimicrobial surveillance report. I just wanted to ask if the results are ready and how are we faring in terms of our antibiotic utilisation in the community? What are our national targets and what are we doing about it?”
“As such, instead of a blanket policy to limit S Passes with minimal exceptions, I would still like to appeal for MOM to consider showing flexibility to employers trying to hire locally with failed attempts to turn to foreign workers.”
“I thank the Ministers. My question is: in the event if we need to step up to using N95 masks because there is wide community spread or for future viral outbreaks, how do you ensure that the public are fitted with the right model of N95 masks?”
“I seek clarification as to whether the overlapping of regulatory scopes might cause confusion and inefficiency in running these different services.”
“Next, IRO should be as inclusive as possible with the various faiths to ensure religious harmony. Finally, the Government should empower NSC to bring in faith groups together for a common cause and promote religious awareness education in Singapore.”
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“The Minister reassured the House that we have the various acts to impose a high standards of responsibility on public agencies. However, upon reviewing that, there seems to be a lack of clarity in this Act regarding accountability for data breaches. The focus seems to be on misuse of data. Can the Minister clarify? My second supplementary question is: the Minister informed the House that the public agencies have regular mandatory internal audits in place to ensure public agencies comply with these standards for data protection and security of information and communications technology systems. In that case, why are these potential lapses not surfaced during previous internal audit checks?”
“Chairman, I asked a Parliamentary Question last month regarding pool safety for private pools. Can I ask Minister Grace Fu if there are intentions to extend the drowning detectors to private pools and make it mandatory because this is more urgent as the private pools actually do not have lifeguards onsite?”
“The aim is to attempt to engage them from young to appreciate the spirit of volunteering, though I will still recheck after them. At the end of our duty, as we walk along the corridor on our way out, I will ask my child to "peek" into a patient's room. I explain to them how the two hours spent earlier has helped to ensure that these terminally ill patients do not run out of essential medications, and are not taking expired drugs which may affect their pain control, vomiting or infection. Ensuring appropriate disposal of these medications also has significant impact on protecting our environment and the safety of our residents. Seeing the patients comfortable in bed during their last days can be especially emotional and underscores the heartfelt importance of the work that we are doing. And this is what has kept me going for the past 20 years as a volunteer. Volunteerism should be a lifetime commitment, not simply a once-off Community Involvement project. It is a calling and must come from the heart. As a community leader and a mother who wants my young children to espouse the values of volunteerism, it also starts with us as leaders to shape the roads for successive generations to follow. The greatest leader is also the most willing servant.”
“To attract these leaders, I would like to propose a two-pronged approach. Firstly, it is necessary to build a pre-retirement awareness of volunteering. An effective way is to locate and extend a personal invitation to leaders who are retired or will be retired in five years' time. The second approach would be to design suitable volunteering opportunities. We should create awareness of the complete range of volunteering opportunities offered and then ensure that volunteering opportunities have specific targets and deliverables. Volunteers would be more attracted to activities with clear job descriptions, well-defined expectations and timelines. Short-term volunteering opportunities can also be offered to those with competing interests and limited available time. Nevertheless, the most important aspect of attracting any form of volunteers will inevitably start with us. We, as leaders of the nation, are duty-bound to lead by example and be a visible beacon on the frontlines. Only after being volunteers ourselves can we be exemplars and speak with passion about the great joy volunteerism can bring, in order to galvanise fellow citizens to be authentic volunteers. Personally, I have been a pharmacist volunteer at a local hospice for the past 20 years. Our volunteer pharmacists take turns every Saturday to visit the institution to sort out medication waste and monitor inventory of medications. On the days when it is my turn, I will bring along one of my four children to help out. I task them to perform the "first cut" expiry date stock check while I sort out bags of medication waste for appropriate disposal and check on stock levels to trigger ordering.”
“However, there are various influencing factors at play in Singapore which reduce the take-up rate of volunteering. Chief among these is the reason that citizens have no time to volunteer. They fail to understand that giving to others does not mean having less time for oneself. As a result, fewer are giving up their time and effort to volunteer for a good cause, even though donations are substantial. As Singapore faces an ageing population crisis, it is even more crucial that youths are being engaged to volunteer with the elderly population. With the SG Cares platform, it is possible to match an individual's community work with volunteering opportunities of their choice. It is heartening to see a 16-fold increase in youth participation from 2009 to 2019, with youths making up almost 80% of the volunteers registered on the website. So, this begs the question: how can we further encourage the increase in number and depth of volunteerism in our nation? I would like to propose that we attract business and public sector leaders who are retired or close to retirement to volunteer. This draws from a large pool of ageing population with longer life expectancy, who are highly educated, active and financially secure. They are also proven managers of people, finances and complex programmes, who understand the benefits of meaningful work and are motivated to contribute to society. The knowledge, experience and energy that these leaders bring represent a significant potential resource for the non-profit and charitable sector. The result is a win-win situation which benefits both the community and retired leaders themselves, as volunteers generally enjoy improved health and wellness in the form of personal accomplishment and lower levels of depression.”
