Janil Puthucheary
Singapore
“Sir, I thank Ms Lee for her two supplementary questions, which address what are our targets and what is it that we measure. Indeed, the issue of how we should think about recycling and waste disposal will be at the heart of our review of our Zero Waste Masterplan.”
“Another strategy that we are embarking on is the strengthening of the reuse of waste residue and treated toxic industrial waste before and after they are landfilled.”
“Sir, about half of our recycling material is exported. It is processed overseas. There are business arrangements between businesses here in Singapore and businesses in the region or overseas, to be able to handle the recycling of waste and recycling of material, whether domestic or non-domestic, already today.”
“Sir, I thank Ms Poh for her questions. Indeed, we do have to shift behaviours. The incentives and disincentives around recycling and waste disposal are an important part of it. We will consider her suggestion on looking at the fees.”
“The heat advisory that goes out is clearly defined. In my original answer, I explained what a heat wave was. There are clear definitions that we have been using in Singapore since 2016, if I recall. It was then last revised in 2023.”
“Sir, in the planning of schools, the Ministry of Education ensures that our students can access a primary school near their homes. Except for a small number, 15 of Special Assistance Plan schools, all primary schools offer the three official mother tongue languages.”
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“Chairman, MCI wants to empower every Singaporean to thrive in our digital future. In my speech, I will explain two ways in which we are laying the foundations to do so. One, by investing in the underlying digital infrastructure to connect all of us and power the digital services and products we use; and two, by building up strong research and innovation capabilities to create new value from emerging technologies. These are long-standing priorities for MCI. Infrastructure and innovation form the basis for our continued access to quality digital services and content. For businesses, these allow them to connect to more customers, raise productivity and generate new business value. Our work in these areas is therefore never quite done. We need to build on our progress, adapt and invest in the future as technology and the world around us and our people’s needs change. With this in mind, we continue to enhance Singapore’s digital infrastructure to not only meet current demands for speed, capacity and reliability, but to cater for anticipated needs and reap future benefits as technology and the use cases evolve. Understanding future demand will help us make calculated bets as we invest in Singapore’s digital infrastructure. It is not always straightforward as technology advances in disruptive and non-linear ways. We have had to carefully assess technological developments, actively consult the industry and boldly imagine the use cases that consumers and industry would participate in and want to experience here. The development of our nationwide fibre broadband network (NBN) is a good example of such a calculated, future-oriented bet to build digital infrastructure.”
“Sir, it is a little bit too early to calculate the expected gain in productivity. The tool is still being developed. The second question about redeployment, our experience in other parts of Government, with the use of productivity enhancement tools or automation, has resulted not in redeployment of personnel, so much as redevelopment of job roles and the tasks that officers are engaged in. This has been our experience for a number of years across the number of Ministries and agencies. It remains to be seen what the effect will be of this tool, as I said, it is early days yet.”
“Mr Speaker, Sir, as part of our efforts to utilise technology to encourage innovation and productivity in the public sector, the Government is exploring how large language models, such as those underlying ChatGPT can help officers do their work more effectively. One such effort is the development of Pair, in which we see potential in helping civil servants with parts of the writing process, such as summarising long reference material, exploring related ideas, or improving the clarity of writing. Pair is still being developed. The Government aims to pilot this with a number of agencies and will carefully evaluate the results before determining how best to roll it out to the broader civil service. To ensure data security, the Government has struck an agreement with Azure OpenAI, the large language model provider, for Government information to remain confidential. In addition to these technical safeguards, work that contains highly confidential or sensitive information will still be written exclusively by civil servants. As suggested by the name "Pair", the intent is for it to serve as an assistive tool that civil servants can leverage to improve their productivity, rather than entirely automating the writing process. Ultimately, civil servants using the tool are still directly responsible for making policy decisions, as well as crafting, refining and customising the content of documents to ensure that they are relevant, accurate and appropriate. The Government is committed to ensuring that we are well-positioned to benefit from innovations, such as ChatGPT, while managing the associated risks.”
“Mr Speaker, I agree with Mr Leon Perera that we do need to simplify our communications and aim for clarity, wherever possible. We also do have to make sure that there is precision and accuracy in the statements. These are tensions that Government officers will require training and support, but I can assure Mr Perera we have the same intent.”
“To be clear, our plans are only for 70% of Government services to be on cloud providers by 2023. We are on track to meet that target. And so, already, we have plans and we have planned for some of our services to be controlled by the Government directly. These would primarily be those that support the work of the security services and agencies that are associated with that.”
“Sir, our cloud services are hosted by three different service providers. So, there is already some diversity in the contractual arrangements that we have and the provision of services from the commercial sector. There is also diversity in the way in which we structure our cloud-supported databases and services, with some things happening on commercial cloud, Government commercial cloud and some things on on-premise solutions. So, there is already some diversity and we will continue to look to see how we can improve the resilience of our cloud service providers and uphold the standards that we have required. To Ms Poh Li San's second question about the degree of control over the cloud service providers and what recourse, there are service standards that are contractually agreed to and the service providers have every interest in working with us to make sure that they do meet those service standards. But in addition to that, like any contractual arrangement between a cloud service provider and the client, our engineers work closely with their engineers, both in terms of setting up the architecture and also, in terms of trouble-shooting when problems arise. So, that close relationship is part of the way in which we ensure the resilience of our service and the recourse when things go wrong.”
