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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“The number of new students per cohort, in every cohort, one in 20 chose healthcare and the majority are nurses. A great majority choose nursing. So, it is not a sector which people are avoiding. People want to join. I cannot wish for more. If you look at 20 students, I know one is joining MOH and our healthcare system. If we keep our intake and the cohort sizes start to shrink, it is starting to shrink, it may well go up beyond one in 20. So, we are getting our fair share, but we need to beef up to replace and expand our foreign nursing workforce. It is a competitive market out there. I do not want to describe in too much details what are the techniques that we are using, but I think Singapore is a fairly attractive place to many nurses out there. Similarly, as it is attractive to many of our young students, they want to join healthcare. I think what the attraction is: we are a safe city to live in and in joining our system, there is a career pathway and there is very good training. By and large, except for the very small minority, it is a well-respected profession. 5.00 pm”
“This is an important subject. I would say, particularly, Members of Parliament such as Mr Ng who come into contact with healthcare workers, you would hear a lot more feedback that is more stark. I think the pandemic has something to do with it. In these three years, really, the workload has been relentless. We know what they have been through. We have to support them fully. In terms of attrition, I should correct some misperception that we are losing doctors, that we are losing local nurses. Actually, the attrition of doctors and local nurses has been stable throughout the pandemic, despite the very hard, very heavy workload. What we have lost is foreign nurses. I think from 7%, 8% or 9%, which was at steady state, it jumped to 14% during the pandemic. That is because many countries were desperate for nurses and we lost foreign nurses because of that. So, in hospitals, in certain wards and the emergency departments, these are sometimes shorthanded – the answer is yes. As I mentioned, this is the main issue. We can set rest days, enforce rest time and all that, but we know our nurses. When there are patients, they will take care of them, even though it is their rest time. I think the best way to support them would be to beef up the manpower. We are not just replacing. We are planning to expand. As I mentioned just now, from 49,000, we want to increase to 69,000 by 2030. If you plot and interpolate the numbers, in between, we do need to expand the manpower. And the work has started. In terms of local recruitment, Senior Parliamentary Secretary Rahayu has mentioned a lot of things we are doing. I should say healthcare is an attractive sector for many young people.”
“I am sorry, I do not recall the care force proposal. If it is meant to be some form of "national service" for women, I think you need to pose this to the Ministry of Defence. For MOH, if we really expand AACs into a ubiquitous support system for our aged and seniors and to be able to befriend them, engage them in activities, teach them digital literacy, teach them how to use HealthHub, how to use Healthy 365, monitor their vital signs, I think we need a lot of volunteers, just befriending. In my own constituency, we are trying very hard to recruit such a care force. You do not require a lot of medical training. In fact, you require a lot of heart and to be able to commit a morning every month during the weekend – every week is better – and just have enough hands and legs; and I think we can do a lot more for our seniors in the community.”
“On telehealth, the short answer is, so long as it is appropriate, efficacious, we would like to extend the support. The Member mentioned remote vital signs monitoring. These are free. If you have the remote apparatus, you can monitor without charge. But if it involves consultation, whether by phone, by video, these are efficacious interventions and they should be covered. What we want is to bring telehealth in, to normalise the funding and support for telehealth, but there is a range of practices. Dr Tan Yia Swam also mentioned there are so many different kinds; and some will claim to be efficacious, but they are not. So, I think we also need a gateway system to make sure that the legitimate ones, useful ones, we support; but keeping out the not useful or even detrimental ones. On the expansion of AACs, we are on the same page. We want to expand quickly as we can. I mentioned and I have alluded to the possibility that this may become a significant national programme. So, give us some time. I am in a hurry. As I mentioned, we are racing against time. The pace of ageing is fast. In the community, we can see in a matter of months, how some of our residents become frail. They do need the support near their homes, in the neighbourhoods, to keep them active, healthy, give them friends. So, I hope I can give an update very soon.”
“Today, we have, through the crisis of COVID-19 and all that we, as a nation, have learnt in overcoming it, a powerful impetus to act – decisively, with resolve and extraordinary will, to see us through this necessary transformation. And if it is true that politics is medicine on a larger scale, we in this House have the duty to ensure that we, our families and fellow Singaporeans will enjoy good health for generations to come. I ask for your support. [Applause.]”
“Because eating well, exercise and so on takes effort, sacrifice, perseverance, the rewards happen gradually and later, and they deny the all-too-human need for instant gratification. Hence, our public policies need to recognise the positive externalities of this spectrum of medicine and overcome and compensate for this hesitancy in order to maximise social good. This is the driving force behind the healthcare transformation that we are witnessing. So, through Healthier SG, we have decided to make preventive care like nationally recommended health screenings and vaccinations to be like public parks and libraries – all over and free. We need to invest in infrastructure and systems that keep people healthy, just as we do for public transport and clean water. We cannot sweat those minority of abuse cases and let them dictate the overall design of our preventive care system, just like how we design the vaccination system during the COVID-19 pandemic. We need to mobilise the support of communities and partners to deliver preventive care well, similar to how we say it takes a village to raise our children. We need every individual to play a part in health and assume personal responsibility, just like national defence. It is a new realm of thinking in healthcare policy, but the considerations are not at all unfamiliar in public policy-making. Mr Chairman, our healthcare system has always reflected the face of Singapore. In the 1960s, we had a lean, cost-efficient system suited to a mainly young and vigorous people. Today, we need a more mature and multifaceted healthcare system, three systems in fact – spanning frontier, biological and social sciences – so as to provide for the more complex needs and opportunities of an ageing population.”