“Firstly, I would like to thank the men in the House for the well wishes. I always say we are so blessed to be living in Singapore where ladies are well respected and treated fairly. I cannot ask for more. 12.30 pm Mr Chairman, in a 2018 June article from the Straits Times, Minister Grace Fu said that, "Singapore hopes to double its volunteerism rate from one in three currently to 70% in five years' time". This is a laudable goal to aim for, and I believe it can come to fruition through a combination of various factors. As citizens of Singapore, we all take responsibility for our lives and actions. The Government does not believe in giving handouts and it is the civic duty of citizens to help the less fortunate in our country. Currently, the rate of volunteerism in Singapore has grown from 9% in 2000 to 35% in 2016, with the total volunteer hours doubling from 66 million hours in 2014 to 121 million hours in 2016. As it is, the benefits of volunteerism are manifold. It is a source of significant contribution to the global economy. According to statistics from the Johns Hopkins Centre for Civil Society Studies in 2011, approximately 140 million people in the 37 countries engage in volunteer work in a typical year. It is estimated that volunteers contribute around $400 billion to the global economy annually. Apart from economic contribution, volunteerism also enhances social connections between different sectors, and builds bridges across governments, enterprises and employees. It encourages citizens to be more active in civic engagement and mindful of their role in society. Positive effects on volunteers as individuals includes increased self-esteem, enhanced emotional skills and capacities, expansion in career paths and an overall healthier physique and mentality.”
“I have two clarifications for Senior Minister of State Amy Khor. The first is: when she shared about the disposal of drugs, that they can be safely disposed and trashed, can I confirm if she was referring to all drugs, including cytotoxics and antibiotics? I understand that NEA does have guidelines on the special handling of drugs, such as cytotoxics and antibiotics. My second concern, as mentioned in my speech, is not just about safe disposal, but it is also about the risk of accidental ingestion as well as diversion for illicit use. So, would NEA be keen to still explore take-back programmes?”
“It is my sincere hope that my suggestions to reduce medication waste and to improve cost effectiveness of our healthcare system be deliberated with all due consideration.”
“This take-back programme should be studied and implemented in Singapore. The Drug Enforcement Administration in the US created the National Prescription Drug take-back days that occur bi-annually in April and October. These take-back days are part of a mission to create safe medication disposal sites, prevent drug diversion or transfer of the prescribed drugs for illicit use, as well as to provide education for the public. Our local survey mentioned above also show that our patients are supportive of such disposal sites. MOH, the Health Sciences Authority (HSA), the Ministry of Home Affairs and NEA should make efforts to support such drug take-back campaigns through collaboration with hospitals and community pharmacies. This will provide a channel for patients to return and safely dispose of unwanted drugs, particularly cytotoxic drugs, antibiotics and substances of abuse. MOH and NEA may also consider collaboration with pharmacists to support patient education efforts in minimising medication waste. For example, when prescribed with new medications, collections should be limited to two to four weeks' worth of supply. This is to prevent wastage in case of adverse effects, or if the medication proves unsuitable or ineffective. For medications taken on a "use when necessary" basis, to obtain them in small quantities and purchase more only when necessary. For long-term medications, consider collection in instalments. For example, to collect three months' worth of supply each time to minimise wastage. MOH may like to consider funding charges for home deliveries or self-collection lockers to encourage instalment collections instead of collecting large supplies at one go. This may turn out to be more cost-effective in the long run.”
“A case in point would be the potentially careless disposal of cytotoxic drugs, a group of medications that contain chemicals that are toxic to cells. They are used as part of chemotherapy regimens for cancer treatment. These drugs are also widely used in the treatment of other chronic diseases. Cytotoxic drugs affect cell functions and have the ability to alter DNA and cause chromosome damage. Thus, they are teratogenic, carcinogenic and mutagenic in nature. Antibiotics, if improperly discarded, can enter our ecosystem and promote resistance to bacteria and fungus, leading to increased rates of infections that are difficult to treat. This is a vicious cycle which we cannot afford to risk happening and should be avoided at all costs. Accidental drug overdose is also one of the most common sources of household injuries. Young children are especially vulnerable to unintentional exposure to prescription and over-the-counter medications. As such, drugs should be safeguarded closely and gotten rid of safely when no longer needed. Inappropriate disposal of drugs can also potentially lead to diversion for illicit use. From my experience as a pharmacist volunteer at a local hospice, it is not uncommon to see controlled drugs in bags of medication waste. I propose that the Ministry of Health (MOH) consider funding to support pharmaceutical services, such as medication reviews and reconciliation, as well as deprescribing efforts. The potential savings from the earlier studies show considerable cost effectiveness of reimbursing a pharmacist for such services. Regarding solutions to safe disposal, we can look to countries like Canada and the United States (US) which have special government services offering to take back and dispose of unused and expired drugs.”