“Mr Speaker, outages and disruptions can happen to any digital service, including those hosted on cloud services. The recent service degradation at a Microsoft data centre had limited impact on Government services. Nonetheless, GovTech has been working with Microsoft to fully restore affected services and prevent similar occurrences in future. In general, cloud service providers offer improved availability, scalability and cost efficiency. These advantages were most evident during the COVID-19 pandemic, when we could quickly deploy services to support national efforts, such as contact tracing, proximity tracking and distribution of face masks. To qualify for Government procurement, cloud services providers must meet our criteria for availability, resilience and security. The same criteria apply regardless of the service provider’s ownership and location of data centres. The services are regularly monitored to ensure compliance with agreed service levels and stringent security standards. Prior to this incident, cloud service providers had been able to meet our requirement to be available at least 99.9% of the time.”
“I thank Mr Leon Perera for his question. The process of conducting clinical trials is independent of the fact of mRNA vaccines. We have a number of platforms, processes and significant investments in developing the ability to do better and more clinical trials here in Singapore to act as a hub for both the patient selection, as well as the information management and subsequent analysis of these trials. All trials related to mRNA vaccines and cancer vaccines will be part of that approach.”
“Sir, cancer is a priority disease area for research in Singapore. Through Research, Innovation and Enterprise funding over the years, competitive cancer research projects in Singapore have been supported by the Ministry of Health (MOH)'s National Medical Research Council, including the development of mRNA-based cancer vaccines. For example, the National University Cancer Institute, Singapore, is developing an Epstein-Barr virus (EBV) vaccine platform using lipid nanoparticle mRNA vaccine technology. The Agency for Science and Technolody Research is leading the research that combines genomic knowledge about EBV and nasopharyngeal cancer (NPC), to develop better mRNA vaccines against EBV that can reduce the risk of developing NPC, which tends to affect Asians more. Scientists at the National University of Singapore are investigating the combined use of a personalised RNA-based cancer vaccine with RNA based immune-checkpoint inhibitor treatments for patients with Acute Myeloid Leukemia. Research on the efficacy of mRNA-based vaccines against cancers is still at an early stage and none has been approved yet to treat or prevent cancer. However, given the potential of this approach, MOH will continue to support the development of suitable mRNA-based vaccines to treat cancer, as well as other important medical conditions in Singapore. This includes: one, providing funding support for such research; two, supporting research collaborations between our researchers and overseas partners; three, supporting local research focusing on diseases that affect our local ethnic populations disproportionately; and four, working through the Singapore Translational Cancer Consortium to better coordinate, integrate and support the work of key local cancer research stakeholders.”
“I thank the Member for her suggestion. It will be considered.”
“Mr Speaker, continuous monitoring of vital signs is routinely performed for all infants admitted to Neonatal Intensive Care Units (NICUs) in all acute hospitals with neonatal care services. In addition to KK Women's and Children's Hospital, Singapore General Hospital and the National University Hospital are also reviewing and enhancing their monitoring measures for higher risk infants, who are not admitted to the NICU but may benefit from closer monitoring.”
“Sir, I thank the Member Ms Joan Pereira for her question. Among the subset of patients having received the vaccine who then subsequently received the VIFAP that she referred to, the data has been released, there were no cases of acute ischemic stroke. So, the short answer to her question is zero. But we do not monitor the VIFAP applicants or recipients only. We monitor and look for safety signals across the entire population of people who receive the vaccines, who come to our clinics or centres, who receive medical care at our hospitals. And we are looking for that safety signal that this type of adverse event has increased. And it has not. That is the clear message that we want to send.”
“Sir, I thank the Member for the question. Allaying such concerns will require a multi-channel, multi-stakeholder approach, as we have been doing for any issues and concerns around the vaccines and the vaccination programme from the start. The transparency of our processes, the information available from experts, academics and the professionals, the honest and complete discussion about risks and benefits – not that there are no risks, but the benefits significantly outweigh the risks – as well as that last-mile communication. I hope Members in this House can assist in that process of last-mile communication, taking the information provided by the Ministry of Health (MOH), by HSA, by the EC19V, by colleagues and replies in this House, and helping to convey to their residents as well.”
“After more than two years of COVID-19 vaccinations, there is now a well-developed and transparent safety monitoring system, where regulators around the world will highlight observations once they detected it, even if not fully investigated. Such is the nature of the recent preliminary signal reported by one of the vaccine monitoring centres in the US about strokes in individuals aged 65 and above who have had the said vaccine. Upon further investigations, the US Centers for Disease Control (CDC) and Food and Drug Administration (FDA) assessed that this was very unlikely to reflect a true risk. The signal of a possible risk was neither observed nor validated in other US safety systems or analyses, or by other countries. Similarly, our local data accrued for the bivalent vaccines so far also do not show any increased risk of ischaemic stroke after receiving either the bivalent Moderna/Spikevax or the Pfizer-BioNTech/Comirnaty vaccine. In fact, HSA’s latest safety report showed that the incidence rate of severe adverse event after taking bivalent vaccines, at about one in 100,000, is lower than that of the original vaccines, at around seven in 100,000. The US CDC and FDA are not making any changes to the vaccination practice in US and will continue to monitor the safety of the COVID-19 vaccines. Similarly, the Expert Committee on COVID-19 Vaccination (EC19V) and Health Sciences Authority (HSA) maintain that the benefit of both the bivalent Moderna and Pfizer COVID-19 vaccines continue to outweigh the risks, especially for vulnerable individuals.”
