Ong Ye Kung
Singapore
“The Ministry of Health (MOH) recently enhanced the Community Health Assist Scheme (CHAS) dental subsidies, which are tiered by income, for common preventive and restorative procedures.”
“Healthier SG GP clinics may also refer their enrolled patients to Active Ageing Centres and Community Health Posts to fulfill their social prescriptions and for subsidised services, such as medication management.”
“Public hospitals, such as the National University Hospital, the Singapore General Hospital and Tan Tock Seng Hospital, have deployed robotic-assisted surgical (RAS) systems for minimally invasive soft-tissue surgeries.”
“The Health Sciences Authority (HSA) welcomes drug producers to choose Singapore as part of their first-wave filings. As long as a pharmaceutical product is approved by at least one regulatory agency, such as China's National Medical Products Administration (NMPA), it would also qualify for the abridged route.”
“A decrease in estimated glomerular filtration rate in patients with diabetes can be due to multiple reasons. Doctors will first investigate the underlying cause before determining whether the patient should be referred to a specialist. Some causes are reversible and cause transient reduction in renal function.”
“Information on the Lasting Power of Attorney (LPA) cannot be made visible on the National Electronic Health Record system as it is protected under the Mental Capacity Act. Such information may only be disclosed by the Public Guardian to specified persons upon satisfactory submission of evidence(s) required under the law.”
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“Over half of the enrollees have started consulting their chosen doctors to develop a personal Health Plan and they have been rewarded S$20 worth of Healthpoints. More than 124,000 enrollees have received their free vaccinations and health screenings. Over the past year, the number of participants in exercise sessions organised by the Health Promotion Board (HPB) has increased by 16%, from 133,000 to 154,000. For sessions organised by PA, participation has gone up 12%, from about 400,000 to 450,000. For SportSG's sessions, it has increased by 20%, from 117,000 to 140,000. So, we see a discernible increase in people becoming active and individuals are also up and about on their own. The change, I think, is somewhat palpable. This is the new Active Singapore. Ms Ng Ling Ling asked if we expect prevalence rate of chronic illnesses to come down due to Healthier SG. That is certainly our aim. With a strong start to Healthier SG, we certainly hope this will happen. But it will take time. We have recently raised chronic drug subsidies for Healthier SG enrollees seeking care at their Healthier SG GP clinics. In the coming year, we plan to implement further improvements to the scheme. First, expand the range of health protocols. GPs are guided by Healthier SG Protocols, to ensure that residents enjoy consistent and quality care. There are 12 protocols so far, which include screening, vaccination and management of common chronic diseases. MOH will expand the range of protocols to cover more conditions, such as stable ischemic heart diseases and stable stroke. We will start to roll them out in early 2025. As announced earlier, we are also starting to work on including aspects of mental health into the protocols. 12.00 pm Second, we will improve the health plans.”
“These proposed changes will better protect subsidised patients against major health episodes. MediShield Life premiums, however, will inevitably go up. The last time we reviewed the scheme, premiums went up by 25% on average. But, rest assured that we will do the necessary to ensure that, as far as possible, premiums can be paid fully by MediSave. For example, we will consider enhancing premium subsidies, or have MediSave top-ups for specific groups. We may have to use more MediSave for small hospital bills, so that MediShield Life can better focus on big hospital bills, and in that way, we moderate premium increases. No one will lose MediShield Life coverage due to a genuine inability to afford the premiums. We will share more details when the Council completes its review in the second half of this year. Mr Chair, while we address these immediate concerns, we should not lose sight of the longer-term, strategic direction of healthcare. That is, continue to build health and not just treat illnesses. We have crystalised this strategy around Healthier SG. Ms Ng Ling Ling, Mr Yip Hon Weng and Dr Syed Harun asked for an update on Healthier SG. I am very glad to say that it has been progressing encouragingly. Let me report some data. Since the programme was launched in July last year, we have invited 2.4 million Singapore residents, aged 40 and above, to participate. As of last month, 765,000 have enrolled with a family doctor of their choice. Sir, 60% are enrolled with GPs and the remaining with polyclinics. This is a good split, because a key thrust of Healthier SG is to empower our GPs to play a greater role in population health.”
“Hence, we recently reviewed cancer drug financing and introduced changes that will allow us to negotiate for lower prices for cancer drugs. As a result, prices for approved cancer drugs have since dropped significantly, some by up to 60%. The impact is still playing out and we will continue to monitor the situation. Third, the Council will consider expanding MediShield Life coverage to new groundbreaking treatments, specifically Cell, Tissue and Gene Therapy Products (CTGTPs). Medical science is advancing rapidly and CTGTPs have the potential to revolutionise healthcare and deliver effective treatment of previously incurable diseases. Some describe these as the equivalent of a moonshot for healthcare. Essentially, the treatment involved is, we extract blood from a patient, then with the blood, you teach and equip the cells in the blood to target and kill, say, cancer cells, then you put the cells back into the patient's body to do its work. It is a one-time treatment. However, while the technology is promising and advancing fast, it is nascent and very expensive. It could cost anything from a few hundred thousand dollars to a few million dollars, per treatment. We want to start including CTGTPs under MediShield Life. But, we need to put in place safeguards to ensure that financing of CTGTPs is sustainable. For instance, we will need to extend MediShield Life coverage only to treatments that are assessed to be safe, clinically effective and cost effective. In other words, if a treatment costs a few million dollars with a small hope of curing a small group of people, it is not cost effective. This is a significant step to help all Singaporean patients, regardless of their income levels, have access to cost effective, novel, state-of-the-art therapies.”