“A recent patient survey conducted by the NUS Pharmacy department and the National Cancer Centre Singapore over a two-week period, also revealed a resolution of patients' medical conditions, medication expired at home and patients no longer requiring their medications as top reasons for unused medications in their household. Such medication hoarding translates to significant potential healthcare cost savings if we are able to curb the current issues of over-prescribing, oversupply and polypharmacy. Apart from incurring huge costs, over-prescribing, oversupplying and medication wastes also lead to issues of inappropriate medication disposal and environmental pollution. Medication waste comprises of both hazardous and non-hazardous waste, controlled drug and expired pharmaceuticals. Currently, the most common way for individuals to dispose of medications is through the outlet of household waste. The patient survey mentioned above showed that 75.4% of patients surveyed throw their medication waste into a trash bin, with 5% throwing into the sink or flushing down the toilet, and 85.7% of patients surveyed are not aware of the correct method for medication disposal. Failure to ensure safe disposal of drugs can lead to environmental risks, as medicines which enter the environment can have a corrosive effect, especially on our local marine life. This, in turn, will adversely affect other species. I understand that most wastewater treatment facilities cannot filter out these drugs. I would like to request that NEA carry out checks to verify if our water treatment facilities have such capabilities, and if the disposal of drugs by flushing them down the toilet or sink poses a risk in Singapore.”
“Mr Chairman, Sir, I wish to call attention to the management of medication wastage in Singapore. As we are aware, escalating healthcare cost is a great concern for Singapore's Budget. It is, therefore, imperative to use the resources given to us as efficiently as possible. As we continue to ramp up our healthcare system with more infrastructure, manpower, funding and subsidy schemes to cater to the needs of our ageing population, active steps must also be taken to review the waste in our current healthcare system. This year, I understand that in Zero Waste, Singapore will be looking into food waste, plastic disposable waste, recycling efforts and business waste. It does not, however, include medication waste in its initiative. At this juncture, I would like to declare my interest as the President of the Pharmaceutical Society of Singapore. Singapore faces a rapidly ageing population and, as a consequence, patients with more chronic diseases. It is then inevitable that polypharmacy, which is the concurrent use of multiple medications by a patient, overprescribing and oversupply have been identified to be significant sources of medication waste. From past home visits by pharmacists to review the medications of patients, high medication waste was noted largely due to expired drugs, drugs prescribed without indication or duplication of drug therapy. One local hospital estimated the drug wastage cost detected during pharmacists' home visits at $663 per patient. Hypothetically speaking, if one pharmacist is given the resource to visit 10 patients a week over a one-year period to perform full reconciliation, the total potential drug savings can amount to at least $329,000, with $176,000 and $153,000 of savings in subsidies and out-of-pocket savings respectively.”
“Mr Chairman, can I ask the Minister for his comments regarding the proposal in my Budget Debate speech to acknowledge allied health professionals' (AHPs') and pharmacists' expertise in a national subsidy framework for cost containment as well as to keep patients in the community, such as the extension of drug subsidy schemes to community pharmacies as well as extension of the CHAS scheme to allied health services in the community because we need a holistic approach to keep patients in the community?”
“Thirdly, we have to empower allied health professionals and pharmacists in the community to take on greater roles in preventive care and health screening for chronic disease management, through the collaboration with MOH, Health Promotion Board (HPB) and community healthcare partners, as this is one of the most effective ways to curb escalating healthcare costs. Residents screened under the CHAS programme can also be referred to the community pharmacist for continued follow-up and reinforcement of a healthy and active lifestyle. I hope that the above proposals can be considered and resources be allocated to support this new model of care through mainstream funding. These proposals will reduce inefficiencies, make our access and processes in healthcare leaner and reduce healthcare costs. As shared in the Minister's Budget speech, FY2019 will run into a $3.5 billion deficit largely due to the additional funding support for healthcare. For now, we have FY2018 surplus to draw on, but we need to remain prudent and constantly look for ways to remove waste in our healthcare system so as to ensure long-term sustainability. Notwithstanding the above, I stand to support the Budget.”
“Health protection interventions, which include vaccinations that match for the actual influenza type, have saved $34 for every $1 spent on them, according to the review. Hence, prevention is cheaper than cure. With the issues shared above, I hope that the following proposals can be considered to make our healthcare more efficient. Firstly, we can acknowledge the expertise of allied health professionals and pharmacists in a national subsidy framework, perhaps, in the following ways: (a) A first contact consultation service for allied health and pharmacy services in the community; (b) A Government subsidy scheme that encourages medication dispensing in community pharmacies; (c) Incentivise community partners to work with pharmacists and allied health through collaborative prescribing and practices, and extension of CHAS scheme to allied health services in the community. This way, GPs can refer CHAS patients to private or VWO therapy clinics for allied health professionals' follow-up management at a subsidised rate for predefined conditions. We need a holistic system to keep patients in the community. Secondly, in line with the Government's strategy to support a skilled workforce, Minister Heng Swee Keat mentioned in his speech on the need to reskill and upskill Singaporeans. One example I can relate to is to provide training support to upskill our allied health professionals and pharmacists in the community setting, focusing on communication skills with the geriatric population and other health literacy skills.”