“Sir, I thank the Member for the questions. The localised short-term supply issues were largely managed through the vendors' own stockpiles. And indeed, a variety of data and ICT tools are used to manage the supply, as well as the stockpiles at the vendor, as well as the national level.”
“I thank the Member for his questions. The supplies were more than adequate and, certainly, our national stockpiles, which include what the vendors have, have remained within our policy thresholds all the way along. We have a fairly granular live view of the stocks held by the vendors, as well as in our national stockpile. So, we are fairly confident that we would be able to meet the demands in general. I would put it to the Member that as COVID-19 becomes endemic and, as a population, we treat it and behave towards it like we do other illnesses, there is less chance of the panic buying or the anxiety-induced purchasing that we saw towards the end of last year. And so, we would be less likely to have similar problems with over-the-counter medication. If I may also offer some medical advice. One way to deal with the anxiety, the routine use of mucolytics and expectorants is not necessary for most of us who have healthy lungs and baseline good health when dealing with an illness such as COVID-19. Secondly, there is no necessity to purchase branded medication. A variety of generic preparations will do the job just as well.”
“My response will also cover the matters raised by Mr Zhulkarnain Abdul Rahim scheduled for a subsequent Sitting. Sir, retailers keep close track of their supplies of over-the-counter (OTC) medicines and medical supplies and bring in more stock or alternative brands when there is a surge in demand. At the same time, MOH also monitors the stock levels of commonly used medicines and medical supplies, especially when there are exceptional surges in demand or disruptions to supply. If necessary, MOH will work with the retailers to procure additional stocks to meet the demand, or issue relevant advisories. In addition, MOH maintains stockpiles of key medicines and medical supplies to be prioritised for the higher acuity patients in our public healthcare institutions. In extreme situations, where there may be global shortages, MOH will take additional measures such as imposing sales limits to prevent hoarding and ensure that the medicines and medical supplies are fairly distributed. Over the past year, our medical supplies, including oximeters and oxygenators, have been adequate to meet demand. Towards the year end of 2022, due to higher incidents of viral infections, there were temporary localised shortages of specific brands of medicines used to treat fever, coughs and cold. Retailers therefore persuaded customers to switch to alternate brands which were not in short supply. In the past couple of weeks, demand has moderated and stock levels have improved.”
“Mr Speaker Sir, may I have your permission to answer Question Nos 7 and 8 on today’s Order Paper together?”
“Mr Speaker, may I call for a Division, please?”
“Mr Speaker, may I call for a Division, please?”
“Mr Speaker, Sir, as explained in Parliament on 12 September and 20 October this year, we will continue to review our system design and architecture, and invest in capabilities to strengthen the resilience of our IT systems and reduce disruptions. We are also reviewing our downtime and business processes to minimise the impact during outages. Our public healthcare institutions have business continuity plans that are activated in case of emergencies. Each institution's business continuity plan is supported by solutions with appropriate functionality and can be used when key applications are unavailable to allow public healthcare institutions to continue with the delivery of patient care services. For example, users would be able to view a patient's historical clinical information but may not be able to enter new clinical information into the system during the downtime. Patients should contact their healthcare provider for medical assistance as needed.”
“Mr Speaker, unscheduled downtime of Government digital services occurs infrequently, affecting service availability less than 0.1% of the time in 2021. Among services that experienced unscheduled downtime, the median cumulative downtime for the whole of 2021 was four hours. This is partly because the majority of Government systems providing services to the public have been moved to commercial cloud hosting platforms, which have high availability. And these platforms, and the services that run on them, are designed for better availability. For systems which provide critical services, there are further measures to better ensure high availability and resilience. For example, backup hardware and network links, as well as monitoring tools to detect and alert system owners of potential problems. When systems go down, we seek to detect the outage quickly and recover service availability fast, while mitigating the impact of the outage. Government agencies have ICT incident management plans and exercise them regularly. Agencies may also activate measures to allow citizens to perform critical transactions offline, in-person or over the phone.”
“Sir, I thank the Member for his two questions. There is a point that is related across both of the questions, which is that we have to have a series of processes that maintains standards for our medical professionals. So, on his first question, it is around the academic standards; the second is around safety and the regulatory practices around the person being fully registered. In both cases, we have a framework looking at the standards required to enter medical school and then, to enter full practice. On the first point of whether those standards for medical students should be altered in some way, I think he would agree with me that it should not. We do have to make sure that the people who go into the medical schools have the aptitude, the attitude, the ability to not just complete their studies but have the ability to do well. Having said that, there are Polytechnic graduates who are making it into medical school – we see them reported in the press. I think the importance is that they have met those standards and then, are able to flourish within medical schools; and they have a fulfilling career. We will continue to study this space. The same principle applies then to his second question, which is about foreign-trained doctors coming to practise within Singapore. In order to serve the mission to the public, we should hold them to the same safety requirements as any other graduate from a local university going out into medical practice. And so, there is a standard set of approaches in order to make sure that they are safe to practise before they get fully registered. And I am sure the Member would agree – we should not reduce those standards.”
