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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“There is no risk of forgetting to switch off your stove and we will definitely improve the way the Eldercare Centres work. As suggested by Ms Janet Ang, for those who are in their last lap of their health journey, we are expanding palliative care, especially at home, to allow our loved ones to pass on as comfortably and with as much dignity as possible. This is the wish of most seniors and we should try our best to fulfil it. Ageing in communities will be the next major area of change and reform in healthcare that we need to work on. When all three systems – acute care system, public health system, aged care system – work together synergistically, healthcare happens everywhere and not just in medical facilities. So, I thank Dr Tan Wu Meng for sharing the story of Ah Ma, and pointing out that the healthcare subsidy should not be tied to services being delivered in brick-and-mortar facilities. This will naturally have to be reviewed as we shift our paradigm. Mr Deputy Speaker, Sir, let me conclude. Some countries may place a stronger emphasis on just one of the three systems or organise them in a way that they end up working in silo. For example, Japan, as a super-ageing society, has a great focus on aged and institutional care. The US acute care system is state-driven, but public health is driven at the federal level. In Singapore, we take an integrated approach. Acute care, public health, aged care, all come under MOH. The Minister for Health, is also the Minister in-charge of ageing issues and chairs a multi-Ministry task force going beyond healthcare. And this is an important advantage for us. MOH is in a position to develop a cogent and comprehensive plan, muster resources to transform and fire up all three systems, to deliver health outcomes for our people.”
“I came across this piece of research, which estimated that the health impact of loneliness for a senior is equivalent to smoking 15 cigarettes a day. We estimate that today, 97% of our seniors above 65 can either live independently or with some help in the community. We must maintain or improve that share and not inadvertently give them the equivalent of 15 cigarettes a day, and weaken their health and ability to live independently. For the large majority of seniors, what they need most is social care, more than healthcare. The way to deliver that is to enable ageing in communities. We will need a range of solutions to anchor ageing in communities. These include building more Community Care Apartments that Second Minister Masagos Zulkifli talked about, on releasing land for private assisted-living facilities. But the greatest asset for managing ageing is actually right before us – and that is our HDB estates. Most estates already have ample shared spaces for interaction and activities, you got your void deck, your coffeeshop, your supermarket, your RC centre, our Eldercare Centre, your community clubs. We did not specifically build them as infrastructure to support ageing, but they are extremely valuable in our ageing society. And that is why MOH is rapidly expanding our network of Eldercare Centres to activate these existing spaces and create more shared spaces and social networks for seniors. We are working closely with AIC to provide training opportunities for our centres to take on an expanded role under Healthier SG. As a social worker told me, a very effective initiative is to simply bring the seniors to that shared space to cook and enjoy a meal together and once they eat together, they socialise, they start doing different kinds of activities together.”
“Because over time, society will, perhaps unintentionally, push more older people to become isolated – which many Members have warned us of. Our instincts backfire from time to time. We would have come across such stories. Let us say, a senior went marketing in a wet market and then he fell. The family may, to protect him, tell him, "Do not go out anymore, we will hire a domestic helper to watch after you." Or a senior cooks forgot to switch off the stove, and fortunately, it was discovered early. The family may tell her, "Do not cook anymore, we order in for you, every meal." We might do all these out of concern for our loved ones, but in so doing, we deprive them of physical activity, a sense of agency, a sense of dignity. We want to protect them, but we unintentionally expose them to an even greater risk of isolation and loneliness. That is when the spirit wears out, the body gives way. If that mindset becomes entrenched, then over time, seniors become a problem to be contained, put aside in nursing homes – out-of-sight, out-of-mind. It is like a room in your house, where you put all your problems and you do not want to see. One day, that room will burst. We must support as many seniors as possible to continue to live in the community, independently or with some help, contributing to the best of their ability, able to choose their own activities, having a full social life with friends and family. I visited Block 115 that Mr Henry Kwek talked about. It is not run on a big budget, a lot of passionate volunteers, we all know who got involved, but it is doing such heavy lifting and making such a huge difference to the seniors living in that block.”
“This comprises the policies and processes for preventive care, including the network of family doctors, their long-lasting relationships with residents, the practice of regular health screening, the culture of good lifestyle habits, all of which keep a people healthy. This is the system that we are now building and strengthening through Healthier SG. We have seen how the two systems complement each other during COVID-19. The public health system strengthened the surveillance of the virus, got people to adopt good hygiene habits, received vaccinations, stayed home if unwell. The acute care system took care of those who got infected and experienced more severe symptoms. But still, the two systems are not enough. In an ageing society like ours, the third system is equally critical and that is the aged care system. This is the support system for the large segment of people who are advancing in age. And this system is not only about nursing homes. The nursing homes, they serve an important purpose, which is to care for seniors who are very frail and unable to live independently, whose families cannot support them. But nursing homes are not and cannot be the mainstream solution to ageing. We are building nursing homes very quickly, from 16,200 beds now, to 31,000 beds in 2030. I am sure we need them as our population ages, but the projected pace of expansion is worrying. In our Asian culture, we value caring for our seniors at home. Our seniors also prefer to age in a familiar environment and we should not lose this. As a society, we must guard against the assumption that seniors will always become sick and frail, and unable to take care of themselves. This is quite a risky mindset because it will exacerbate our challenge.”