“This will allow our healthcare system to extend their reach to a greater population and improve accessibility to appropriate care in a more financially sustainable manner. Overseas studies have demonstrated that patients with musculoskeletal conditions, such as non-severe back or neck pain as well as hand injuries, benefited from early access to physiotherapy and occupational therapy at the primary care or emergency department. Take, for example, in the Queensland Health system in Australia, physiotherapists treating patients from Emergency Department (ED) triage Categories 3, 4 and 5 with a range of agreed musculoskeletal presentations. These roles typically involve assessment, intervention, referral for further treatment and assessment, and discharge when appropriate. Allied health first-contact ED services assist the Hospital and Health Services to meet their National Emergency Access Targets (NEAT). Another example involves the advancement of community pharmacists' roles through the extension of Government subsidy schemes for drugs, provision of vaccination to the public to bolster national flu vaccination rates as well as clinical pharmacy services, such as medication review or reconciliation services, in the community. This will, in turn, improve accessibility and affordability of medications in the community, enhance the provision of health information, improve health literacy in the community, and reduce overall healthcare expenditure. A 2017 systematic review published in the Journal of Epidemiology and Community Health looked at studies that calculated the return on investment for public health interventions. The researchers identified 52 studies that looked at interventions at a local and national level.”
“This model encourages healthcare professionals – doctors, pharmacists, nurses, allied health professionals – to work in synergy to provide cost-effective but holistic care to achieve positive health outcomes. This is in line with MOH's Beyond 2020 master plan. We have to focus our resources to upskill and empower our allied health professionals and pharmacists in the community to take on greater roles to provide value-based care at a sustainable cost. In my current role, I see a huge potential for allied health professionals to be engaged in the team-based collaborative practice framework where practitioners can practise at the top of their licence to be the first touchpoint for the management of certain physical, psychological, podiatry or speech-related disorders. One example is paediatric patients with only speech delay but without other medical conditions are seen and evaluated by doctors in polyclinics. However, they have to be seen by another doctor in KKH before they can be referred to our speech therapy department. Under the current financial structure, patients will need to be evaluated by another doctor in KKH before they can be accorded subsidised treatment. I am concerned that this leads to additional consultation costs as well as delay in seeking proper speech intervention. Similar examples are in adult restructured hospitals as well as patients who need outpatient rehabilitation. Is it not possible to streamline the process even for doctors who work within the same healthcare cluster? Empowering allied health professionals as the first contact point under a defined criterion of a collaborative framework, coupled with the right financial subsidy framework, can free up our doctors to focus on more complex medical conditions.”
“1 billion MGP, and the upcoming Elderfund scheme, to support Singaporeans who are severely disabled; (c) Substantial increase in subsidies offered to lower- and middle-income patients for long-term care services, specialist care and medications; (d) MediShield Life and the new CareShield Life as universal healthcare insurance to ensure lifetime coverage and higher monthly payouts; (e) Expansion of aged care services, such as home care services, eldercare centres and nursing homes, to cater for the needs of our ageing population; (f) Ramping up of healthcare facilities and infrastructure with at least one hospital built every two years, and strengthening of healthcare worker numbers and capabilities; (g) Implementing the MOH's Community Network for Seniors scheme that links seniors who live alone with befrienders and volunteers, and help them with social problems and early referral of complex needs to MOH. At this juncture, I would like to salute MOH for taking on the nation’s future health challenges but, at the same time, would like to share my grave concerns for the escalating healthcare cost. Before I go on, I would like to declare my interest as the President of the Pharmaceutical Society of Singapore, and the Assistant Director, Allied Health Office at KK Women’s and Children’s Hospital (KKH). Aon, an insurance survey group, quoted hospitalisation, physician services and clinical investigations as the top three leading causes of inflation for spending in healthcare. With the increasing burden of an ageing population, and the steep and continuous increase in incidence of chronic diseases, coupled with increasing complexity in the management of chronic diseases, more can be done to promote a team-based model of care.”
“Mr Speaker, Sir, I thank the Minister for the progressive and strategic Budget. For this debate, I would like to focus on the healthcare budget. Rising healthcare cost and expenditure on the elderly are critical issues affecting our overall healthcare system and are highlighted in the recent Budget speech by Minister Heng Swee Keat last week. As a healthcare professional working in the public sector for the last 20 years, I can see the transformational change in our healthcare system, especially in the last eight years. From a previous healthcare system designed to tackle acute medical condition for a much younger population to new models of care and financial assistance schemes implemented to cater for the ageing tsunami, we have seen many changes. I will highlight some I consider to be especially significant to acknowledge the hard work and foresightedness put in by MOH and the various health and community partners. (a) Introduction of CHAS to allow Singaporeans to enjoy subsidies at private general practitioner (GP) and dental clinics for treatment and screening; (b) Introduction of the PGP and now the $ 6.”
“Can I ask the Minister, with PDPA exemption for MOH, what will be the recourse that the victims can seek as a result of this exposure of sensitive information? This is to address public trust for better accountability.”