“Mr Speaker, over the last 10 years – from 2010 to 2019 – our medical schools have increased their combined annual intakes by around 60% from around 320 to 510. In 2020 and 2021, we admitted another 40 medical students each year. These were students whose overseas medical studies were disrupted by the COVID-19 pandemic. While our main source of doctors will continue to be our local medical schools, about 200 locals who study or practise medicine overseas return to Singapore annually. Most of them study or work in Australia, the United Kingdom or Ireland. In addition, we supplement recruitment with qualified doctors from recognised universities from other countries, to ease the workload in specific departments and hospitals. Currently, the top five countries that our foreign doctors are recruited from are India, Malaysia, Myanmar, the Philippines and the United Kingdom. The attrition rate of doctors from the public healthcare sector into private practice is acceptable and it ranges from 3% to 5% in the time period 2019 to 2021. We continue to make various efforts to retain our doctors within the public healthcare sector.”
“Simplistically, we had different variants with different transmissibility and infectivity characteristics, but we also had very significantly different measures in place at different time periods over the nearly three years. And so, I would think it would be too much, too reductionist, too simplistic to look at the overall picture. This would require quite a detailed study to be able to come to a conclusive position as to which was a greater risk at any one point in time. I think it is a little bit too simplistic to say it is one or the other. But I would be happy to take this up if the Member would like to file a question and we will try our best to provide her what data we may or may not have. Her third question was whether the design of the wards, the ventilation, can affect hospital-acquired infections. Indeed, there are things that have been studied prior to COVID-19. There are people looking at this and looking at this not with respect to just one infection but a wide variety of infective agents which may affect our patients within the hospitals. So, the short answer is yes.”
“Sir, the numbers may be an under-estimate. We did not do daily testing on everybody. I think the Member would agree this would be inappropriate to subject every person within this space – whether a healthcare worker, a patient or a visitor – to daily testing. We took a risk-based approach within nursing homes and hospitals, as we did within the community and in different locations. Under different circumstances, the risks change, and so, we did a risk-based approach on testing. Having said that, we have quite a lot of data over the last three years. That data is applicable to the community setting, the hospitals as well as the nursing homes. This has allowed us and the scientists in our system to model the transmission and the clusters and the spread of COVID-19 within different settings. So, to answer the question, yes, it may be an under-estimate, but I think we are confident that we have a robust handle on the relative proportions. So, it is approximately correct – 330 versus 3,000. I do not think our under-estimate is so far off that the numbers would be reversed, for example, or that we are in the order of magnitude of a significant percentage off. We are about right and we have some confidence that we are about right. Her second question was whether patient-to-patient transmission or healthcare worker-to-patient transmission, which was a greater contributory factor in our setting, in our system. I do not have the data in front of me. I would encourage the Member to file a separate question if she would like further information on that. But if I may make a related, tangential point, which is that the COVID-19 circumstances changed quite significantly over the three years.”
“From 1 April 2022 to 30 September 2022, there were around 330 reported cases from COVID-19 clusters in hospitals. Over the same period, around 3,000 COVID-19 cases were reported by the nursing homes. These constitute a small proportion – less than 1% – of total reported community cases. As we move towards living with COVID-19, we no longer adopt a zero-COVID posture in hospitals and nursing homes, where all patients or nursing home residents need to be tested before admission and where infected patients are isolated in hospital COVID wards. Notwithstanding, we continue to take necessary precautions to protect patients and residents, and are ready to step up the COVID-19 measures, such as visitor restrictions, when necessary. Vaccination is our primary defence. It cannot completely stop infections but is very effective in preventing severe illness from COVID-19. We have provided COVID-19 vaccinations to over 90% of eligible nursing home residents. With these measures, we have kept Singapore’s overall case fatality rate at about 0.1%, well below the global average of around 1%.”
“I thank Mr Gerald Giam for his questions. Yes, they can enrol with polyclinics and we will continue to review the issue of the annual withdrawal limits.”
“We need the support of all healthcare professionals, the healthcare clusters, community partners and many more. We need to, and will, put in place systemic enablers for this challenging set of reform to succeed. Ultimately all of us need to also play our part in taking some responsibility for own health and change our behaviours. By working together, we can improve health for all of us. [Applause.]”
“To raise mental health awareness, we have developed MindSG, a trusted online resource portal that provides comprehensive and current information on mental health. To improve access to community mental health services, we developed Community Outreach Teams (CREST). We have the redeveloped Alexandra Hospital coming up, which will provide psychiatric services. The National Addictions Management Service at IMH will be extended to other hospitals, including Changi General Hospital and National University Hospital, to make the services more accessible. We have been working closely with AIC and GP partners to have more GPs provide mental health support. As of March 2022, there were over 390 GP partners trained to care for persons with mental health conditions in the community. We have convened the Interagency Taskforce on Mental Health & Well-being with members from over 30 organisations. The task force has reviewed our mental health needs and identified four focus areas. First, to strengthen services and family support for parents and youths. Second, to provide and improve access to quality and affordable mental health care by integrating health and social services. Third, to provide employment support for persons with mental health conditions. And four, to improve mental health literacy among the citizens and create an inclusive society for persons with mental health conditions. We have completed our public consultation on the issue of Mental Health Strategy in August. Members of the public and key stakeholders have shared their feedback, and we are now refining the recommendations. The task force will share its findings soon. Mr Deputy Speaker, Sir, a Healthier Singapore requires a whole-of- society approach.”