“We have to ensure that standard clinical practices and healthcare policies do not run ahead of the evidence of clinical benefit and cost-effectiveness. And that is one end of medical science. In the broad middle, medicine is a biological science. This is where medicine finds wide applications in the treatment of diseases. It is the heartbeat of our acute care system. It has improved lives all over the world. 3.15 pm When people unfortunately fall sick, hospitals do their best to treat them. Safety nets are set up to try to make healthcare costs affordable. But make no mistake, we do not like sickness and all countries in the world hope that demand for medical care is as low as possible. Therefore, the system must be designed with an emphasis on personal responsibility, to ensure prudence and discipline in spending on sickness. And that is why co-payment of medical bills and insurance payouts remain an important principle of our system. Then, there is the other end of the spectrum. Here, medicine comprises of relatively simple and general interventions that apply to entire populations – adequate sleep, eat healthily, exercise regularly, do not smoke, do not doctor-hop, go for periodic screenings and vaccinations. Unlike medicine in hospitals where we wish for less, we want more of such socially good medicine that enhances health, well-being and productivity. As Rudolf Virchow, the father of modern pathology and social medicine famously said in 1848, "medicine is a social science, and politics (is)…medicine at a larger scale". But this is, of course, back in 1848. However, while the benefits are significant in this spectrum, many people are unable to bring themselves to do these simple things that make us healthier.”
“If all goes well, we expect to incorporate such an arrangement into our mainstream healthcare system next year. I hope that the Government, businesses, community and the people can work together to reform our healthcare system, change our views towards ageing and to help our seniors to enjoy a fulfilling, happy and peaceful golden age. (In English): Mr Chairman, let me conclude by addressing Mr Henry Kwek's question on longevity science. The Geriatric Education and Research Institute and the Centre for Healthy Longevity as well as other similar centres, they are doing very good work. In the transformation of healthcare, we are dealing with much broader and much more fundamental questions. They are: what is medical science? How does it translate into public policy? I think the definition of medical science lies on a spectrum. At one end, medicine is a frontier science. As a matter of life and death, it attracts a lot of R&D, including very exciting work on human longevity. Some of the advances sounds like science fiction. Today, you can 3D print body replacement parts, you can teach yourselves to fight a disease, you can edit genes to treat cancer. Many medical moon shots have been fired. But we need to exercise caution when translating medicine as a frontier science, no matter how promising and exciting, into public health policy. Emerging treatments usually work for exceptional cases. While these get reported in the media, they usually are not suitable for the majority of patients. Furthermore, they are, by nature, very expensive. So, if we are not wise or careful in the development of frontier medical science, the country can end up paying a lot, including wiping out savings of many people, for very little good outcomes.”
“They go to the centre for one or two days a week and prepare some food to serve the seniors living nearby. They work together – some cut meat, some clean beansprouts, some do the cooking and some do the plating. Once they eat together, they start to make friends and become good neighbours. Afterwards, they start to take care of one another and watch out for one another's health. The operation of a place like "独一无二" relies on donations from kind-hearted donors. The Government will consider how to fund such programmes, so that they can spread across the whole island. Third, we will make changes to the MediSave policy. Currently, some senior Singaporeans who are wheelchair-bound or bedridden have to seek home medical care. But under the current policy, MediSave cannot be used for home medical care. In the second half of this year, we will adjust the policy, so that this group of patients can use MediSave for home medical care to reduce their medical burden. The fourth point is more sensitive, which is end-of-life arrangement or hospice care. Many people avoid this topic. They think it is inauspicious and see it as taboo. But surveys conducted in recent years show that many Singaporeans prefer to pass on at home, in the company of their loved ones. In order to fulfil the wishes of Singaporeans in this area, we need to work harder. Next, we will work together with palliative care provider Dover Park Hospice and their close partner, TTSH, to conduct a pilot programme. Under the pilot, we will provide more grants and subsidies. To encourage these operators to expand their services, we will also allow them to determine the type of palliative care to deliver to the patients based on their care needs, as well as the family circumstances.”
“Staying healthy is our own responsibility, but the Government will also have policies to take care of the elderly. Let me briefly explain some of the key policies that we have in place. First, MOH is working on the Healthier SG programme, which will be launched soon. Starting from July this year, we will invite Singaporeans aged 60 and above to enrol into the programme. They can choose a family doctor to be their long-term health partner. The first consultation will be free-of-charge. After the first consultation, the Government will provide an award worth $20. Subsequently, annual vaccination and health screening as recommended by MOH will also be free-of-charge. MOH will work with community centres and grassroots organisations to help with the enrolment. Second, we will try our best to let our seniors to age in the community that they are familiar with. As we enter the golden years, the biggest fear is not diseases, but loneliness and isolation. Once the seniors lose the companionship, care and love of their friends and family, their health will deteriorate and their bodies will become frail. Ageing in place – with the companionship of family members, neighbours, friends and community volunteers – seniors can stay healthy or even reverse their frailness. This is an attainable vision, but not one that can be achieved by MOH alone. Fortunately, we have many community partners that provide care services in our housing estates and build precious relationships with the residents. Recently, I visited a cafe in Marine Parade. The cafe has a unique name. It is called "独一无二" because the cafe is located at the void deck of block 52. It belongs to Montfort Care’s AAC. The volunteers who help out in the centre are seniors themselves.”
“However, for the great majority of Singaporeans who are healthy, the best way to keep healthcare costs low is to stay healthy. This is another reason why Healthier SG and ageing in communities are the two top priorities now. Mr Chairman, in Mandarin, please. (In Mandarin): [Please refer to Vernacular Speech.] I believe all of us have noticed that Singapore's population is ageing rapidly. There are more and more seniors in our neighbourhood. The burden on the society, family, healthcare system and our national finances will become heavier as well. Population ageing is an inevitable trend, but this does not mean that our hands are tied or that we have to give in. We cannot reverse the demographic change but we can change our views towards age. Many seniors who are above 65 may be old in age, but are young at heart. Recently, I met an auntie when I was doing a walk-about in my constituency. She said to me amicably, "Minister Ong, you are so young. I am almost 90 but you are only 60 plus.” I replied, "Auntie, actually I am only 53!" Auntie said, without a trace of embarrassment: "Uh, nowadays whether you are in your 50s or 60s, you all look the same!" I thought about it later. Indeed, the auntie was spot on. My grandmother passed on in her 50s. I have never met her. My grandfather passed on in his 60s. In my memory, he looked haggard and old. But now, many uncles and aunties in their 60s are still very active and do not look any older than me. As the quality of life improves, the life expectancy of Singaporeans has been increasing as well. What age is considered old? The best response is to take care of your health. If you can do this, you can refuse to admit that you are old.”