“The age markers remain relevant and can continue to guide us in understanding life stages, key events and risks throughout our lives. But we need not be strait-jacketed by them, especially when it comes to health and ageing. For example, there is no reason why 50s has to be the onset of chronic illnesses. We can stay healthy and not have chronic illnesses in our 50s. There is no reason why once you cross 65, you go into the wrong side of the dependency ratio. There is also no reason that why being in our 80s must be associated with frailty. We can delay it as long as you can, well into your 80s or 90s. Policy planners will continue to monitor the statistics based on age, but as individuals, we can choose to differ from these widely accepted assumptions. And the Government can make policy changes and reform our systems to help individuals achieve that. To do so, we need to recognise now that the healthcare system is not one system, but three interconnected systems, working together to deliver good outcomes. The first system is the acute care system. This is what typically comes to mind when we think of the healthcare system. It comprises hospitals, specialist clinics, emergency departments – the places that treat us and cure us when we are very sick. We are expanding this system, building more acute and community hospitals in the coming years. The second system, less known, is the public health system. One important part of the public health system is the control of infectious diseases. And we can see these systems springing to rigorous action during the pandemic. The other important part of the public health system is the one that improves the health of our population.”
“For schools, shrinking student intakes, which is why MOE has to merge schools and some of us find our alma maters gone. Within communities, we have to make sure estates are now barrier-free. At traffic light junctions, the green man will have to appear longer because people take longer to cross the road. If you are a driver, you will have to slow down in the HDB estates and we already have silver zones. For families, more and more couples will find that they have to take care of two sets of aged parents, in addition to their own children. In the healthcare sector, we see rising disease burden and escalating demand for hospitals, clinics, doctors, nurses, budget and so on. Most importantly, the seniors themselves, as they see more of them, they will be asking, "How do I live purposefully and healthily, with dignity, in my old age?" Mr Henry Kwek, Ms Tin Pei Ling, Miss Cheng Li Hui and Ms Carrie Tan raised these concerns and, importantly, they warned us of the danger of isolation of seniors and the importance of social contacts for seniors. Ageing is a major topic. Its impact spans across various sectors. Today, let me just address the implications on healthcare. Our basic premise must be this – ageing may be an inexorable trend but a rapid escalation of disease burden and suffering need not be a given. We can manage this, provided we stay healthy. Many of us, myself included, are guilty of being caught in the old mould where life stages are determined by age – five years old, go preschool; 12 years old, take PSLE; 20-plus, graduate; by then, roughly, you should find a boyfriend or girlfriend and apply for BTO; late 20s, get married; 50s, beware of onset of chronic illness; 60-plus, retire; beyond 80, you may start to become frail.”
“However, many of our healthcare workers have also experienced abuse by patients and family members who lashed out at them because hospitals and clinics are high-stress environments. I hope that our healthcare workers will look past a small minority that show disrespect and have faith that the great majority salute you, which includes everyone in MOH. I believe I speak for every one, every Member of this House, that we, too, respect them and their work, whether they are men or women, young or old, locals or foreigners. [Applause.] Abuse against healthcare workers cannot and should not go unaddressed. We hope to raise public awareness on abusive behaviour that should be stopped and equip healthcare workers to better handle such situations. Mr Deputy Speaker, Sir, ultimately, we need to squarely tackle the challenge before us, which is that our society is ageing fast. It is a worldwide trend. By 2030, the old will outnumber the young in the world – the first time in recorded human history. East Asia, in particular, is ageing faster than any other region in the world due to declining fertility and people living longer lives. Within East Asia, the countries ageing the fastest are Japan, South Korea and Singapore. We are called the "advanced agers". Members have heard this statistic many times. By 2030, one in four Singaporeans or thereabouts will be 65 and above, up from one in six today. But it is not just a statistic. The number translates into real impact on our lives and we have yet to feel the full brunt of it. For companies, you will face a shortage of workers, requiring you to move into automation, adopt less manpower-intensive business models while using foreign workers judiciously.”