“Meanwhile, to reassure Members of the House, regular oral health and eye screening programmes are already easily and readily available as a routine service in many settings, and we will continue to offer these. For example, Project Silver Screen conducts check-ups for seniors at community locations for age-related decline in vision, oral health and hearing, so that they do not have to visit a clinic or hospital, and so that timely interventions can be provided. Likewise, we would like to assure Mr Dennis Tan that there are already similar preventive dental health programmes in place. To Mr Abdul Samad's comment, there are nationally recommended health screening tests widely available at CHAS GP clinics, polyclinics and participating community providers. In future, Singaporeans should go to their enrolled clinic to enjoy free screening. Finally, let me address mental health and well-being, a topic important to many we engaged during our public consultation. Several members such as Ms Tin Pei Ling, Ms He Ting Ru, Dr Wan Rizal, Mr Melvin Yong and Mr Dennis Tan have also raised this. Good health is also about good mental health. The current planned interventions under the first phase of Healthier SG will support mental well-being. People have asked when will we start to look at mental well-being? Yesterday – actually, years ago! The interventions we already planned under Healthier SG, starting with our initial emphasis on eating well and regular exercise, will have a positive effect on mental health. But allow me to also highlight what we have put in place over the last few years to promote mental health and well-being, even before Healthier SG.”
“This guidance is based on scientific evidence to ensure that screening tests are safe, effective and suitable for population level screening, means it applies to everyone across the population. We need to strike a balance, to balance the practice good preventive care, but consider what the test involves, without going overboard. In some cases, some of the tests, some of the screening tools, are better applied to targeted population. It may be better for some cases to take a calculated, risk-based approach, to offer tests that are effective and easy to administer to high-risk groups. One example is what we are doing for those aged 50 and above, such as with the 2-day Faecal Immunochemical Test (FIT) which is for colorectal cancer. So, there are some tests which the science suggests we should apply it to the entire population and there are some tests which the science suggests we should apply to targeted population. We will continue to review emerging scientific evidence on these screening tests as well as the effectiveness of our financing models. Fundamentally, access will not be denied to those who need it. Ms Janet Ang asked about regular eye and dental screening. These are important, we must look after our teeth and have our eyes checked, and most of us do so. The screening processes and tools are less appropriate as a mass exercise for all under the population approach for Healthier SG and again, are more suitable as targeted effort for certain groups of Singaporeans. Healthier SG is a multi-year effort, we will continue to review and include other necessary care protocols in future.”
“This includes our healthcare clusters who will serve our residents as regional health managers. Only authorised personnel will be allowed to access the data, which will be limited to what is necessary for their work. MOH will be seeking feedback on the Bill later this year and we look forward to hearing your views. Ms Mariam also highlighted the importance of data analytics. Data-driven intervention is indeed our intent. We will continue to work with clusters and partners to share data and deploy such capabilities to help our residents. It is important therefore that we set up the NEHR, with the safeguards and obligations spelled out in the proposed Health Information Bill. We are strengthening the IT platforms, the services and the connections across all the partners: family doctors and healthcare clusters. I thank the many IT teams, public and private, who are collaborating on this. It is with their help that we will improve the flow of data, impact health outcomes and optimise the user experience for residents and our healthcare providers. I am glad that Mr Xie Yao Quan has also highlighted the importance of having sufficient IT and cybersecurity talent. While we have built up expertise, a key challenge remains to attract and retain skilled IT professionals in a competitive market. We will continue to remunerate competitively. We also hope that healthcare IT colleagues see the contribution they make and the fulfilling career they can have in transforming our system, caring for our society. Ms Ng Ling Ling suggested that more comprehensive health screening is needed as we move towards preventive health and Mr Abdul Samad further suggested more MediSave utilisation for this. We take guidance from the recommendations of the Screening Test Review Committee.”
“We know that it is not easy for GPs to upgrade to an IT system that is Healthier SG compatible, and they will have one year from the launch of Healthier SG to adjust. We will also provide a one-off IT support grant to support this transition. MOH and AIC will continue to support GPs in this process. We want them to come on board Healthier SG. Our plans will require a close collaboration among family doctors, the healthcare clusters and a wide range of service providers. However, the use of IT and record-sharing differs widely, hindering coordination and communication across partners today. Going forward, to deliver Healthier SG, we must transform how we communicate and share data for more holistic, integrated and coordinated care. Ms Mariam Jaafar and Dr Tan Yia Swam spoke about this. One key tool will be the National Electronic Health Record (NEHR). NEHR will capture summaries of patient medical records in one platform. Those healthcare workers who need it to support the clinical care that they are delivering, such as family doctors, will be able to draw from, and contribute to, a common platform. We have put in place controls to restrict the access to sensitive health information to selected user groups only. There are also additional authentication processes for the sensitive health information and we audit the access to this set of information. We will continue to implement safeguards to balance patients' need for privacy and to ensure that the correct healthcare providers are able to access critical information necessary to provide care to patients. We will introduce new legislation, the Health Information Bill, in 2023. This Bill will facilitate the proper collection, use and sharing of health data among healthcare providers in a safe and secure manner.”