“They provide three modes of palliative care – at home, in day hospice or in the inpatient hospice. They have also been raising significant amount of charity dollars every year to complement Government funding to support their operations. However, their capacities are heavily utilised. To unlock their capacity constraints, hospices will need additional resources. At the same time, instead of having three funding formulas and three funding streams for different hospice settings – home, day, inpatient – we can bundle them into one per patient funding rate, set it at an adequate level and then empower the hospice to decide which settings are most suitable, depending on the care needs of the patients, and also their family circumstances. We will pilot this new approach with Dover Park Hospice, which is working closely with TTSH. We will grant them more resources through a new bundled-per-patient funding rate and we will learn from the pilot, review the arrangements, with a view to mainstream the scheme next year. Let me end this section with some comments on questions raised healthcare costs, posed by Dr Lim Wee Kiak and Mr Xie Yao Quan. Healthcare inflation in 2021 is 1.1%, 2022 is 2.2%, and this is calculated post-subsidies and significantly lower than general inflation in both years. We will continue to keep healthcare costs affordable through our S+3Ms framework. Low-income Singaporeans, in particular, can be assured that additional financial assistance will be available to you, if you need them. We will also extend financial assistance. This is a question raised by Mr Xie Yao Quan. We will extend financial assistance on a case-by-case basis to needy PRs, especially those with a strong nexus to Singaporeans.”
“Doctors too, can now leverage technology to attend and care for more patients. To support and encourage the use of telehealth during the pandemic, we extended usage of MediSave and CHAS Chronic subsidies for teleconsultations for chronic disease management. And this policy was meant to be time-bound, effective only during the period of the pandemic. Now that we are in Disease Outbreak Response System Condition (DORSCON) Green, we will not lapse it because telehealth has become widely accepted and has demonstrated to be effective. Hence, we have decided to continue the pandemic arrangement and normalise the use of appropriate telehealth and make it part of routine chronic disease management. Third thing, stronger support for palliative care. Mr Yip Hon Weng and Mr Xie Yao Quan have asked about this. Survey findings consistently show that the great majority of Singaporeans prefer to pass on at home, in familiar surroundings, in the presence of loved ones, instead of an unfamiliar hospital surrounding. However, currently three in five deaths still happen in hospitals. We have a long way to go in fulfilling the wishes of Singaporeans. Hence, we are improving the clinical protocols in the hospitals. We are upskilling providers to develop general palliative care capabilities. We are engaging in early conversations with patients and their loved ones on their wishes. Later this year, MOH will be embarking on an outreach effort, to encourage more Singaporeans to plan ahead with a Lasting Power of Attorney (LPA) and Advance Care Plan (ACP). But we also need to work on expanding the capacity of the palliative care sector. Community palliative care providers – namely HCA, Assisi, Dover Park – they have been doing a tremendous job.”
“But this will take some time. It is a complicated issue. In the meantime, we will make three smaller, no-regrets moves. First, MediSave claims for home care. Dr Tan Wu Meng has told the story of Ah Ma twice – once during the White Paper on Healthier SG and once just a couple of hours ago. He put up a compelling case on why financing schemes need to be premises-neutral – to support patients like Ah Ma, who is immobile, homebound and finds it challenging to visit the polyclinic or the hospitals and, therefore, they have to rely on home care. Hence, in the second half of this year, we will extend the use of MediSave to homebound patients receiving home medical care. They will be able to tap on the MediSave500/700 and Flexi-MediSave schemes. As a start, this will apply to 25 home medical and home nursing providers that are receiving subvention and support from MOH. Collectively, they serve close to 10,000 patients. When the scheme stabilises, we will consider extending to the rest of the service providers. Dr Tan Wu Meng also suggested allowing patients to take their blood tests at polyclinics before their surgery and to standardise their forms. We will look into that, but we are mindful not to add further workload to the polyclinics, especially with Healthier SG coming onstream and they are extremely busy. But let us study the proposal carefully. 3.00 pm The second thing we will do is normalise telehealth for care delivery. During the COVID-19 pandemic, we wanted healthy individuals to recover from COVID-19 infections at home, so as to minimise their visits to the clinics. Telehealth made this possible. Infected persons isolated at home, they could seek consultation from a doctor online and have medication sent to them.”
“To do this well, our community partners will need stronger support in both money and manpower. MOH is studying how best to strengthen our support to AACs. This is, potentially, another major healthcare programme, alongside Healthier SG. This is urgent work. We are racing against time because the pace of ageing in Singapore is relentless. But if done well, this will be one of the best gifts to our seniors. Mr Chairman, over the years, MOH has been explaining the need to shift healthcare from hospitals to the community. With the three healthcare systems, we are making this into a concrete reality. But if care is shifting from hospitals to community, so must the other aspects of healthcare. We need to be service-centric, not premises-centric. Take regulation, for example. We cannot just have standards and rules for hospitals and clinics. We need them for wherever healthcare services are delivered, including senior centres in the community, residential homes, mobile clinics or even remotely, via telemedicine. That is one of the key purposes of the Healthcare Services (Amendment) Bill, which we will present to the House at the end of the COS debate. Patient data is another good example. They need to flow across different healthcare providers and settings. That is why we will be presenting the Health Information Bill to improve the current situation of data collection and sharing. Likewise, the same argument can be made for healthcare financing for patients. The healthcare financing framework, which is "S+3Ms", namely, subsidies, MediShield Life, MediSave and MediFund – they must extend beyond hospitals to wherever healthcare services are delivered. We are, therefore, undertaking a review of our healthcare financing framework to make it more premises-neutral.”