“Despite what has been done, we are still seeing about 10 cases over five years. Does the Senior Minister of State think there is something more we can do about it, for example, to include mandating some of these pool fences in private swimming pools? Is this something doable?”
“Cannabis is now legalised for recreational use in Uruguay, Canada and eight other states in the US, while decriminalised in the Netherlands, Spain, Portugal, Jamaica, Slovenia and Columbia within recreational limits. With such ease of access to such substances overseas, how can we heighten public awareness, especially for our children going abroad to study during their formative years, so that they are more prepared for the potential risks? Can we incorporate such awareness programmes with "rehabilitated ex-offenders sharing their experiences" into briefing sessions for students before they go abroad? Should we conduct more studies to find out the risk factors and reasons as to why these kids pick up such habits when they were away from home? To add on, cannabis may be the active ingredient in many non-medicinal products presented in a myriad of formulations, such as cigarettes, vaporisers, herbs, lotions and oils. Some may mistakenly purchase these items innocuously, without knowing that the active ingredient is prohibited in Singapore. How can we ensure that the public is well informed of these risks when they travel overseas and avoid unknowingly bringing in these illegal products when they return home? Can we include a mandatory inflight education video/booklet for people departing and returning to Singapore? Lastly, with medicinal cannabis now legalised in 44 countries worldwide, each claiming their benefits for certain intractable medical conditions, though yet to be proven but there are increasing clinical trials, how do we plan on handling patients prescribed with First Schedule Class A drugs, for example, cannabis for medicinal purposes, if they intend to enter Singapore? Notwithstanding my proposal and concerns above, I stand to support the Bill.”
“According to the Singapore Medical Council (SMC) Annual Report from 2012-2017, there is an average of two to three cases of errant prescribers who were being censured, fined and suspended every year due to inappropriate prescribing or sale of hynoptics, codeine-containing preparations or controlled drugs. Could this be just the tip of the iceberg? I quote Prof Tay Boon Keng, Emeritus Consultant and SMC Council member, who is also the Chairperson of the Ministry of Health (MOH) Opioid Guidance workgroup: "These past errant cases are all from the private health sector and tremendous expense was taken to take action (mostly legal) against these practitioners. In contrast, as prescriptions in public hospitals and polyclinics are limited by information technology (IT) system restriction and second layer of screening by pharmacists, this problem is almost non-existent." Are there plans for MOH or MHA to consider dispensing separation for controlled drugs and other drugs of abuse, including hypnotics and codeine-containing preparations, to deconflict prescribing and dispensing of such drugs with potential for abuse? Such a move will allow pharmacists to provide oversight of such prescriptions, evaluate for appropriateness of use and duration of treatment, as well as contribute to national aggregated information to flag out high-risk prescribers or patients. The dispensing separation will add additional barriers to access for addicts and, hence, reduce opportunities for abuse, prevent unintended addiction to a significant extent by the general public, and safeguard physicians from such malpractices. Secondly, over the years, there has been an increase in the use of cannabis by drug abusers worldwide.”
“Mr Deputy Speaker, Sir, I declare my interest as President of the Pharmaceutical Society of Singapore. I salute our Government for maintaining strict control over the misuse of controlled drugs in Singapore, especially with the recent and timely amendments to the MDA to hold accountable any person knowingly or recklessly leaving controlled drugs exposed within a child's reach. We have seen many tragic stories of children ingesting such controlled drugs by accident which had resulted in overdose cases ending up in hospital emergency departments. At my recent attendance at the World Pharmacy Congress in Glasgow, I learned from pharmacists practising in Africa, Canada, the United Kingdom (UK) and the United States (US) about the worldwide issues regarding drug abuse. The situation is currently out of control, resulting in countries no longer looking to curb the problem, but instead, resorting to setting up needle stations to try to, at the very least, prevent abusers from contracting the human immunodeficiency virus (HIV) or Hepatitis C infections. Such a defensive approach does not attack the root cause of the problem. The harm caused by the abuse of these substances on the abusers, their families and the society at large is devastating. First and foremost, even though the situation is much more controlled in Singapore due to our strict laws regarding drug trafficking, I still have my reservations and concerns for potential abuse in prescribing of controlled drugs in Singapore.”
“Sir, I thank both Ministers for their detailed Statements. While we understand that there are deficiencies and they will be implementing comprehensive recommendations, we must not forget that our IHiS staff have been working very hard and performing their best over the years as we move towards a Smart Nation. So, can I ask what are the resources – as we are piling them up with more recommendations and more work – as well as emotional support that we are rendering to these ground IHiS staff while they are going through this trying period, to boost their morale as we learn and move forward stronger together in this Smart Nation journey?”