“The intent is for all participating clinics to have at least one family physician per clinic. There is a seven-year runway to achieve this. PCNs support clinics in their network to achieve the requirements for Healthier SG and AIC can also provide support to clinics. We will find ways to facilitate the participation of solo GPs in Healthier SG. Dr Tan Wu Meng and Ms Joan Pereira raised concerns about the administrative burden of data submission and whether the IT systems would adequately support the work of GPs. Many GPs we engaged also highlighted the importance of IT and that the systems need to be improved. We will work closely with GPs and their IT vendors, this work has already started with GPs and their IT vendors, to support the enhancement of IT systems, to simplify administrative processes, improve data flows and sharing – all while ensuring data security. The indicators that will need to be submitted for outcome tracking and remuneration have been streamlined, taking reference from existing clinical indicators that doctors would routinely document and track, in their own records, to deliver good care. We want GPs to use a Clinic Management System (CMS) that supports their daily operations well and connects to all the key public health IT systems. And this then, will save them time on administration so that they can focus on the patients. We are working closely with the commercial CMS vendors to improve their products and strengthen their backend services. Some GPs today continue to use pen and paper services, we will provide them an interim web portal, for them or their staff to enter the essential information while they adopt a CMS and we have given them some time to do so.”
“Mr Edward Chia asked about telehealth providers. Telehealth will be an important enabler. In line with this, we will also consider how remote providers, without standard in-person clinic facilities, can be included. We will share more on how GPs can leverage telemedicine to offer regular check-ins for their residents under Healthier SG in future. Let me also address Mr Ang Wei Neng and Ms Denise Phua's queries about doctors on company panels. We need to ensure that as many GPs as possible who are on employer panels join Healthier SG. The Singapore National Employers Federation (SNEF) and NTUC, employers and union leaders agree that they will need to get more of their panel GPs to join the Healthier SG programme. What does this mean for an employee? If most panel clinics are on Healthier SG, the employee can benefit from Healthier SG benefits and employer medical benefits when they enrol with a Healthier SG provider that is on their employer's panel. If and when they change employers or retire, they can stay with the same clinic and continue to enjoy the Healthier SG benefits. These Healthier SG benefits will build on top of the employer medical benefits. Regardless of the coverage of the employer medical benefits, employees on Healthier SG will receive a free consultation on their health plan and will be encouraged to complete the free nationally recommended screening and vaccinations. With effective preventive health, some employers may see savings in employer medical benefits. SNEF has been urged to plough back these savings into other health and wellness programmes to enhance the health of employees and SNEF is supportive. Mr Ang Wei Neng asked about the family physician requirements and how it will impact solo clinics.”
“To Ms Hazel Poa and Mr Gerald Giam's comments on MediSave, we have limits on the use of MediSave to ensure Singaporeans have sufficient savings to meet their various healthcare needs throughout their lifetime. We will continue to review the adequacy of each Medisave limit. MOH also reviews the list of conditions on the Chronic Disease Management Programme (CDMP) regularly and has recently expanded the list to include three new conditions such as gout, allergic rhinitis and chronic hepatitis B, bringing the total to 23 conditions. To Mr Xie Yao Quan and Ms He Ting Ru's questions on personnel and overseas Singaporeans who are healthcare workers, we are actively growing our pool of family physicians to meet our target of 3,500 by 2030. The annual intake for family medicine has been increasing and we will continue to review the training numbers. MOH has been working with the Family Medicine Training Advisory Committee and the College of Family Physicians Singapore on expanding the number of training places. We are also increasing exposure to family medicine in the undergraduate curriculum and have incorporated preventive care in all clinical modules. We conduct regular recruitment and retention efforts to reach out to overseas Singaporean medical students studying in medical schools recognised by us. We provide them with details on applying for jobs in Singapore and offer them Pre-Employment Grants to help with their school fees, in return for being bonded to work in our public sector healthcare institutions. We also offer, as appropriate, housemanship training positions or more senior jobs. Our aim is to facilitate as many of them as possible to return home. Overall, about 200 overseas trained Singaporean doctors come back every year.”
“There will be a base rate that will differ for enrolled patients with and without chronic conditions. This is regardless of whether the enrollees, the residents, are compliant with the health plans. On top of this base rate, additional payouts will be provided upon the completion of critical care components recommended in the GPs' care protocols and the residents' Health Plan. For example, have patients with diabetes gone for their annual eye and foot screening? So, at the start, doctors will be paid not on the basis of whether the blood pressure or the blood sugar levels have come down, but whether the patient has engaged with the interventions that will help bring down the blood pressure and the blood sugar levels – at the start. GPs have shared that educating and encouraging Singaporeans to turn up for screening requires dedicated time and effort, and the design of the service fee addresses this and minimises the impact of cherry-picking. This new annual service fee is on top of the existing Government subsidies and the patient revenue that GPs already receive for services rendered. GPs can also expect more revenue from these patients with the increased uptake of recommended preventive care services which will be fully subsidised. And more comparable drug prices will help patients, who may have otherwise visited polyclinics, to see their GPs instead. Taken together, all of these means that GPs will be fairly remunerated for the care that they deliver under Healthier SG. Ms Denise Phua highlighted the plight of busy GPs. We hope this set of changes will also help them gradually evolve from a volume-driven model to one with more opportunities to connect with and empower their residents for health.”