“They have built up very precious personal relationships with residents. We have been working with them to implement pilot programmes for ageing in communities. Recently, I visited Montfort Care's AAC at Marine Parade. They told me there are 5,000 seniors in the area they are in charge of and they have so far identified 400 seniors living alone. These 400 are their top priority for engagement. So, like MOH, they know from experience, the pain and detriment of loneliness. Montfort is hosting many activities for seniors. Like many AAC partners I have visited, Montfort came to the conclusion as everybody on how best to attract seniors – it is to makan together. So, once or twice a week, they get donors to donate food, and volunteers to prepare the food, serve it in a nice environment like a nicely done up void deck, and seniors will come and gather. From there, they make friends. Then, they start to watch out for one another. The centre's staff can then further engage them to ensure that they are taking their medication, they are going to their health screenings, and they can monitor their health. The other attraction is the gym. I did not know that until I visited many of them, especially now that we have many Gym Tonics on the ground. Many seniors who do not like to leave their homes will go to the gym. It is called "Gym Tonic". It is a bit corny. It is not gin and tonic. Many seniors who do not like to leave their homes will come to the gym. I suspect they heard enough stories of how gym work actually strengthens them and people who were immobile are able to walk again and even reverse frailty in certain circumstances. We are putting these ground experiences together into an effective and workable operating model for all AACs, even as we expand the network.”
“However, building more nursing homes is not a sustainable long-term solution. We run the risk of becoming over-reliant on it. Why do I say that? Because the worst enemy of the aged is often not diseases, but isolation and loneliness. Without the companionship and love of family members or friends, the loss of function will hasten and they become frail very quickly. As I mentioned in this House before, research shows that the impact of loneliness on an elderly is equivalent to smoking 15 cigarettes a day. Our seniors need friends, relationships, love and activities around them. They need to feel active and purposeful, doing full-time work, part-time work, volunteer work, take walks in the park, hear the laughter of children, occasionally get into a squabble with their kakis – all these keep them healthy. These things can even reverse frailty in certain instances, but they can happen only if the seniors can age actively in the community. The Ministry of National Development (MND) has announced that they are building more Community Care Apartments. It will help. But it will not cater to the great majority. Therefore, what is more important is for seniors to be able to age in their current homes, which hold unique memories. To do so, we can leverage two important assets. First, our HDB estates. They are designed with many common spaces for interaction amongst residents – void decks, exercise corners, coffee shops, supermarkets, hawker centres. They served a different imperative in the early years of our nation building, but now, these common spaces offer opportunities for seniors to age healthily in the community. Second, our community partners, who have been providing social care and support in our housing estates.”
“Under Healthier SG, this group of patients has the choice to get their supply of polyclinic chronic drugs at Healthier SG GP clinics at around the same price as polyclinic drugs. This is because we will provide a new Healthier SG CHAS Chronic Tier subsidy for selected drugs. They will be available at your enrolled Healthier SG GP clinic. I should emphasise that this Healthier SG CHAS Chronic Tier is an option for this group of patients. It is an option because we know that some of these patients in this group are used to certain brands of drugs and they prefer to get it from their GPs even though the drugs are not subsidised. So, now, we make the subsidised and cheaper alternatives used by polyclinics available to these patients through their private GP clinics, but they are not compelled to switch. They can stay with the unsubsidised drugs that they are used to if they wish to. Another benefit is the removal of cash co-payment when using MediSave for chronic treatment. Patients can use MediSave to pay their bills fully, up to the withdrawal limit. This will also be effective early 2024. Finally, Ms Ng Ling Ling asked about TCM. We are working closely with TCM practitioners by providing more support on R&D to generate evidence on the efficacies of TCM. There will be more developments in this area, which I will update the House when ready. Let me move on to the third system, which is the aged care system. Several Members of Parliament have asked about this. We are building many more nursing homes, doubling from 16,000 in 2020, to over 31,000 in 2030. Nursing homes have, indeed, provided important support to many families with frail parents. It is highly subsidised and supports families who are no longer able to take care of their loved ones at home.”
“So, 3,000 Healthpoints is quite a lot. This is MOH's way of saying, "Well done! Welcome to Healthier SG." Three, nationally recommended health screenings and vaccinations, like influenza and mammograms will be free of charge for eligible residents. Four, after seeing the doctor, you want to heed his advice and to be more physically active, our community organisations will be organising more activities near your home. Participation will earn you Healthpoints. Dr Tan Wu Meng talked about sessions being terminated. There was a time when we were cost-conscious and wanted to be cost-effective. Those with fewer participants were suspended. I think we have changed our approach. Because of Healthier SG, we want to provide stronger support. So, even for those with a lower participation rate, we want to work with the local community, beef up participation and give sufficient lead time for us to be able to do that. But what has been suspended, I am afraid we cannot undo. So, please erase that from your memory and let us look forward. Ultimately, the best payback is better health for everyone. In early 2024, a second tranche of benefits, which will require more operational preparation, will kick in. This includes, one, enhanced subsidies for chronic drugs at GP clinics. This needs a little bit of explanation. Today, CHAS already provides significant subsidies for patients with low chronic medication needs. Just with their CHAS subsidies, they pay $0 or very little for their visits and medications. However, there are patients with complex chronic diseases who need several drugs and medication. The current CHAS benefits are not enough for them. Hence, these patients tend to go to polyclinics to get their subsidised drugs.”
“45 pm It is voluntary for GPs to be a Healthier SG clinic. We have about 1,600 GP clinics in Singapore focused on primary care. Our assessment is that the great majority appreciates the objective of Healthier SG. They think it is a move that should have come earlier and they want to be part of it. But the sums have to work for them and we are working with them closely. We hope to secure the great majority of them to be our partners in Healthier SG eventually. I announced last week that we will launch the Healthier SG enrolment for Singaporeans aged 60 and above in July this year. I also announced that we will launch a pre-enrolment exercise in May 2023. This is an early bird exercise. Who does it apply to? Those aged 40 and above, already have chronic illnesses and regularly visit their GPs. But their GPs need to sign up for Healthier SG. If they have not signed up, please try to persuade your GPs to sign up. This will ensure that this group of patients who need Healthier SG the most do not get crowded out. Mr Ang Wei Neng suggested using health carnivals to encourage sign-ups and volunteered the Pioneer Division to be the first. We are keen to take it up and will discuss with you as well. And I hope you are the "pioneer". You are, indeed, the pioneer and many more community and grassroots organisations will come after you. You will come second, after Sembawang. [Laughter.] From July 2023, the first tranche of Healthier SG benefits will also kick in. This includes, one, a first Healthier SG doctor consultation which will be fully subsidised by the Government. Two, once the first consultation is completed, you will be awarded 3,000 Healthpoints worth $20. I did a check. To earn 3,000 Healthpoints using Healthy 365, you must walk 5,000 steps for 300 days.”