“And after subsidy and MediShield Life, there is still a substantial out-of-pocket component left. This is when higher healthcare costs really start to bite. MOH has, therefore, tasked our MediShield Life Council – which is from various stakeholders led by a private sector person – to comprehensively review the scheme, but we have given the Council some direction. First, enhance MediShield Life to give Singaporeans greater assurance against large bills. This means increasing how much a patient can claim from MediShield Life – this is what we call claim limits – for both surgeries and hospital stays. We envisage a fairly significant increase in the claim limits. For example, for an episode involving angioplasty where a stent is placed into your heart to open up a blocked artery, plus, say, a few nights in ICU, the claim limits may need to double, times two. This will reduce out-of-pocket costs significantly. Second, enhance other outpatient coverage. We also need to raise the claim limits for treatments, such as kidney dialysis, to reduce out of pocket expenses for patients. The Council will also explore extending coverage to more types of outpatient care. Some of the most costly outpatient treatments are for cancer. Ms Sylvia Lim asked if we could improve financial literacy for patients to better plan against such a disease. There are resources available online and we will raise the public's awareness to them. But I think the issue goes beyond financial literacy. It is actually more serious than that. We are facing an especially difficult challenge for cancer, as treatment costs were rising uncontrollably. So, I am not surprised at the survey results that you cited at all.”
“It is specifically designed for the great majority of subsidised patients who are encountering a major health episode. The last sentence needs some deciphering. It contains a couple of important phrases, which I will explain. I said it covers great majority of subsidised patients, because most Singaporeans seek subsidised care and the "great majority of them" need financial assistance to foot their healthcare bills. Hence, for a C Class Ward patient, he will find that after subsidy, MediShield Life claims should substantially pay for the rest of his hospital bill. For a patient that goes to a private hospital, he will find that MediShield Life covers only a modest part of his hospital bill. That is how MediShield Life is focused on the subsidised patients, especially those that uses C Class wards. Then "a major health episode", because this upholds the spirit of insurance, which is to protect us against rare occasions when we incur a big hospital bill because we fall seriously ill. With that context, let me report the state of MediShield Life today. It was designed such that nine out of 10 subsidised bills are adequately covered. Nine out of 10. What remains are relatively small and expected co-payments, which can be paid from MediSave. However, this nine in 10 benchmark is being eroded, because the size of hospital bills is getting even bigger. Bill sizes have grown by 5% annually in public hospitals and by 7% annually in private hospitals over the last few years. As a result, the proportion of subsidised bills adequately covered by MediShield Life has come down to around eight out of 10 and is expected to slip further. What is the practical impact? Subsidised patients are seeing hospital bills that are unexpectedly large.”
“MediShield Life covers a significant part of the remaining bill after subsidy, but we ensure some co-payment by patients, mostly through MediSave, so that there is less of a buffet syndrome. MediFund comes in for the lowest income who cannot afford the co-payment. This is a key reason why we can achieve good health outcomes with national healthcare spending of 5% of GDP, compared to jurisdictions with blanket assistance schemes. With these two truisms in mind, what can we do and what are we doing about rising healthcare costs? First, let me start with the S, of S+3Ms. Subsidies will have a big role to play. When I first joined the Government in 2015 and entered this House, I was the Acting Minister for Education. The Ministry of Education's (MOE's) budget was the second largest amongst Ministries, at about S$12 billion, and only behind the Ministry of Defence's (MINDEF's). MOH's was the distant third, just over S$9 billion. Today, nine years later, I am now the Minister for Health. MOH's budget has far surpassed MOE's, to almost S$19 billion and not very far behind MINDEF's. MOH's budget is tax-funded. It is channeled to fund many aspects of the healthcare system: build new healthcare infrastructure, operate hospitals, polyclinics and nursing homes, procure medicines and equipment, developing new IT systems, hiring doctors, nurses and all our medical personnel. MOH's budget is tax-funded and constitutes healthcare subsidies, which have been rising significantly over the years. Then, the second M – MediShield Life – will also need to work harder. To this end, we will be conducting a comprehensive review of MediShield Life. MediShield Life, as I mentioned, is a national health insurance scheme. It covers everyone for life, even those with pre-existing illnesses.”
“It continues to be free at the point of delivery. But is it really free? Not really. The British have to pay high taxes to finance the NHS, because there is no cost at the point of healthcare delivery, the waiting times at the NHS are very long. I talked about eight million people waiting. So, British patients are also paying with their time and their patience. There are different ways to pay for healthcare: by taxes, by compulsory social security payments, through insurance premiums or personal savings or your personal time. Ultimately, the people always pay one way or another. That is truism number one. 11.45 am This leads to the second truism, which is how we pay affects how much we pay. If a government uses taxes to make healthcare "free" at the point of delivery, then it will likely lead to the buffet syndrome that I just mentioned. There will be over-consumption, wastage and high-cost inflation. If a government leaves the people to buy their own health insurance, people will tend to be very careful, which can moderate healthcare expenditure. But if someone did not buy insurance and is uninsured, they will be underserved. That is why in Singapore, we weaved together a more robust way to pay for healthcare. It comprises subsidy funded by taxation; MediSave which is own personal savings; MediShield Life which is a national insurance scheme; and MediFund which is the final social safety net – what we termed S+3Ms. S+3Ms ensures universality because it provides all Singaporeans access to quality healthcare. It is also a targeted system, focusing assistance on those who need it the most. To illustrate, subsidies of up to 80% are extended to C Class wards in public hospitals, but not A Class wards, not private hospitals.”