“This is possible through the vaccine herd effect or herd immunity, which makes a disease hard to spread because there are very few people who are susceptible. To facilitate these actions, the use of rapid diagnostic health devices should be promoted and distributed widely at a highly subsidised rate. This will make it more cost-effective to use these devices compared to paying for a course of antibiotics. AMR is a major worldwide complication that has persisted and will continue to persist. It is something that we simply cannot afford to disregard in the slightest if we are not to invite disastrous consequences. It requires the synergistic coordination and collaboration of everyone in Singapore to combat and safeguard against. The cooperation of citizens, operators, healthcare professionals, diagnostic and pharmaceutical industries, educators, researchers, various Government Ministries and policymakers should be sought out in order to fend off this dire situation. Globally, many countries struggle with this deplorable predicament. I firmly believe that Singapore, being a country of first-world infrastructure and data management, armed with capabilities of a Smart nation, can and should employ data analytics and her pool of highly educated citizens to weather this storm. I am certain that we can proclaim to the world that it is, indeed, possible to come out on top and rein in AMR. Notwithstanding my proposal and concerns above, I stand to support the amendment Bill.”
“Such a high return occurs because of all the disease and death prevented. In light of this review, a national public awareness programme should be incepted to educate the general public on the potential side effects and infections from the uninformed use of antibiotics. Citizens should be warned to refrain from asking for antibiotic prescriptions from their doctors. I understand that the Health Promotion Board (HPB) is already working on this, but more aggressive and intense public education campaigns must be carried out to raise urgent attention. Clostridium difficile, a bacterium which infects the bowels and causes diarrhoea, is one such example of an infection usually related to antibiotic use, particularly in hospitals. It has been responsible for an estimated 14,000 deaths annually in the US. Other potentially deadly side effects due to drug allergies include anaphylaxis, a life-threatening allergic reaction, or fatal skin reactions like the Stevens Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN), fungal infections which lead to severe itching from vaginal yeast infections or burning mouth sores from oral thrush, and antibiotics-associated diarrhoea. There is a compelling need to empower patients to speak up and discuss risks versus benefits of imbibing antibiotics with their doctors to help them take ownership of their own health. Emphasis on the importance of hand hygiene and infection preventive measures in the community should not be understated. Similarly, the importance of flu vaccination and the fact that getting vaccinated protects loved ones around you, such as those more vulnerable to serious flu illnesses like babies and young children, as well as older people and people with certain chronic health conditions.”
“I would, therefore, like to advocate an AMR taskforce to discuss and recommend strategies to ensure appropriate use of antibiotics in a community setting, such as the reviewing and streamlining of an antibiotics formulary available for perusal within the community and exploring prescribing-dispensing separations, where possible. It is also essential to urgently come up with clinical practice guidelines on the use of antibiotics, the appropriate course duration of use, as well as the conducting of audits on the appropriateness of antibiotics utilisation, especially for broad spectrum antibiotics like quinolones, in the community setting. Educational programmes for healthcare providers in the United Kingdom (UK) have shown considerable effectiveness in reducing the prescription of antibiotics in primary care, and maybe similar programmes should be enacted in Singapore. Flu vaccinations are currently claimable by MediSave for specific population groups. This coverage should be extended nationwide and offered at a subsidised rate to our Pioneer Generation under the Community Health Assist Scheme (CHAS). Flu vaccinations should also be introduced into the national childhood immunisation programme to ensure that school children benefit from this and, at the same time, increasing the overall national take-up rate. A 2017 systematic review published in the Journal of Epidemiology and Community Health looked at studies that calculated the return on investment for public health interventions. The researchers identified 52 studies that looked at interventions at local and national levels. Health protection interventions, which would include vaccinations that match the actual influenza type, have saved $34 for every $1 spent on them, according to the review.”
“I acknowledge with relief that MOH has set up the National Strategic Action Plan on Antimicrobial Resistance, engaging various Ministries and agencies, such as the Agri-Food and Veterinary Authority (AVA), National Environment Agency, Public Utilities Board and so on, to evaluate various core strategies from public and healthcare professional education, surveillance and risk assessment, research, prevention and control of infection to the optimisation of antimicrobial use, and I applaud MOH for their tremendous effort in tackling this pressing threat. While a lot of surveillance and engagement work has been focused on hospitals since 2009, much more salient efforts have to be applied to get to the root of the problem. This includes how we can further enhance our AMR surveillance to grasp the utilisation rate of diagnostic toolkits which can be used to differentiate viral and bacterial infections, as well as where and how much antibiotics are being sold, prescribed and dispensed in each hospital, general practitioner clinic, retail pharmacy and for animal use. It is then necessary to extract such detailed information and apply data analysis or audits to identify specific abusive users and establish a feedback mechanism for better accountability. As such, I would like to propose measures that are imperative in resolving and lessening the impact of AMR in Singapore. Currently, we have systems in public hospitals to curb the misuse and overuse of antibiotics, but we will require a similar framework in the community where 80% of the primary healthcare is provided by private practices.”