“But we should not overbuild or worse, think that the solution to future challenges of healthcare lies only in infrastructure and the number of beds. Ultimately, with an ageing population, we need to become healthier. And this brings us to the second system, which is the population health system. We are building it up through Healthier SG. Dr Tan Wu Meng, Dr Lim Wee Kiak, Mr Ang Wei Neng, Ms Ng Ling Ling and probably a couple more others, have asked for updates on Healthier SG. Let me provide them by walking through the experience of Healthier SG. We want each of our residents to enrol with a family doctor, to build a long-term patient-doctor relationship. We think the doctor is best placed to guide a resident to better health. That makes family doctors the lynchpin of Healthier SG, the most important component. Therefore, we have been engaging our private sector GPs to co-develop Healthier SG. We are supporting GPs in many ways: IT grants, annual service fees for Healthier SG when they take care of enrolled participants. This is a new stream of revenue for the GPs, for managing the health of enrolled residents. We will also be fully funding preventive services, like nationally recommended vaccinations and health screenings for enrolled Singaporeans. GPs will very likely have to deliver more of such services, which is another source of revenue. We have been explaining to GPs that with greater investment in preventive care, the primary care will grow, both in terms of size and importance. I thank Ms Ng Ling Ling for reminding me of that very simple back of envelope calculation. The money is there. The investment is there. The pie will grow. But GPs will incur more costs, but they will also earn more fee-based income and services-based incomes from the Government. 2.”
“When hospitals take such a firm stand against abuse, the hospitals must feel confident that their management, MOH, the Minister and hopefully, this House and the public, will stand behind in protecting our healthcare workers against abuse. MOH has convened a workgroup to study this issue. They have completed their work. We will be sharing the findings on MOH's plans later this month. The second undergirding issue is we need the right IT systems and tools, to allow patients' key health data to be collected and shared across health providers safely and securely, to ensure seamless and integrated care. Senior Minister of State Janil Puthucheary will elaborate on this. Third, we also need to improve the support system and safety net for vulnerable groups, especially to the lower-income families. Minister Masagos will elaborate on this. Let me move on to talk about the three healthcare systems. Let me start with the one we are most familiar with, the acute care system. We have about 11,000 public hospital beds today and we intend to add 1,900 more public hospital beds over the next five years. This will mainly come from Woodlands Health Campus which we are waiting eagerly for, and this will progressively start operations from end of this year. Tan Tock Seng Hospital Integrated Care Hub (TTSH-ICH) will also start operations this year. Preparation works for the redevelopment of Alexandra Hospital and the new Eastern Integrated Health Campus are also in progress. While not part of the acute care system, polyclinics are a very important part of our healthcare ecosystem. The Sembawang Polyclinic will start operations in the second half of this year, and so too the Tampines North Polyclinic. Another eight will come on stream by 2030. We need to have adequate hospital capacity.”
“We have to do first whatever we can to develop our local pipeline of talent, including some of the suggestions that Mr Gerald Giam has put forward – attract retired nurses to return; serve as locums; increase male participation, that will be most welcome. But we still need to complement it with foreign healthcare workers, from varied sources. Various Members raised the issue about the welfare of workers. I thank you for this. But fundamentally, the best safeguard for their welfare is to have sufficient manpower. Insufficient manpower and you have people who are so responsible, they are going to burn their weekends, they are going to burn their rest days and so on. You have to simply beef up the manpower resources. Senior Parliamentary Secretary Rahayu will speak more about it. As for foreign healthcare workers who become valuable members of our team and demonstrate commitment to Singapore, we should be prepared to integrate them into our society, just as we do for many foreign professionals. At the same time, and a few Members have raised this, society needs to appreciate and respect healthcare workers. The great majority of our patients, and their loved ones and their family members, do. This is hugely motivating for our healthcare workers. But abuse and harassment by a small minority is a rising issue in our healthcare institutions. This is not acceptable. We will need to take a firmer stand against this. We need, as Mr Ang Wei Neng suggested, a consistent understanding across the healthcare system on what constitutes abuse of healthcare workers. We need to then empower hospitals to take a firmer stand against such abuse.”
“This is a system comprising of hospitals, specialist clinics, treating the sick. Second, the population health system. I would say this is a teenager or adolescent. We are putting more emphasis on this through preventive care, through Healthier SG. And third, the aged care system. This one is a baby, still developing. We need aged care to take place predominantly in the community and not at nursing homes. The imperative for this transformation is our rapidly ageing population, which I think is the biggest social development for this generation. The impetus to act now is COVID-19, which made things that were hitherto impossible now possible. In crisis, we made it possible. So, do not waste a crisis. Most importantly, through the crisis, the crisis brought to the forefront the power of preventive care, like good hygiene, screening tests and vaccinations. Mr Chairman, today, I will give the House an update on the three systems and answer questions at the same time. But before that, there are a few common, foundational issues undergirding all three healthcare systems, which my colleagues in MOH will address. First, we need the right size and quality of manpower. Senior Parliamentary Secretary Rahayu will be speaking on this. But let me make a few comments first. We need, based on our projections, to increase the number of nurses and support care staff by about 40% – from 49,000 now, to 69,000 in 2030. I have explained in the House before, that with a rising population of seniors who will fall sick more often and the shrinking population of new local entrants into the workforce, the numbers simply do not add up. We will not have enough local healthcare workers to support our healthcare needs.”