“We all agree we need to compensate our healthcare workers fairly and competitively. As healthcare demands have gone up in many countries, the competition for medical manpower is now international and has become more intense. And this pushed up manpower costs and, therefore, healthcare costs. Finally, insurance. Insurance gives us peace of mind. But when the coverage becomes too generous down to the last dollar, we start to see excessive prescriptions and tests and even unnecessary treatments. This is the classic buffet syndrome, which has driven up claims. Already paid for, might as well overeat. It has driven up claims and, therefore, it has driven up insurance premiums. Yet, it is frustrating to see insurance companies continue to offer unsustainable terms – presumably they are competing for market share. So, how do we address rising healthcare costs? We need to first recognise two truisms in healthcare financing. The first truism is that, ultimately, the people always pay. Let me explain with a personal example. When my wife and I moved to Switzerland for a year for me to do my Master's programme, that was in 1999, we had to make a social security payment. I cannot remember the name, but it was not cheap. A few thousand Swiss francs for the both of us. It was compulsory. If we do not pay, we could not live in Switzerland. Then, we got pregnant. My wife found a good gynaecologist. Each time we visited her, we can just go in and go out. We did not have to pay anything. Was it really free? Not really. We paid for it already, through the rather expensive social security fee. In Britain, the National Health Service (NHS) operates by the principle of free healthcare at the point of delivery. No UK government has ever touched that principle.”
“Over the last five years, the number of Singaporean seniors increased by almost 20%, from 560,000 to 690,000 now. We are on the verge of becoming a super-aged society. These are not macro numbers, it directly affects individuals and families. So, when in a family, one member grows older and falls seriously ill, the entire family feels the burden of healthcare costs and also the caregiving burden. The second reason, advancement in medical technology. Technological advancement can make a car or a smartphone cheaper and better. But in healthcare, it is often not the case. New treatments may work better, but always cost more. For example, advancement in orthopaedic surgeries have made knee replacements much easier to do. In my constituencies, I met many seniors who have gone through knee replacements. Sometimes, they have gone through both and when I meet them – I have gone through one – we end up comparing our battle scars. In the past, people with degenerating blood vessels in their eyes due to old age, they will lose their central vision. Now, the condition can be treated and controlled through repeated intravitral injections. These advancements allow a person who cannot walk, to walk again; allow a person who would have been blind, to see again. The value to the patients is priceless. The cost to the patients has also gone up. Third, healthcare costs inflation. Even for the same treatment, not talking about medical advancement; the same treatment, the cost has gone up. Inflation all around the world has gone up in recent years and that has also affected healthcare costs. A key component of healthcare delivery cost is manpower. In Singapore, manpower is more than half of the cost to run the healthcare system.”
“Germany, also much higher than us in terms of the ratio, is facing a major challenge meeting the healthcare needs of their seniors across their länders or their states. Conversely, Singapore, we are delivering quite good healthcare outcomes. A commonly accepted broad measure is the expected health span and lifespan of our people. In Singapore, a person is expected to live up to 74 years old in good health, one of the highest in the world; compared to 66 in the US; 70 in the UK; 71 to 72 in Germany, France, Denmark, Netherlands, Australia and so forth. Singapore achieved this by spending about 5% of our gross domestic product (GDP) on healthcare, compared to 10% to 13% in most developed countries; 17% in the US. In short, we have better outcomes with less spending and lower hospital beds and doctors-to-population ratios than many OECD countries, because it is not just a numbers game. The quality and the mix of doctors, the geographical spread of the country, how the whole system is run, the behaviour of patients – all makes a big difference. We have a lot of room for improvement, but there is no reason to feel bad about ourselves or to envy others. We are, in fact, in a good place as we continue to learn from others and strive for improvements. Chairman, let me now address the next concern, which is rising healthcare costs. Dr Lim Wee Kiak, Ms Mariam Jaafar and Ms Ng Ling Ling asked, what is driving up healthcare costs? In this section, I will talk about the likely reasons for rising healthcare costs, explain the realities of healthcare financing and then what we are doing to try to moderate costs. A major factor for rising healthcare costs is that we are getting older, and as we get older, we are more likely to fall seriously ill.”
“If, somehow, doctors get registered but do not practise, it does not help. If doctors are practising, but they go into areas like aesthetics, it also does not help very much. In Singapore, graduates from medical schools are already finding it more competitive to get residency positions to be trained as specialists, because there is not much of a shortage in many of these specialist areas. On the other hand, we are facing shortages in areas like family medicine, internal medicine, geriatric medicine and rehabilitation medicine. This is because as Singapore becomes a super-aged society, we have more patients with complex and multiple medical conditions, needing doctors with these more broad-based skillsets. Hence, MOH has been increasing the number of training positions in these specialist areas. We have also seen in many countries, how supply of doctors creates its own demand. As more doctors compete for business, there will be a tendency to prescribe more tests, scans, medications and procedures. Patients are not likely to say no because your health is at stake, and especially if healthcare is free or insurance covers all the costs. Hence, while Mr Ang Wei Neng provided numbers to show that Singapore's doctor-to-population ratio is lower than some Organisation for Economic Co-operation and Development (OECD) countries, this did not translate to poorer health outcomes, less accessibility or affordability in Singapore. For example, we know that the US healthcare system is not the most accessible unless you have the right insurance. The UK's higher doctor-to-population ratio than us, has eight million patients on their waiting lists and is suffering from a chronic capacity crunch.”