“For example, if your doctor leaves the clinic to join another group, you have the option to switch and enrol with your doctor's new clinic. Others may prefer the convenience of staying with the same clinic in the same location. Ms Ang also asked if three generations could enroll to the same doctor as well. This is ideal. But for now, we have to consider the capacity of GPs for the enrolment process, especially early in the roll out of Healthier SG. And we will consider this approach that Ms Ang described as we open up to other age groups. Ms Denise Phua and Mr Gerald Giam also asked about enrolment to polyclinics. They will assign enrolled patients to a regular care team, so that there is one team looking after the resident for continuity of care. Ms Joan Pereira asked if enrolled patients can use branded drugs at their own cost. They can. However, the enhanced CHAS chronic drug subsidies will not apply. The enhanced subsidy tier applies to a targeted list of clinically effective and cost-effective chronic drugs, which will be reviewed regularly. For drugs outside of this list, the current CHAS subsidies will still apply. MOH will announce more details next year, including standard safeguards and reviews to guard against excessive purchases as raised by Mr Gan Thiam Poh. GPs have questions about their remuneration, the design of the annual service fee, will they be penalised if patients refuse to adhere to their health plan and would some GPs be incentivised to cherry-pick patients. They are also concerned about the impact on their business when drug prices are made more comparable with those at the polyclinics. These points were also raised by Dr Lim Wee Kiak and Mr Gan Thiam Poh. Let me first explain how the annual service fee will work.”
“Mr Deputy Speaker, Sir, the Healthier SG strategy focuses on GPs and residents, as we encourage them to develop closer, longstanding relationships to better enable preventive care. Family doctors, General Practitioners (GPs) will play an important role. MOH is supporting GPs to help them on board to Healthier SG. We have consulted GPs extensively about this and I thank them for their time and valuable feedback. GPs are supportive of Healthier SG and agree with the focus on health, not illness. They have raised some concerns and suggestions on how this will be implemented. Several Members of this House have also raised similar concerns and provided suggestions. GPs require support for their enhanced role. We have worked with primary care teams to develop 12 care protocols. These will provide clarity and consistent processes for the GPs and the clusters who will support them. The protocols are on providing screening and vaccination, and managing common chronic conditions like diabetes, hypertension and lipid disorders. This will be a multi-year effort and we will continue to develop more care protocols, such as for mental and dental health. Mr Xie Yao Quan suggested we strengthen the integration between GPs and the healthcare clusters. Our clusters will work closely with the Primary Care Networks (PCNs) to do this, developing clinical programmes for shared care. Ms Janet Ang and Mr Ang Wei Neng asked about the enrolment process. Enrolment is tagged to the clinic, to enable service delivery even when a specific doctor is away or unavailable. After enrolment, residents can still visit other clinics if needed. Residents can also choose to change their enrolled clinic.”
“Sir, I thank Mr Melvin Yong for his question and for his suggestion, which is a good one. We are doing such things. There is a broader question of how to support parents and help them be that right guide, the right set of first influencers for their children. There are a few things that we are doing. The first is a requirement that Internet service providers are required when they offer residential services, to offer residential and mobile Internet filtering services to help parents ensure that children have safe access to the Internet, with several initiatives to provide resources and support to parents – I described one in my original answer. NLB also organises "S.U.R.E. Celebrates Media and Information Literacy" events in October. This provides Singaporeans with skills, how to be discerning when using online information sources and it also includes programmes targeting children, such as the "S.U.R.E. for School". MOE also works with parents – and not just with the children – to provide online resources, parenting kits and articles to give them the skills, knowledge and tools to be able to help guide their children and better manage their children's online habits.”
“Sir, I thank Dr Wan Rizal for the question about the stringency of the processes. Sir, I would reiterate that these processes are part of the healthcare licensee expectations, the regulations that we have for the administration of a wide variety of drugs and vaccines. We will indeed be reviewing this licensee, this clinic, as well as the personnel that are involved. The vast majority of the clinics and vaccine providers do a great job of ensuring that the patients are cared for safely, the vaccines are provided safely, with the correct dosage. And so, I think we have to identify, first of all, whether this is an issue with an individual member or personnel, whether it is something about the processes at the site or whether it is something systemic about the overall vaccination process. All our data, so far, suggests that the last is not likely – the vast majority of our doses have been delivered quite safely. Nevertheless, MOH continues to review all of this.”
“Sir, I thank Mr Gerald Giam for the questions. The patient should be notified as soon as the care provider knows that there is an error. That would be a reasonable expectation because the patient should then be directed for immediate care following on from the error. And that is going to require the informed consent of the patient. They need to know why they are perhaps under observation or required to attend an emergency department. He asked about the penalties for late reporting to MOH. It would depend on the circumstances and reasons, and who it was that perhaps knew, but did not report. So, as the matter is still under investigation, it would be premature for me to comment.”
“In the event of any vaccine administration errors and medical emergencies following vaccination, the vaccination providers are required to report to MOH no later than three hours after the incident. The providers are also required to inform the patients immediately when a vaccination error has occurred, provide appropriate immediate care and then, monitor the patients' health with daily calls for the next seven days to ensure their well-being. In the event of an error, MOH will investigate. And if there are any systemic issues, we will work with the providers to review and improve their work processes. MOH is currently investigating ProHealth Medical Group about the incident on 15 September 2022 and will take appropriate enforcement actions if there are any regulatory breaches. As of 26 September 2022, out of approximately 16 million doses of COVID-19 vaccines administered, there had been 11 persons affected by overdosing and 119 persons affected by underdosing of the vaccinations. Of these, seven were children, aged between five and 11, who did not have any adverse reactions. The adults had either no adverse reactions or recovered uneventfully.”