“Thank you, Mr Chairman, let me start by answering a couple of COVID-19 related questions posed by Dr Tan Wu Meng. He asked about excess deaths. I reported in the House late last year that as at end-June 2022, our age standardised death rate throughout the pandemic was 549.9, per 100,000 person years. This is higher than the base rate which we used in 2019, which is 525 per 100,000 person years. So, there is some excess death. As at end December 2022, the number has gone up further and slightly to 555.7. This is expected as we are taking in the mortality of all major infection waves throughout the pandemic. This indicates an excess death rate of 30.7 per 100,000 person years. Nevertheless, due to the concerted effort of Singaporeans, we remain one of the countries with the lowest mortality rate and excess death rate in the world throughout the COVID-19 pandemic. Dr Tan also asked about strengthening our vaccine capability. This is something we are actively looking at, both in terms of building up our research and development (R&D) capabilities and also anchoring local manufacturing capabilities here. I will give a fuller update at a subsequent Sitting, because we are going to table our full After-Action Review in the House. This will take place not too long after the COS debate. A major after-effect of the COVID-19 pandemic is that it inspired us to accelerate the changes to our healthcare system. As a result, the healthcare system is now at a very decisive stage of a major transformation, working off a foundation that took many, many years to build. And now, we look at the healthcare system not as one system, but as three interlinked systems. First, the acute care system, which is mature, well-developed.”
“Under the Tobacco (Control of Advertisements and Sale) Act, any person who is convicted of selling, offering for sale, possessing for sale, importing or distributing e-vaporisers, is liable to a fine not exceeding $10,000 or to imprisonment for up to six months or to both for the first offence, and to a fine not exceeding $20,000 or to imprisonment for up to 12 months or to both, for the second or subsequent offence. The Ministry of Health is closely monitoring the trends of e-vaporiser use and holistically reviewing the strategy against vaping, including legislated penalties, enforcement, deterrent and education measures, to reduce both demand and supply of e-vaporisers. We will continue to work with our partner agencies to curb and prevent e-vaporiser use.”
“The number of cases of harassment and abuse of public healthcare workers that were reported to the Police, under section 6 of the Protection from Harassment Act, rose from 40 in 2018 to 99 in 2022. Based on a recent survey of healthcare workers, about seven in 10 incidents of abuse or harassment, witnessed or experienced by healthcare workers, were from patients and their caregivers.”
“Over the last five years – 2017 to 2021 – the incidence rate of pregnancies and abortions among teenagers remained largely unchanged, at four in 1,000 and two in 1,000 teenage females respectively.”
“Achondroplasia is a genetic condition that causes abnormal bone and cartilage growth, leading to short stature and disproportionate growth. The drug Vosoritide, sold under the brand name Voxzogo, is intended to increase linear growth in children with achondroplasia. The Medication Assistance Fund (MAF) scheme was implemented in August 2010 to support patients who require moderate- to high-cost treatments which have been assessed to be clinically and cost-effective. Vosoritide is currently not registered in Singapore and no application has been submitted to the Health Sciences Authority (HSA). The Ministry of Health has, therefore, not assessed the drug for clinical and cost-effectiveness, nor conducted pricing negotiations with the manufacturer. Manufacturers who wish to register medications for supply in Singapore may submit an application and the scientific data to HSA for quality, safety and efficacy evaluation.”
“Out of about 7,000 Assisted Conception Procedures (ACP) cycles a year that tap on MediSave, the Ministry of Health (MOH) receives about 30 appeals to use MediSave beyond the prevailing withdrawal limits in a year. As MediSave is primarily intended to help Singaporeans put aside savings for their basic healthcare needs in retirement, MOH will accede to appeals to use MediSave beyond the ACP withdrawal limits only in exceptional cases, taking into account factors such as the family's financial and social situation. For example, we have in the past approved appeals from couples who encountered unexpected medical complications during a cycle and were unable to afford the cost of treatment.”
“There is no direct data on deaths caused by second-hand smoke. Deaths attributable to second-hand smoke are usually estimates based on modelling studies. The Global Burden of Disease 2019 study estimated the annual deaths attributable to second-hand smoke for Singapore to be 296 in 2019.”
“The Ministry of Health regularly reviews the Subsidised Drugs List (SDL) and coverage of the Medication Assistance Fund (MAF) to ensure that commonly used drugs are affordable. Currently, there are 17 anti-retroviral drugs in SDL or MAF, including emtricitabine and tenofovir disoproxil fumarate, for use as human immunodeficiency virus (HIV) treatment, but not for pre-exposure prophylaxis in adults. In Singapore, pre- and post-exposure prophylaxis usage is supplementary HIV preventive options for individuals, as they are not fully effective and do not protect against other sexually transmitted infections. They should be very careful and avoid sending the wrong signal that these drugs can substitute the recommended HIV prevention methods, such as avoiding casual sex and correct use of condoms.”
“The Health Promotion Board (HPB) is spending more on promoting physical activity, by significantly expanding the number of physical activities in the community. It hopes to increase our activity outreach from 31,000 to 47,000 participants a week. However, with greater outreach to benefit more people, HPB has to concurrently lower the maximum Healthpoints that an individual can earn in the National Steps Challenge, given the limit to our resources. Our experience is that whether participants are clocking 5,000, 7,500 or 10,000 steps a day, they are already inculcating a habit of staying active, with potentially minimal influence from Healthpoints.”
“The majority of dental needs of geriatric patients can be met by general dentists at the polyclinics, Community Health Assist Scheme clinics and private dental clinics. Seniors with more complex needs or with medical conditions can be cared for by specialists at the two national dental centres, National Dental Centre and National University Centre for Oral Health, and hospital dental clinics. There are, currently, 12 dentists with specialised training in geriatric dentistry and another five in training. Our dental school currently provides geriatric dentistry teaching in the undergraduate curriculum and a postgraduate training programme to give dentists a better understanding of the needs of geriatric patients.”