“[Please refer to "Clarification by Minister for Health", Official Report, 6 March 2024, Vol 95, Issue 131, Correction By Written Statement section.] Still, more are training to be Allied Health Professionals and nurses. So, we are taking quite a lot of talent. We are also offering awards and grants to actively attract Singaporeans who graduated from overseas medical schools back into the local public healthcare system. Where does Singapore stand, in terms of our doctor to population ratio? Ours, in terms of practising doctors, is about 2.6. Let us put that number into some perspective. Compared to developing countries, we are ahead, we are higher. Compared to developed economies in Asia, we are similar. Korea, Hong Kong and Taiwan are all around 2.6. Japan is also 2.6 and despite having actually aged much earlier than us, with about 30% of their population 65 and older. Then, if you compare to developed Anglo-Saxon countries – the United Kingdom (UK), United States (US), Canada – we are just slightly behind. It is really when we compare to European countries – continental European countries, Australia – that we are a notch behind. Why is that so? I think there are various reasons. It could be a legacy of the welfare state. It could be the fact that European countries do not really have a tradition of planning for manpower. We can explore if further increases are needed, but we have to recognise that talent is in short supply across all sectors. And healthcare, we should attract our fair share, but not disproportionate share of talent. Beyond this fair share, countries can also end up chasing its own tail. Why is that so? For one, it is not a simple numbers game. The right mix of doctors is just as important as the sheer number of doctors.”
“We will also further expand the capacity of MIC@Home, as a first step, from 100 in 2023, to 300 in 2024, with the potential to scale up further. The third change is to encourage telehealth. Sir, 40% of attendances in a typical polyclinic are for chronic care management. Last year, we extended subsidies and allowed the use of MediSave for the use of telehealth, for chronic care. By the second half of this year, we will also expand MediSave coverage to telehealth consults for preventive care services, such as follow-up reviews after regular health screening. This represents another 10% of polyclinic attendances. With this change, telehealth is treated almost the same way as physical consultations in terms of financial support. The only difference is telehealth for common illnesses, that is, when patients experience symptoms, like cough, cold and fever. Patients still cannot use MediSave for such consults for common illnesses. Also for a good reason. We are holding this back as many people have been using such teleconsults as an easy way to get medical certificates (MCs). So, there will need to be greater discipline in issuing MCs before we consider this final move. Another key aspect to expanding capacity is to enhance manpower. Mr Ang Wei Neng and Dr Tan Wu Meng asked if we need to produce more doctors to meet demand. Yes, we have been and will continue to do so. In fact, intakes into our local medical schools have increased by about 30% over the past 10 years, to about 500 now. If you consider each cohort, it is now slightly over 30,000. About half of them, 15,000 or so, 15,000 to 17,000 go to university; and out of that group, 500 are training to be doctors.”
“More broadly, we will also align the community hospital subsidy framework to the acute hospital subsidy framework. It used to be different. That way, patients receive the same subsidy rate, which is 50% to 80% throughout their inpatient stay, regardless of settings. With this enhancement, most community hospital patients will see smaller hospital bills. The second change is to make Mobile Inpatient Care at Home (MIC@Home) a mainstream service. What is MIC@Home? This is a pilot project where we set up virtual hospital beds at the homes of patients, and have doctors and nurses visit them, as if they are in the hospital. Dr Tan Wu Meng, Mr Pritam Singh, Ms Ng Ling Ling and Ms Mariam Jaafar have asked or talked about such a scheme. 11.30 am At the end of last year, more than 2,000 patients have benefited from the scheme. This translates to around 9,000 hospital bed days saved. Having done this for several months, we are convinced that the scheme works well for the patients and has great potential to relieve stress at hospitals. Hence, from April this year, MIC@Home will become a mainstream model of care in our public healthcare institutions. As a result, patients can be assured that they will not pay any more for MIC@Home than they do for acute inpatient care in a public hospital. All our hospitals intend to price MIC@Home similar to, or lower than, a normal hospital ward. Patients will be supported by subsidies, MediShield Life and MediSave, no different from a physical inpatient stay. In response to Assoc Prof Jamus Lim's suggestion, I do not think we therefore need to give an incentive for transition to home care now. It will be better to develop MIC@Home into a well-accepted mainstream mode for acute inpatient care.”
“With our efforts, the number of long-staying patients have come down and these are patients defined as medically stable for discharge but they have been staying in the hospitals while waiting for longer-term care and they have been staying for longer than 21 days. This is what we refer to as long-staying patients. Two years ago, it was about 300 such patients at any one time in our hospital system. Now, it is under 200 patients at any one time and there is still room for improvement. To facilitate appropriate transfers from acute hospitals to community settings, we will also be making a few policy changes, as follows. One, more funding for community hospitals. Acute hospitals have experienced friction in transferring suitable patients to community hospitals. Why? For example, certain diagnostic services, such as computed tomography (CT) and magnetic resonance imaging (MRI) scans and certain more expensive drugs, are not subsidised in community hospitals today. This is based on the consideration that these are recovering patients and they may not need these interventions. Unfortunately, this means operational delays in transferring patients to community hospitals. There are patients who are medically ready to be transferred, but they are just waiting for a follow-up scan. They should be transferred without delay and do the scan at the community hospitals. Others worry that after transfer, what if, unexpectedly, I need a scan for some reason. Hence, they insist on staying in the acute hospital, just in case. To remove this friction, from the last quarter of this year, we will allow more diagnostic services like CT and MRI scans and relevant drugs to be subsidised at community hospitals.”