“Therefore, if we are honest with ourselves, we know the numbers simply will not add up if we just rely on local nurses or local manpower, no matter how hard we try to expand the local pipeline. Therefore, if we want to take care of our seniors and the sick, if we want to reduce the workload of healthcare workers or at least make it more manageable, we must expect foreign healthcare workers to play a bigger role in the coming years. This is especially so in areas where there is a more severe manpower crunch, such as aged care or palliative care. The great majority of our nursing workforce will still be locals but the number and role of foreign nurses will need to grow. MOH is, therefore, securing various pipelines of good foreign healthcare workers from different source countries to bring them here and further train and develop them. Some may leave us after a few years but we will try to keep the majority, especially those who have become an integral part of our care teams. Dr Tan Yia Swam suggested granting the good performers PR and MOH is supportive of this. ICA always assesses PR applications holistically, including taking into account the economic and social contribution of the applicants. So, when it comes to evaluating applications from foreign healthcare workers, ICA will certainly consider the important contributions of healthcare workers and MOH's support for the applicants. At this juncture, Mr Deputy Speaker, I would like to say a few words to our healthcare workers through you. I believe the great majority of Singaporeans respect and appreciate our healthcare workers. We have seen the outpouring of public support in the recent past for the sacrifices made by frontliners as they steadfastly battled the COVID-19 pandemic.”
“If we look at local nurses, the normal annual attrition rate every year is about 6.4%, which is not high by any industry standard. In 2020, when the pandemic struck, it went down to 5.4% because many of our nurses who were planning to retire or resign, in the face of the pandemic, decided to stay and fight. In 2021, there was a slight rebound to 7.4%. In 2022, this year, so far, the numbers have reverted to that of normal years. There was no mass exodus of local nurses. These are the numbers. Nurses have remained dedicated and steadfast and bravely stood their ground in the face of the pandemic. What has gone up is the attrition of foreign nurses – from about 8.9% in normal years to 14.8% in 2021. This is where there is record high attrition, at least, over past few years. We know the main reason, and Dr Tan Yia Swam talked about it, which is that the pandemic has increased the demand for nurses all over the world and our foreign nurses are being poached by other countries. They go to New Zealand, Australia, the UK, UAE. So, if we want to tackle the manpower crunch in healthcare, the starting point is to hold on to our foreign nurses in the face of heightened international competition. Only then can we reduce the workload for all nurses, which many Members have called for. But we must be clear where our starting point is. Remember, healthcare is one sector that is directly affected by our demographic changes. An expanding aged population needs more healthcare and more healthcare manpower. A shrinking young population limits the number of new local talents that we can bring into healthcare.”
“Our community pharmacists are now able to provide smoking cessation and weight management services and there are plans to train them in influenza vaccination. But first, there must be enough people to train. There is, again, a certain narrative going around – some Members alluded to this narrative – that hospital staff are leaving because they are overworked, attrition rate is at a record high, people are avoiding the healthcare sector and that we must do campaigns, reduce workload and raise salaries to attract more people. That is the common narrative now going around. There are some elements of truth in this narrative, such as there is, indeed, a manpower crunch and hospital staff have been working very hard, especially during the pandemic. But the rest is less than fully factual. They propagate some negative energy and may not help us tackle the actual problems. Take the attractiveness of the healthcare sector. Are young people really avoiding the sector? Ten years ago, ITE, Polytechnics and Universities in Singapore took in about 1,500 nursing students a year. Now, this has gone up to 2,100 and we are trying to increase it further to 2,300 in the next couple of years. Our education institutions receive many more applications than there are places. At this number, we are attracting 4% of the student cohort into nursing. If we maintain that number while cohort sizes shrink, the percentage will drift up to maybe 5% of each cohort. That means that for every 20 local students you see in a class, one will be trained to become a nurse and they are applying. So, healthcare has a very fair share of the local talent pool, considering there are so many sectors vying for local talent. On attrition rate – is it really at a record high?”
“So, a palliative care provider can receive a standard based fee for each palliative patient they take care of and then they decide which services are in the best interest of each patient, whether they should go to inpatient hospice care, home care or day care. They do not have to worry about separate funding for separate services under separate settings. That is where we have a lot of potential. Let me now move on to the next important topic, which is manpower. Several Members – Dr Tan Wu Meng, Dr Tan Yia Swam, Ms Mariam Jaafar, Mr Dennis Tan and Ms He Ting Ru – raised concerns about manpower and I appreciate that. It is a major challenge. The key challenge is to have sufficient nurses, allied health professionals and support care staff to operate hospitals, clinics and also eldercare centres. These few groups number about 58,000 now and MOH estimates that this will need to grow to 82,000 in 2030 – 58,000 to 82,000 from now to 2030. We will broaden training for our healthcare workers – nurses, allied health professionals and pharmacists – so that they can take on the crucial roles alongside doctors in preventive care. For example, nurses in the community will be trained in lifestyle coaching to empower residents to make good choices according to their care needs. Undergraduate allied health courses comprise specific modules on population health, health promotion and chronic disease management. Mr Mark Chay suggested some useful training for doctors on physical fitness. I think we will follow up with discussions with him on how we can improve or broaden the range of courses that doctors can go to for their continuous training.”