“Sir, my response will also cover matters raised in Parliamentary Questions filed by Mr Gerald Giam1,2, scheduled for a subsequent Sitting, on 4 October 2022. I invite the Member to seek clarifications today and consider withdrawing his questions if it is adequately answered. Sir, there are professional and statutory requirements for the provision of healthcare. All healthcare professionals are expected to be competent in providing safe and good quality care. Licensees of healthcare institutions also bear a responsibility to ensure that their staff, including part-timers or locums, are properly onboarded and adequately trained to perform the tasks that they are assigned, through establishing appropriate protocols and processes. Professional Boards require that all registered healthcare professionals keep up-to-date on current standards of care and treatment, and participate in Continuing Professional Education (CPE) programmes or activities to renew their Practising Certificates. CPE consists of educational activities that serve to maintain or increase the knowledge, skills and professional performance of healthcare professionals. All COVID-19 vaccination providers under the National Vaccination Programme (NVP) are licensed and regulated by the Ministry of Health (MOH). Specifically, for COVID-19 vaccination, we issued additional regulations to stipulate the prevailing eligibility criteria, the dilution and administration of the recommended dosage for each vaccine, the management of emergencies and incident reporting. Vaccination providers are expected to assess their staff competencies in COVID-19 vaccination administration.”
“Mr Speaker, may I please have your permission to answer Question Nos 10 and 11 on today's Order Paper?”
“Sir, I thank Ms He for her questions. The support for frontline staff, indeed, the support from MOH and IHiS is largely around the communication and providing clear information about what has happened, what are the expected steps taken to restore functionality and how much time will be required. Because, the next set of decisions, which BCPs and processes to implement are done at an operational level, depending on the needs of each team. So, from IHiS and MOH, a lot of the support is around communication. Within the healthcare ecosystem and the clusters, clearly, they mobilised staff, they mobilised the senior staff and the junior staff, everybody had their hands on deck to cope and deal with the outages as well as the extra processes required for the outages. And that includes overtime for some staff, having to work extra hours, and then, consequently, overtime claims as a result of that. And so, the entire team mobilises together to support each other and we provide as much support as we can to help them through this difficult time. Is training provided? Yes, business continuity plans, disaster recovery plans, are drilled regularly in the healthcare units and teams. They are part of standard training for all the healthcare workers that are in our public healthcare sector and the training is updated on a regular basis. This is not something that is standardised in every team and in every unit across the healthcare ecosystem because these are peculiar to the operations and flows within each clinical team. And so, you have standards that are set broadly, expectations that are set, guidance that are set. But then each team will develop the granularity of their business continuity plans and these are then drilled as well.”
“Sir, I thank Dr Tan Wu Meng for the questions. His first question was about the benchmarking of reliability and usability. We do indeed take reference from other parts of the technology industry and healthcare technology industry. There are service level agreements about the uptime availability, as well as the user interface usability for the products that IHiS manages and these are indeed benchmarked against best-in-class around the world. The second question was about the hardware, were there similar issues and what are we doing to look at vulnerabilities, and I think, other vulnerabilities with similar hardware. The bugs that we have detected as part of these incidents have not previously been described before in other parts of the world. The hardware that was involved is used in other parts of Government systems but in relatively limited numbers and they are configured differently. And this is partly because the way in which the Government requires its data flow and its inter-operability, its system architecture, is different from the requirements of the healthcare space. And so, the specific configurations for this type of hardware in the rest of the Government, is not present. But nevertheless, we are working together, the various agencies that are involved in public sector technology – Cyber Security Agency, GovTech, IHiS and others – share information and are looking to scan across the various infrastructure that we have to check on these possibilities.”
“All the firewall hardware involved in the incidents are from the same established device manufacturer. Fixes for some of the issues have been made available and have been deployed. For the others we continue to work with the manufacturer. In the meantime, we have increased capacity in the network for more operational buffer to increase resilience. I thank the Members for their questions. We will continue to review our system design and architecture, and invest in capabilities and readiness to reduce disruptions. Disruptions like this can occur again in the future and we continue to have at the ready back-up systems, downtime procedures and manual processes. Once again, Mr Speaker, allow me to express my thanks to all the personnel of our public healthcare system who kept our patients safe and the services running and for the members of the public who were involved and affected during these days for their patience and understanding as we tried to cope and mitigate the circumstances as best we could.”
“On 27 August, when the engineers tried to restore the two failed nodes, under the supervision of the manufacturer and following the manufacturer's procedures, which had been successfully used in the past, the operation failed. It is this failed operation that caused the cluster of firewall nodes to malfunction and subsequently caused the outage. The engineers worked to reset the systems to the prior state without the function of the two affected nodes and service was progressively restored. The failure of the nodes was caused by bugs in the firmware of the devices. They have since been identified by the manufacturer, CISCO, and the devices have been patched. The outage on 5 September was caused by the simultaneous failure of two further nodes, again from the same manufacturer and of the same model. The way in which this failure on 5 September occurred, was noted to be different from the previous incident, it was assessed that it would take longer to restore operations, and hence, the decision was made to switch operations to the back-up systems. The root cause of why these two nodes failed is still under investigation. There was a suggestion in one of questions from Members that the failures may be due to the lack of manpower at IHiS. IHiS has a headcount of 3,500 personnel. They have a lot to do and will always welcome more manpower, but a lack of manpower was not the cause of these failures. Our cybersecurity specialists are monitoring our network and systems for threats in our public healthcare network at all times. When the network problems occurred, IHiS initiated an investigation and also alerted the Cyber Security Agency. Based on the investigations thus far, there are no indications of security compromise to the affected systems.”