“In 2026, Sengkang General Hospital and Outram Community Hospital are expected to expand by about 350 beds by converting non-clinical areas into hospital wards. Then in 2027, the Elective Care Centre at Singapore General Hospital (SGH) is expected to open; that has 300 beds. In 2028 and 2029, the redeveloped Alexandra Hospital is expected to open progressively. Then in 2029 and 2030, the new Eastern General Hospital Campus is expected to open progressively. Then we move into the early 2030s, that is when we hope to see the completion of a new regional public hospital that we have started work on. We have just completed one in the North, Woodlands Health. We are building another one in the East. We are expanding SGH in the central region. So, the next new public hospital should be in the West. We are planning to site it in Tengah Town, which is an emerging population centre. It will best complement current hospitals in the West. The new hospital in Tengah will be run by the National University Health System cluster. Mr Ang Wei Neng is nodding his head. Notwithstanding this plan to expand capacity, we should not be trapped in the mindset of "building hospitals" when thinking about capacity. There is potential to better anchor care outside of hospitals, in the community. Not all patients require high acuity care and constant monitoring in a hospital throughout their treatment course. Many need convalescent care and rehabilitation, with the assurance that medical help is readily available nearby. That is why we have built more community hospitals for sub-acute and rehabilitation patients, and Transitional Care Facilities for patients who are waiting for longer-term care arrangements.”
“But please be assured that hospitals will triage patients quickly upon arrival and start treatment for urgent cases, even if the patient is waiting for a bed. Mr Ang Wei Neng raised the issue of Changi General Hospital which was also reported in a Straits Times article. Changi is an old structure. It only has four ambulance bays. [Please refer to "Clarification by Minister for Health", Official Report, 6 March 2024, Vol 95, Issue 131, Correction By Written Statement section.] So, the queue will build up quite fast. But actually, that is not the limiting factor. We can always triage in the ambulances. It is a small problem. What we need to watch out for are Intensive Care Unit (ICU) occupancy, resuscitation occupancy. If those are full, we divert the ambulances. Ambulance bays are full, we can handle. On the surface, it looks bad; but actually, operationally, it is not a huge problem to overcome. Assoc Prof Jamus Lim suggested using more Urgent Care Centres (UCCs). UCCs have been useful and effective. We have also been using the General Practitioner (GP) First scheme, especially around Changi area, and that is also useful, and we will continue to deploy all possible methods to alleviate patient loads at the EDs. To tackle the challenge more fundamentally, we need to expand capacity and catch up with the time lost, due to the COVID-19 pandemic. We opened about 640 new acute and community hospital beds since June last year. They make up the over 11,000 public hospital beds that we have today. That is the stock we have – 11,000. We intend to add another 4,000 beds by 2030. And we should see new capacity coming on stream every year, from now to 2030. Starting this year, and next, in 2024 and 2025, Woodlands Health will commission up to 700 beds.”
“Thank you, Chairman. I will devote a large part of my speech to address two pressing issues for healthcare: one is the hospital capacity crunch; the other is healthcare cost. Then, I will talk about the major transformation that we are bringing about in our healthcare system which will further address these two concerns. Mr Pritam Singh, Mr Ang Wei Neng and Assoc Prof Jamus Lim raised the issue of capacity and waiting times at polyclinics and hospitals. Post-COVID-19, indeed, this is the experience of many countries around the world. Waiting times have gone up all around the world. In Singapore, what is driving up hospital bed occupancy is the increased number of seniors with complex conditions post-COVID-19, and we saw a surge in the numbers. I have reported to the House earlier that average stay in hospital went up from about six days to seven days pre- and post-COVID-19, and that alone represents a 15% increase in patient load. This is happening against the backdrop of a rapidly ageing population, which compounds the problem and makes it a long-term challenge. Mr Singh suggested that we provide dynamic waiting times of emergency departments (EDs) across hospitals publicly, in real time. It is possible, but we have been reluctant to do so, I think for a good reason. Ambulances today already have a process in place to ferry patients needing urgent care to the nearest appropriate hospital for priority treatment. However, at the EDs, 40% of cases are not life-threatening or urgent, but they ended up there anyway. So, our worry is that giving dynamic information may perversely drive more non-urgent cases to hospitals and worsen the overall situation. I know it is very uncomfortable, very unsettling for a patient who is quite unwell to have to wait many hours for a bed.”
“The design of the long-term retention scheme for nurses seeks to encourage them to build a lifelong career in nursing in the publicly-funded healthcare system. When the scheme starts in September 2024, we will start accumulating the year count of nurses on the scheme. If a nurse resigns, this will be considered an exit. If the nurse rejoins the public system in future, the nurse's previous years on the scheme can be reinstated regardless of the reasons for leaving.”
“Across the requested age bands, the attrition rates of doctors from the public hospitals who have left the public healthcare sector are provided in Table 1 below.”
“From 2018 to 2022, the proportion of women who sought Assisted Reproductive Technology (ART) treatment choosing private AR centres had increased. Majority continues to seek treatment at public clinics.”
“My response will also cover the matters raised in the Oral Question filed by Mr Xie Yao Quan for a subsequent Sitting. [Please refer to "Savings Scheme to Pool Undisbursed Payouts from Nurses Retention Scheme", Official Report, 5 March 2024, Vol 95, Issue 130, Oral Answers to Questions section.] The Award for Nurses' Grace, Excellence and Loyalty (ANGEL) scheme will be funded through employers’ contributions for each year that a nurse remains in service. However, unlike that for uniformed SAF officers, ANGEL is not designed as a long-term savings scheme where payout is awarded only when the officer retires. Instead, it is a retention scheme, where typically $100,000 will be awarded to nurses over four regular payout milestones across a 20-year service period up to prevailing retirement age. Hence, while the funds are centrally managed through the Ministry of Health (MOH), there is a limit to which the deposits can be deployed for investments for a long horizon. MOH will continue to regularly monitor and review the competitiveness of nursing salaries in the public healthcare system, including the quantum of annual ANGEL deposits, to ensure that the package as a whole remains competitive.”