“Based on data from 2017 to 2021, approximately 1% – or 200 out of 19,000 – of women who had attempted Assisted Reproduction (AR) treatment had fully utilised all six co-funded ART cycles and did not achieve a successful live birth. Amongst those who have fully utilised all six co-funding cycles without a successful live birth, approximately 50% of them, or 100 women, have continued to seek ART treatments, that is, started a seventh cycle, without any co-funding in either public or private AR centres.”
“Hand, Foot and Mouth Disease (HFMD) is not notifiable to the Ministry of Health as it is a common childhood illness that is usually mild and self-limiting. Hence, the numbers are not tracked. Nevertheless, we have a sentinel surveillance programme for HFMD involving selected hospitals, polyclinics and general practitioner clinics, to monitor trends in polyclinic attendances, severe cases requiring admission and the types of circulating pathogens.”
“The Ministry of Health stopped all uploads of TraceTogether Bluetooth data on 26 April 2022.”
“The Health Promotion Board (HPB) launched the "It's OKAY to Reach Out" campaign in October 2021 to promote mental health awareness and literacy among Singaporeans, empower individuals to develop coping skills to manage their mental well-being, and encourage them to reach out for support when they feel overwhelmed. The programme was not discontinued in March 2022 and is still ongoing, with sustained outreach through social media, online and on-ground programmes. Aside from “Its OKAY to Reach Out”, HPB also runs a range of other mental health awareness programmes. One campaign is aimed at helping parents better understand their child’s emotional health and identify behaviours of concern. Additionally, HPB’s mental health promotion efforts include raising awareness on MindSG, a one-stop online national portal for mental health and well-being resources.”
“Based on the typical duration of cancer treatment, most patients would have completed their treatment with non-CDL drugs by 30 September 2023. For those whose treatments extend beyond 30 September 2023, there are a few possibilities. One, it is possible that as the CDL continues to expand, it may include their treatment by then. Two, doctors and patients may consider shifting towards CDL treatments that are clinically proven and more cost-effective. Three, if non-CDL treatments continue to be needed, they may still be covered by private insurance products such as IP riders or critical illness plans that they previously purchased. Four, patients who require non-CDL treatments and face affordability issues may opt for subsidised care at Public Healthcare Institutions, where they may apply for additional support such as MediFund.”
“The Cancer Drug List (CDL) was introduced to accord the Ministry of Health (MOH) the leverage to negotiate for lower drug prices, thus enhancing the cost effectiveness of cancer treatments in Singapore, and lowering financial burden on patients and families. How it works is that for a treatment to qualify for inclusion in the CDL, the supplier needs to ensure prices justify the effectiveness of the treatment. Once in the CDL, the treatment will benefit from government subsidy and healthcare insurance claims. Since announcing the changes in 2021, we have managed to reduce prices of drugs in the CDL by 30% on average, and by over 60% for some drugs. As more suppliers reduce their prices, more drugs are also included in the CDL. The number of treatments in the CDL has increased from 270 when it was first published in August 2021, to 340 as of 1 February 2023. This represents about 90% of all Health Sciences Authority (HSA)-approved treatments. The rest of the treatments are not in the CDL because the prices do not yet justify the effectiveness, and suppliers are not willing to moderate their prices. But we will continue to work with them in good faith and try to expand the list. On average, about 90% of patients in private medical institutions and about 95% of patients in Public Healthcare Institutions were on CDL treatments over the period of 1 September to 31 December 2022. While some patients are undergoing treatment using drugs not on the CDL, most of them continue to be covered by their Integrated Shield Plan (IP) insurance. Insurers have committed to preserve the current IP coverage of policyholders at least until 30 September 2023.”
“Following the recent salary revision for junior doctors in the public healthcare sector, House Officers and first year Medical Officers (MOs) can expect a 7% and 13% increase in their starting salaries from 1 January 2023 respectively. Eligible in-service MOs or Residents up to post-graduate year (PGY) 6, and Dental Officers up to PGY 4 can expect a salary adjustment based on their years in service and bond period. The amount of adjustment made depends on the market movement of salaries across different levels of seniority. The Ministry of Health (MOH) will continue to review the salaries of doctors in the public healthcare system so that they remain competitive.”
“Healthcare subsidies are generally means-tested using per capita household income (PCHI) and annual value (AV) of residence to ensure that subsidies are targeted at those who need it more. AV, in particular, is a good proxy reflecting the financial situation of the applicant, but it is not a perfect proxy as it excludes those who are asset rich and cash poor, but for various reasons, are unable to monetise their assets. However, if we conversely disregard AV when determining the appropriate level of subsidies, wealthy retirees living in a high AV residence (such as landed property) would receive higher subsidies than low-income families in residences with a lower AV (such as a two-room flat). As such, while neither PCHI nor AV are perfect measures, collectively they are the best available proxies to measure an individual’s means and access to family support. To support retirees who are asset rich but cash poor, the Government provides additional non-means-tested support under other schemes. For instance, seniors aged 65 years and above receive higher subsidies of 75% at polyclinics, regardless of means. Pioneer Generation and Merdeka Generation seniors also receive additional benefits regardless of PCHI or the AV of their residence, such as subsidies for MediShield Life premiums, MediSave top-ups and higher subsidies for outpatient care. Individuals who face difficulties in paying for their healthcare expenses after subsidies, MediShield Life and MediSave may apply for discretionary financial assistance such as MediFund at public healthcare institutions, where a broader set of factors beyond PCHI and AV would be taken into account.”
“Nutri-Grade mark was rolled out in December 2022, to help consumers make informed beverage purchases. We believe that, with time, more and more people will familiarise themselves with it. Nutri-Grade measures seek to decrease median sugar level across beverages, increase consumer preference for beverages with lower sugar and saturated fat content, and reduce Singaporean's overall sugar consumption from beverages. The Health Promotion Board tracks these through market data on beverages' supply and demand, and the National Nutrition Survey. There has been good progress so far. The measures for freshly prepared beverages will come into effect in end-2023.”