“I understand that the National Research Foundation (NRF) announced the launch of a new Antimicrobial Resistance Interdisciplinary Research Group in January 2018 in conjunction with the Singapore National Strategic Plan on Antimicrobial Resistance, hopefully, to better understand how microbial resistance happens and to develop new antibiotics to curb these "superbugs". A study from the Singapore-Massachusetts Institute of Technology (MIT) Alliance for Research and Technology shows that AMR currently results in about 700,000 deaths per year worldwide, with recent studies predicting an increase to 10 million deaths per year by 2050, outpacing the mortality of cancer. The economic burden will follow a similar trend as a result. In the US alone, "AMR bacteria infect two million people every year at a healthcare cost of S$27 billion. On a global scale, AMR is predicted to cost up to S$130 trillion by 2050." These statistics are very distressing and not at all encouraging. According to a WHO report, only 11 antibiotics in clinical development could address pathogens considered critical threats, and three in four of the antibiotics under development belong to existing classes of antibiotics, against which microbials resistance has already been observed or could easily develop, due to the innovative nature of these "superbugs" in evading our current controls. So, at this rate, the world, including Singapore, will run out of antibiotics before long, and we might possibly go back to the era where even simple skin infections or urinary tract infections could kill us. The severity of this threat should not be underestimated, and I urge that we deal with this issue critically and swiftly. Tackling the AMR problem would require a multi-pronged and multifaceted approach.”
“Mr Deputy Speaker, Sir, thank you for the opportunity to speak on the amendment of the Infectious Diseases (Amendment) Bill. First of all, I would like to declare my interest as the President of the Pharmaceutical Society of Singapore. I understand that the recently amended Bill has been focused on strengthening contact tracing, surveillance, communication and the disclosure of information for infectious diseases. However, it is to my surprise that there is not much mention regarding the legalisation to curb the global and national issue of antibiotic resistance. To provide some background information, antibiotic or antimicrobial resistance occurs when microbials or micro-organisms, such as bacteria, viruses, fungi and parasites, change in ways that render the medications used to cure the infections they cause ineffective. When the micro-organisms become resistant to most antimicrobials, they are often referred to as "superbugs". This resistance occurs naturally but is facilitated by the inappropriate use of medicines, for example, using antibiotics for viral infections, such as cold or flu, sharing antibiotics or excessive inappropriate use of antibiotics in animals. I shall henceforth refer to antimicrobial resistance as AMR. On 30 March 2017, a new Bill 1840 was brought before the United States (US) Congress to provide tax incentives to "reinvigorate" antibiotic research due to the grave nature of AMR. The growing resistance of human infections to antimicrobial agents has emerged as one of the most pressing health problems in Singapore and the world.”
“If implemented, necessary steps will be taken to refine the CPP model in line with industry standards to ensure appropriateness of care. This will lead to improved patient access to healthcare through right siting of patients and lead to healthcare cost containment in the long run. Doctors in the community can then be freed up to see more complex patients and be subvented appropriately based on the complexity of medical conditions seen as well as clinical indicators met. This privilege can later be considered for physiotherapists and occupational therapists to empower them as the first triage point under the new rehab model of care. These are highly trained Allied Health specialists with postgraduate degrees and at least three years of work experience. Overseas studies have demonstrated that patients with musculoskeletal conditions, such as non-severe back or neck pain as well as hand injuries, benefited from early access to physiotherapy and occupational therapy at the primary care or emergency department. Locally, even if early access is available to these patients, they are required to visit the doctor for an MC. Mr Deputy Speaker, in short, these proposals will reduce inefficiencies in the current healthcare system, while allowing for better patient experience and contain healthcare costs through the optimisation of healthcare teams, without compromising clinical care. As we move into the ageing tsunami, there is an urgent need to proactively review our healthcare system and remove inefficiencies, making our processes leaner so that healthcare costs will not end up as a financial burden to our next generation. Notwithstanding my requests stated above for MOM and MOH's consideration in future EA amendments, I stand to support the Bill.”
“I understand that the current EA is not prohibiting such a practice and, in fact, some healthcare clusters and Civil Service organisations have already implemented this practice for many years, but there is a need for MOM to mandate it in the Act so that these benefits can be accelerated across the nation, rather than to let nature take its course. I understand that there is always the perennial concern of employers – how to prevent the abuse of this system by employees who like to "keng"? In response to that, I would like to propose creating controls, such as audits and provisions for the privilege to be withdrawn for employees who abuse the system, and a surveillance system to be put in place to ensure that we do not miss out on cluster infections. In any organisation, there will always be a small percentage of employees who will abuse the system. The benefits of allowing for sick leave without MC will outweigh the small number of abuse cases. In fact, even with our current situation, it is not difficult to get a day off from work by faking an illness to get an MC. A survey conducted by online portal Jobs Central in 2012 reported that almost 20% of some 3,300 Singapore employees admitted to faking an illness to get away from work at some point in time. Should MOM and MOH choose to adopt my two suggestions, the benefits to patients and our healthcare system will be manifold. It will help organisations save on unnecessary medical claims from employees just to get MCs for simple viral infections or minor ailments. The right to issue MCs by CPPs also elevates the recognition of the CPPs’ role. It is a necessary amendment to level up the CPP model to be in line with doctors.”