“Community care sector manpower grew by some 9% per annum between 2018 and 2022. The Ministry of Health and our agencies provide funding support for a suite of initiatives to attract, develop and retain workers in the community care sector. For example, the Senior Management Associate Scheme facilitates the training and induction of mid-career professionals, managers, executives and technicians to join the sector as centre managers and operations directors. We also ensure that our current workforce is future-ready through training and development programmes and provide subsidies, such as the Community Care Training Grant. We have also worked with community care organisations (CCOs) to redesign CCO job roles to elevate community care careers and improve their attractiveness.”
“Table 1 below shows the average charges for counselling at public Assisted Reproduction (AR) centres for couples before they undergo Assisted Reproduction Technology (ART) treatment for the first time.”
“The Ministry of Health (MOH) monitors infectious diseases threats through collaboration with international counterparts and partners, horizon scanning and risk assessment. Locally, MOH monitors disease trends, including for tuberculosis (TB), through reporting of diseases by healthcare professionals and laboratories and sentinel sites. Since COVID-19 pandemic, we work with the National Environment Agency to deploy wastewater testing as a permanent and regular mode for disease surveillance. Our response to the spread of infectious diseases is tailored based on the circumstances, including their transmission mode and severity. For example, in the case of TB, it spreads through prolonged close contact. We will therefore conduct contact investigations to identify persons with close and prolonged contact with infectious TB cases. Such persons are screened for TB and treated, if found to have active TB disease or latent TB infection. This is a tried and tested way to reduce transmission of TB. New technologies and methods are continuously adopted to complement and improve our surveillance systems. We will continue to improve our current systems by leveraging new IT and analytic tools to generate insights from various surveillance data.”
“Currently, the national blood inventory for all blood types is at a healthy level. The Health Sciences Authority (HSA) has been taking proactive measures to maintain the blood supply at a level that can meet the national blood demand. These include organising more group donations, sending SMSes to blood donors of specific blood groups to donate when inventory falls and using social media messages to encourage more blood donations. As for rare blood types, HSA maintains a registry of suitable donors and may freeze the donated blood and thaw them for use as necessary. HSA has in place contingency plans and emergency preparedness protocols, as part of the National Blood Programme, to respond to emergencies and to meet blood demand surge.”
“Phenylephrine is used in non-prescription cold and cough medicines. It has been used for many decades in many countries, including Singapore, without any significant safety concerns. The Health Sciences Authority (HSA) is currently reviewing the data on the effectiveness of phenylephrine and its relevance in the Singapore context. We note that the US Food and Drug Administration has yet to make a final decision despite the recommendation from its advisory committee. HSA will update members of the public if any significant regulatory action is taken.”
“The salary guidelines for the community care sector were developed following consultations with public sector healthcare leaders and community care organisations. The published job banding and salary points are specifically for community care settings such as nursing homes, eldercare centres and hospices.”
“The Ministry of Health (MOH) does not track how long patients wait when attending outpatient appointments at public hospitals. Instead, MOH tracks wait times to the date of the appointment as an indicator of accessibility to Assisted Reproductive treatment. This is a more meaningful indicator as almost all patients seeking this treatment are on appointments.”
“The total intake for nursing programmes offered in our Institutes of Higher Learning (IHLs) was about 2,100 in Academic Year (AY)2022 – comprising 1,300 students from the polytechnics, 500 from the Institutes of Technical Education and 300 from the National University of Singapore. The total intake increased by about 100 students in AY2023. Based on the 2022 Graduate Employment Survey (GES) conducted by the IHLs, approximately 90% of the nursing graduates who were in full-time permanent employment within six months of graduation, practised nursing. The 2023 GES data for nursing graduates is currently not available.”
“For inquiry hearings relating to professional matters, the Nurses and Midwives Act 1999 and the Nurses and Midwives Regulations 2012 do not specify the position on representation by designated officers of the trade union whom the nurses are members of. They do provide that the nurse may appear for an inquiry hearing in person or be represented by his or her legal counsel.”
“The current penalties for sellers of illegal products are a fine of up to $100,000 and/or up to three years imprisonment under the Health Products Act. This is higher than previous penalties of up to $5,000 and/or up to two years imprisonment under the Medicines Act back in 2007. To enforce against such violations, the Health Sciences Authority (HSA) conducts surveillance, collects intelligence on illegal activities and employs an e-commerce surveillance tool to proactively scan listings on major local e-commerce platforms to detect and remove illegal health products from online marketplaces. In 2023, approximately 14% of illegal health product listings on major local e-commerce platforms were by overseas sellers. While HSA does not have extra-territorial powers, it works closely with the local platforms to remove these product listings. HSA also actively participates in international operations and exchanges information with overseas enforcement counterparts for them to take actions. In 2023, HSA participated in two international operations led by INTERPOL targeting illegal health product sales and removed a total of over 7,000 online listings.”
“Joint pain, or arthralgia, is a symptom that can be associated with many conditions, such as infections, for example, dengue, injury, gout and menopause. The Ministry does not track the number of women in Singapore suffering from joint pain. The KK Women's and Children's Hospital and National University Hospital have been involved in media outreach efforts to raise awareness of menopause and its associated symptoms, including arthralgia. The Ministry will await data from future studies to better inform our model of care for menopausal women, such as an upcoming clinical study by the Integrated Women's Health Programme, to explore whether curated exercises and estrogen therapy can alleviate the symptoms of menopausal arthralgia.”