“There is a range of safeguards in place to ensure mental health services funded by the Ministry of Health (MOH) are safe, ethical and effective. For example, providers have to put in place care processes, clinical governance frameworks and regular audits. Professional standards are also regulated by the relevant professional boards and councils, such as the Singapore Medical Council (SMC) and the Singapore Nursing Board. The public may also provide feedback or lodge a complaint with MOH, the SMC or the relevant professional associations, if they have concerns over the clinical services provided by mental health professionals. In addition, professional associations such as the Singapore Psychological Society and Singapore Association for Counselling have published guidelines on professional and ethical conduct for its members. The National Mental Health Competency Training Framework Workgroup, set up by MOH and the Ministry of Social and Family Development, is also developing a common set of training standards and competencies for mental health professionals and para-professionals.”
“As of 31 January 2023, about 11% of Singapore Residents aged six months to four years have taken at least one dose of the Moderna/Spikevax or Pfizer-BioNTech/Comirnaty vaccine. Health Sciences Authority (HSA) has reported that as of 31 December 2022, out of a total of about 16,448 vaccine doses administered, there were a total of five suspected serious adverse events, which is what we need to focus more on. This translates to a 0.03% incident rate. Incidence rate of adverse events (serious and non-serious) is 0.05%. The Ministry of Health publishes the vaccination status of Singapore Residents, but had not yet included the youngest age group as their vaccination exercise had only started towards the end of last year. As more in this age group are taking up the vaccine, we will consider adding it to support our public health strategy.”
“We need to continue to grow our healthcare manpower to meet the rising demand for healthcare services due to an ageing population. Nationally, the number of nurses, allied health professionals and support care staff will need to increase by around 3,000 annually, and the number of junior doctors will need to increase by around 700 annually. There are several ongoing initiatives to meet our manpower needs. Our education institutions continue to nurture healthcare workers for the future, and the courses have been well sought after by students. Public healthcare institutions continue to train and develop their staff. We have in place various mid-career conversion programmes. We continue to improve and redesign our model of care and job responsibilities. We continue to actively recruit foreign healthcare workers to complement our local core workforce. In addition, we regularly monitor and review staff salaries in our public healthcare institutions to ensure that they continue to be competitive against the market.”
“We need doctors of varying skillsets to meet the healthcare needs of Singaporeans. As our population ages, we will increase our focus on preventive care in the community through the Healthier SG strategy. Hence, beyond hospital specialists, we will need to train more doctors to be Family Physicians. Both are offered as residency programmes. Between 2017 and 2021, about 53% out of the average annual cohort of about 420 local medical graduates were matched to a residency training position. While doctors are eligible to apply to start training from the second year of their graduation, the application process is competitive, and it may take several years before they join residency. About 96% of the 400 residency training positions offered each year are filled by locally trained doctors and foreign trained locals. Many doctors continue in public healthcare institutions after their bond. They do broad-based practice in a hospital setting, and the Ministry of Health supports their development of broad-based clinical skills through the Hospital Clinician scheme. Others practice in our polyclinics, which serves as important training and primary care sites. As for doctors who leave the public healthcare institutions, we do not track their career path. A proportion go into primary care as General Practitioners or may continue their post-graduate training in Family Medicine. These doctors are an integral part of our healthcare system and are essential to the success of the Healthier SG strategy.”
“The incidence rate of serious side effect arising from COVID-19 vaccinations is about 0.007%, or seven in 100,000. Since we started COVID-19 vaccinations, the clusters have reported to the Ministry of Health (MOH) 20 instances of serious adverse events, soon after the healthcare workers received their vaccinations. I should emphasise that these are reported serious adverse events, where the causal link to vaccinations have yet to be established. Six cases resulted in between 15 and 30 days away from work, and three cases resulted in more than 30 days away from work. For staff who are unable to resume work due to severe reactions from COVID-19 vaccinations, our public healthcare clusters have supported them by granting medical benefits, outpatient sick leave and hospitalisation leave, even working from home when practical and required. Our public healthcare clusters remain committed to support staff who experience side effects arising from COVID-19 vaccinations. There has been one reported case of a staff from Singapore General Hospital (SGH) who was unable to resume work shortly after her COVID-19 vaccination. SGH continues to stay in touch with their former staff to provide support. MOH has also shared with the former staff on the Vaccine Injury Financial Assistance Programme (VIFAP) application process. If received, her application will be reviewed by the VIFAP independent clinical panel.”
“Our public healthcare institutions, including the three key clusters of SingHealth, National Health Group and National University Hospital, are structured as companies for autonomy and flexibility in operations. MOH Holdings Pte Ltd (MOHH) is the 100%-Government owned holding company for these public healthcare institutions. In addition, MOHH supports the public healthcare institutions through key functions such as IT services, infrastructure development, service integration and manpower and leadership development, and internal audit. To do so, it also held companies such as Integrated Health Information Systems and Agency for Integrated Care that provide services to the public health institutions. MOHH is not-for-profit. It recovers cost from the public institutions for the services it provides, with MOH funding the rest of its expenditure. The accounts of the public healthcare institutions it supports are published. All grants to MOHH from MOH are accounted for in the Government Financial Statements submitted to Parliament. Members of the public can obtain MOHH’s full audited financial reports, as well as that of the public healthcare institutions it supports, from Accounting and Corporate Regulatory Authority.”
“As shared with Mr Louis Ng during the 2 August 2022 Parliament Sitting, the cross-cluster Staff Well-being Committee was formed in 2019 for the public healthcare clusters to share best practices with one another and provide feedback to the Ministry of Health (MOH) on enhancements to improve staff well-being across all categories of staff. The committee has since completed its work and provided its recommendations to MOH. Arising from one of its recommendations, MOH announced the formation of a Tripartite Workgroup to address the issue of abuse and harassment of healthcare workers in March 2022. The Workgroup is currently finalising its recommendations which will be released soon. Clusters have also enhanced support measures for their staff. Besides the appointment of Chief Wellness Officers to improve staff well-being, the clusters have also put in place counselling services, peer-support networks and staff support assistance plans. We will continue to work closely with MOH Holdings and the public healthcare clusters to improve staff well-being.”