“Currently, these practitioners can only provide excuse chits to patients. If patients require MCs, they have to be directed to medical doctors where they have to wait again for the doctors to furnish their MCs. It causes unnecessary delays to patients and can be disruptive to both the CPP and the doctor. Currently, most employers accept MCs but not excuse chits. The reasons I have stated provide sufficient grounds for MOM and MOH to consider certifying CPPs licensed to provide MCs to the general public. This brings me to my second point, which is, for MOM to consider working with the Tripartite Alliance and encourage employers to allow for up to three non-consecutive days of sick leave per year without MC. I am sure that everyone who works will have had to obtain an MC when they are unwell at some point in time. You might have woken up perhaps with a flu, feeling feverish and decide that you are not able to go to work that day. However, you would first have to get an MC. That would mean going to the nearest private clinic or polyclinic, queuing up with other patients and risk spreading infection. Apart from being unproductive and potentially spreading your contagion, being out and about would exacerbate your illness when you should be getting the much-needed rest at home. One may even conveniently ask for unwarranted antibiotics since they are already at the clinic, contributing to global antimicrobial resistance problems. Allowing employees to take up to three non-consecutive days of sick leave per year without MC will also display a strong signal of trust and partnership between employers and employees. It will also create better accountability and higher morale amongst staff because the system had shown them that their employers trust them.”
“This framework came into operation on 1 March 2018 and certifies a practitioner under the national collaborative prescribing assessment framework to be able to review and prescribe independently within the scope of their Collaborative Practice Agreement (CPA). This certification is done in a setting that requires the issuing of MCs, for example, in ambulatory care clinics. All CPPs have to undergo and pass a three-month National Collaborative Prescribing Programme. In each institution, a privileging and training framework is in place for CPPs to see patients in a clinic. Practitioners must have at least three years of experience, with at least a year in team-based care before enrolling into the National Collaborative Prescribing Programme. CPPs are regularly reviewed by the Credentialing and Service review committee to ensure safety and appropriateness of care. They are also required to maintain a competency portfolio for re-credentialing, whenever necessary. Nurses under the CPP framework are registered Advanced Practice Nurses (APN) who have completed the Master of Nursing Programme accredited by the Singapore Nursing Board (SNB) for APN training or its equivalent and have successfully completed a postgraduate one-year APN Internship programme. Likewise, CPP pharmacists are advanced practice pharmacists or specialist pharmacists registered with the Singapore Pharmacy Council (SPC) who have completed postgraduate training or its equivalent and fulfilled the compulsory continual professional education (CPE) points for maintenance of licensure by SPC. As Members can see, practitioners under the CPP framework go through rigorous training, are constantly audited to ensure that high standards of care are upheld and are well-equipped with necessary industry certifications.”
“Mr Deputy Speaker, Sir, I declare my interest as the President of the Pharmaceutical Society of Singapore, Assistant Director of Allied Health Office at KK Women's and Children's Hospital and Co-Chair of the SingHealth Allied Health Executive Committee. I would like to impress upon the House two things regarding the upcoming Employment (Amendment) Bill. Firstly, for MOM and MOH to explore allowing registered Collaborative Practice Prescribers (CPPs) who are running clinics in hospitals and polyclinics to issue MCs. Secondly, for MOM to work with the Tripartite Alliance and encourage employers to allow for up to three non-consecutive days of sick leave without MC per year. I am deeply concerned about the rising healthcare costs in Singapore and the expenditure on elderly healthcare. These are issues affecting our healthcare system and have been highlighted in the 2018 Singapore Budget. With the increasing burden of an ageing population, along with the surge in incidence of chronic diseases and complexity of chronic disease management, we need to focus on a team-based model of care where various healthcare professionals – doctors, pharmacists, nurses, allied health professionals – come together and work in synergy to provide cost-effective care outcomes in line with MOH’s Beyond 2020 master plan. As such, we need to empower our allied health professionals, nurses and pharmacists to take on greater roles in the area of minor ailments and chronic diseases management to provide value-based care at a sustainable cost and to actively look into ways to eliminate inefficiencies in our healthcare system. One such approach that I would like to suggest is to allow practitioners under the recently approved CPP framework to be able to issue MCs.”
“Mr Deputy Speaker, Sir, I stand to support the Environmental Public Health (Amendment) Bill. I would like to take the opportunity to thank MEWR for their efforts in introducing the PWCS in Singapore. I think the benefits are tremendous, as mentioned by quite a number of Members. On top of it, we can also hope that it helps to reduce infestation of pests, reduce carbon emission and even, in future, help with separation of wastes for recycling. I have four points for clarification. Would the Senior Minister of State clarify, with regard to the implementation of this system, taking into consideration the high capital cost balanced with the manpower and truck cost savings? What will be the eventual bill payable by residents compared to the current manual handling process? What is the average payback period for implementing such a system at district level? What will be the downtime plan in the event of prolonged pipe blockage or other system failures? And lastly, what types of wastes cannot be handled by this system, for example, hazardous chemicals, or residents throwing spongy items that may block the pipes, and how is the Ministry intending to educate the public on this? Notwithstanding my request for clarification, I am in support of this Bill.”