“We do not have the data requested by the Member. However, based on data from the Health Sciences Authority, between 2019 and 2023, for the offences of purchase, use or possession of e-vaporisers, there were 813 repeat offenders under 18 years old. This made up 25% of the number of offenders under 18 years old. The Health Promotion Board works closely with the Ministry of Education, schools and institutes of higher learning on preventive education and providing nicotine cessation support for youths. These programmes include QuitLine and tele-counselling services, as well as onsite counselling through Student Health Advisors. During these sessions, youths learn about the detrimental effects of smoking and vaping, and pick up strategies to quit and manage withdrawal symptoms. In 2023, about 2,350 youths received smoking and vaping cessation counselling from these programmes, of which 38% have either reduced or quit smoking and/or vaping after a one-month post-counselling.”
“The Ministry of Health does not have specific data on the current number of organisations in Singapore that have programmes and benefits for female workers who are experiencing menopause-related health issues. Nonetheless, there are several sources of support for women undergoing menopause, such as public educational resources available on HealthHub and public healthcare institutions' webpages. Additionally, interest groups, such as Dynamic Daisies under KK Women's and Children's Hospital, promote awareness of general women's health and support for women undergoing menopause transitions. Women may also seek medical advice from their regular family doctor or gynaecologist to manage their menopause-related health issues.”
“The Ministry of Health does not track the number of female Singapore Citizens who have received menopausal hormonal treatment. All Singaporeans who are referred to public Specialist Outpatient Clinics from appropriate referral sources and who are assessed to require menopausal hormonal treatment are eligible for subsidies.”
“In 2022 and 2023, close to 4,700 Singapore Citizens and Permanent Residents made MediSave Care withdrawals from either their own accounts, their spouse’s or a combination of both. Of these, around 120 withdrawals were made solely from a spouse’s account.”
“There are more than 1,300 general practitioner (GP) clinics in Singapore, which are on the Community Health Assistance Scheme (CHAS) and where Singapore Citizens can enjoy subsidies when receiving medical care. Currently, about 500 CHAS GP clinics operate after-office hours, with 20 operating 24 hours. Extended operating hours is however a business decision made by the private GP clinics and not a Ministry of Health (MOH) planning parameter. Residents in need of affordable and accessible services may search for clinics via https://www.chas.sg/clinic-locator for clinics near them and the clinics’ opening hours.”
“All Assisted Reproduction (AR) centres are required to provide couples with key information on the AR procedure, such as estimated costs, success rates and procedural risks. It is mandatory for all AR centres to ask couples if they would like to receive psychosocial counselling prior to and during any AR procedure and refer couples for such counselling should the couple request or if the AR practitioners assess so. This is to help couples be mentally and emotionally prepared for the AR procedure. The psychosocial counselling will be tailored to each couple’s unique situation and may include topics such as coping with stress and anxiety and managing expectations from AR procedure. The Ministry of Health does not track the mean number of psychosocial counselling sessions that couples attend.”
“To promote vaccinations under the National Adult Immunisation Schedule (NAIS), the Ministry of Health (MOH) has been conducting public education campaigns, sending targeted SMS messages to recommended groups, and enhancing subsidies for vaccinations. Under Healthier SG, vaccinations under NAIS are now made free to enrolled residents. In recent months, we have seen a significant increase in vaccination take-up rates. From January to November 2023, more than 277,000 flu vaccinations were administered to persons aged 65 years and above, 150% and 50% higher than the numbers in the preceding two years. MOH will continue to monitor uptake rates and review our vaccination policy where necessary.”
“The Ministry of Health reviews all our legislation regularly, to ensure that they remain adequate to serve the public interest. The Member may wish to give us any specific feedback on the Act's operation. The Mental Health (Care and Treatment) Act allows for the admission and detention of any person, who is suffering from a mental disorder and who may be at risk of self-harm or causing harm to others, in a designated psychiatric institution for mandatory psychiatric assessment and treatment. Patients admitted in accordance with the Act will be supported by a multidisciplinary team comprising of doctors, nurses, occupational therapists, psychologists and counsellors. Safeguards are in place to ensure the proper care and treatment of the patient in the institution. For instance, regular inspections are conducted by Appointed Visitors, which comprise of lay persons and doctors, who are not staff of the psychiatric institution, to review the care and well-being of the patient. Upon discharge from the Act, the patient will continue to have regular outpatient appointments and may be followed up by Community Mental Health Teams. The patient will also be supported for reintegration into the community and referred to community-based resources for employment needs – for example, assistance from employment support agencies which provide customised training for jobseekers with mental health conditions and pair jobseekers with suitable employers to ensure a meaningful employment outcome.”
“In this incident, the former nurse allegedly obtained banking details of patients under his care through unauthorised access to their phones and, thereafter, committed various offences by using the information obtained. He was dismissed after he was discovered and recently charged in court. To date, there has been no evidence of breach in the hospital's IT systems. Our public healthcare institutions (PHIs) take a serious view of the security of patients' personal belongings and have in place measures to help ensure their protection. These include the provision of secured storage facilities, the installation of surveillance cameras in public areas and the deployment of trained security personnel, to enhance security within hospital wards. PHIs will not hesitate to take strict disciplinary action against any personnel who illegally access patients' belongings or report them to the police.”
“Government-funded nursing homes do not determine admissions based on the patients’ Monthly Per Capita Household Income. They admit patients with care needs as long as there are available beds.”
“The Ministry of Health (MOH) monitors the data, including breakdown between men and women, for nationally recommended health screening. But we have no plans to do for fertility screening. Nationally recommended screening are done mostly for chronic diseases such as diabetes, hypertension, high cholesterol and some cancers, because evidence supports screening of the general population for early detection and intervention to prevent disease progression. It is therefore important that MOH tracks screening participation to inform screening policies. On the other hand, fertility assessments are individualised to the couple, depending on their specific circumstances. For many couples, fertility issues are mainly due to their age. There is no evidence to support fertility for the general population. Hence, couples should seek medical advice from polyclinics, general practitioners or fertility specialists if the woman is below 35 years old and have tried to conceive for a year, or if the woman is above 35 years old and have tried to conceive for six months.”
“The National Tuberculosis (TB) Programme has been using Whole Genome Sequencing (WGS) since 2020. WGS has enabled comprehensive analysis of the genetic make-up of the TB bacteria and precise identification of related cases. It is through such techniques that we could identify the Bukit Merah and other clusters in Singapore. The control of TB does not rely solely on contact tracing and cluster detection. It is important that persons with symptoms of TB, such as prolonged cough for more than three weeks, seek early medical assessment to ensure prompt diagnosis and treatment of TB. None of the cases in the current cluster at Bukit Merah have any evidence of multi-drug resistant TB.”
“The first question on leadership and culture, I fully agree. Ultimately, that is the soul of the organisation. Without the right leadership, right culture, it will not serve our purpose. As to what incentives there can be, I personally think it is difficult to have incentives or schemes that will ensure you have the right culture. That is fundamentally inherent in the soul of the organisation, but having said that, I think rules, regulations do matter. Which is why I mentioned just now that we want to be singularly licensed. We put in other quality factors such as: primarily for Singaporeans; affordability, which will be measured in terms of bill sizes; as well as value-based care, how you intend to do value-based care. All these will be taken into account as we had put put in the tender and as we evaluate interested bidders. As to why we did not think about the model earlier, I think there are practical considerations. We have been expanding our public healthcare and hospitals, and there is a need for manpower, for doctors. As the Member knows, doctors and surgeons take time to develop and to mature and to be good in their skills. The resource, in terms of manpower and talent, is limited. If we over push this, we can end up having a bidding war of our healthcare professionals and talent, which is why we are always careful as we develop our healthcare capacity. Having said that, between now and end of the decade, we are developing and building more public hospitals. In addition, we think we can, we should be able to accommodate one more more affordable private hospital.”
“This is good in the sense that it is a demonstration of the public’s confidence in public hospitals, but it is not so positive because it adds considerable load to the public healthcare system. We are better off with a variegated system, where residents who are well-insured with private policies, have less need for subsidies, can opt for a lower-cost private hospital care if they wish to. Private hospitals will also bring new insights and ideas to the management and delivery of healthcare. The additional diversity will enrich and improve the quality of our healthcare system. MOH has received good responses from various professionals and the industry after our invitation for consultation. I prefer not to make any pre-judgements on the constraints or success factors on this new private hospital model. I am sure we will receive many useful inputs and suggestions on how to help us improve and refine our model, and make it a success.”
“The various professionals – specialists, surgeons, general physicians, pharmacists, rehabilitation professionals – will have to work closer as a team to serve the patients. Third, cost-effective care – we intend to impose bill size restrictions on the private hospital as we do not want a high-cost care model. We intend to specify these as conditions that potential hospital operators will have to meet and will be evaluated on. This means that land price will not be the sole criterion in determining the hospital operator. Why do we want to establish a new private hospital model with these key features? The main reason is that it provides a better range of options in our healthcare landscape. Today, we have public healthcare which is heavily subsidised by the Government and which we try to make as affordable to Singaporeans as possible. But the nature of subsidised care is there is a wait time, which can be quite lengthy for non-urgent electives. The public healthcare system is complemented by private healthcare services, where we have a range of hospitals. Most are quite high in cost and you need to be able to afford or be well-insured to access them, with little or no wait time. There are a few private hospitals that are lower in cost, such as Mount Alvernia, some say maybe Raffles Hospital. MOH’s view is that we can increase options for lower-cost private hospitals so that private healthcare better complements public healthcare and we have a more adequate range of options for Singaporeans. About 10 years ago, the share between public and private hospital workload was 85:15. Today, it has shifted to 90:10 and the ratio continues to move towards the public hospitals.”
“Mr Speaker, Sir, let me first give some background on not-for-profit hospitals. Not-for-profit hospitals are common around the world, such as in the United States (US), Netherlands, Japan, Korea. It does not mean that they operate at a loss. In fact, all hospitals need to be financially viable, or they will have to close at some point. A well-run not-for-profit hospital is sustainable in its operations, but do not distribute dividends to its shareholders. Instead, it ploughs back its profit to improve hospital services and facilities, and other activities such as charity. There are various reasons why hospitals would run as not-for-profit organisations. The key ones are that it is more in line with the public health mission of hospitals and it helps them access philanthropic funds. Apart from that, there are no major inherent differences in the way good for-profit and not-for-profit hospitals are run, in terms of quality of care, attention to value-based care, talent recruitment, development and so on. We see those qualities in Mount Alvernia Hospital, the only private, not-for-profit hospital in Singapore. The Ministry of Health (MOH) is consulting the industry to establish a next private hospital. Much attention has been given to the proposed not-for-profit feature, but actually, that is not the key feature. Instead, we think the more important features are: First, the hospital is required to serve primarily Singaporeans. Second, there will be stronger governance – it will be singularly licensed, that is, it will only have one healthcare licence, which means that the hospital operator needs to have strong oversight and control of its doctors’ clinical practices.”
“Takeda has withdrawn the application to register its dengue vaccine in Singapore following a review by the Health Sciences Authority (HSA) on its submitted scientific data. We note that the vaccine’s application was also withdrawn in the United States. At this point in time, there is no other application for registration of dengue vaccine to HSA. The Ministry of Health will continue to monitor the development of dengue vaccines as part of a multi-pronged approach to dengue control in Singapore.”