“They still get the same budget, except that the basis of calculation has moved away from based on workload to capitation – the population that they are taking care of. So, they receive fixed capitated budgets for residents of different age bands. For the very young, they have to do a lot more work, at a higher capitation rate. Young adults will have the lowest capitation rates and as you get older, as you need to pay more attention to their healthcare, capitation rate goes up again. So, age bands are a reasonable proxy for both workload as well as health risks. Ms Sylvia Lim asked whether we can publish the rate. For now, I think it is better we keep this as internal parameters within MOH. In any case, the annual reports and financial statements of the clusters are available, if you get them from ACRA. Clusters, in turn, will cascade down Healthier SG key performance indicators (KPIs) to all their institutions and partners. But they will not yet capitate the budgets of hospitals, polyclinics or community hospitals. So, below the clusters, healthcare institutions will still be funded the same way for now. But capitation funding is a direction we want to move towards. It is a big change and we will have to study and plan each move carefully, making sure every institution, every partner is ready before we do so. When it happens, it must be accompanied by a significant granting of autonomy so that healthcare institutions can make the right-siting decisions properly. I will give Members an example. Let us take a palliative care hospice, for example. Today, we fund them through workload – same formula – but we can capitate their budget.”
“But she had a very thoughtful and insightful explanation of value-based care and I think it is worth responding to her. She cited several good international practices. I want to assure the House that our hospitals have already been implementing value-based healthcare through many such initiatives too. We just did not feature them in the White Paper under Healthier SG. There are many examples. One, all the community measures taken to help resuscitate out-of-hospital cardiac arrests by making defibrillators available in the community, training members of the public to perform CPR, alerting them through apps, that there is a cardiac arrest nearby. And so far, the survival rate of out-of-hospital cardiac arrest has improved by 10 times – 2% to 22% over the years. Changi General Hospital has set up a post-acute myocardial infarction clinic to support patients in their post-heart surgery recovery. The idea is to review the patient's condition early within two weeks. This has resulted in a reduction of the 30-day re-admission rate from 14.3% to 9.6%. There are many such examples and I hope Ms Mariam Jaafar and the House will be comforted that our clinicians are always thinking of better ways to deliver better clinical outcomes. Let me now comment about capitation. A few Members have raised the issue of capitation. I agree with Members on the benefits of capitation funding, but we are doing it step-by-step and carefully. I explained how we are doing it at the GP level during my opening speech by extending them a standard base fee per enrolled resident. So, it is loosely a capitation payment. At the healthcare cluster level, we have changed the basis of calculating their budgets to be capitation-based.”
“That is what the manager always says. Ms Hazel Poa went further to say, let us measure the targets achieved by the GPs. And if they do not achieve, clawback the service fee. But as Dr Tan Yia Swam cautioned, it is important for GPs and MOH to work together, for GPs to feel that they are integral part of this change. And I agree with Dr Tan. Ms Mariam Jaafar, my colleague from Sembawang, and an experienced management consultant, immediately raised a red flag. I think she has seen enough organisational changes to notice the danger of blindly chasing KPIs and targets. Because I talked about what the manager would do. But what will a leader do? A leader that is driving the change will have a different starting point. He or she, the starting point is, bring everyone on board, make sure everyone understands and buys into the mission in objective. Then, we jointly set KPIs and targets and then do our best to achieve them in the right spirit. If we do not do that, then we are not leading. We are only managing. And if in our zeal to over-manage, we penalise people for not meeting targets in the middle of a big change, that is when people become cynical and they lose heart, and then you get perverse outcomes like what Dr Lim Wee Kiak said. Imagine if we really say to the doctors, "If you do not meet your KPI, we will claw back your service fee". Then, it is very simple for the doctors. Number one, either I do not join Healthier SG; or two, I join, but I cherry-pick the healthy residents. So, the way we look at KPIs, always, you are able to differentiate the leaders from the managers. Since we are on the topic of outcomes, I want to respond to Ms Mariam Jaafar. She is not here today, she has to fly off for work.”
“So, we cannot remove the differences up to the last cent and for the higher-income households, the difference may well remain in dollars. But parity of drug prices is an important concern, told to us by many residents when we did our consultation. And we will try our best to make sure there is drug price parity, especially for the lower income. Let me move on to the next subject which is delivering outcomes and KPIs. A number of Members talked about KPIs and outcomes and there was an exchange between Mr Gerald Giam and Ms Mariam Jaafar yesterday. Of course, we have to measure outcomes and set targets. That is why we listed short-, medium-, long-term KPIs in the White Paper. The work has just begun. Healthier SG is a dynamic multi-year transformation exercise. There will be twists, turns and uncertainties along the way. MOH is having extensive discussions with clinicians and other stakeholders to set out the technical definitions and our approach to data sharing and measuring these outcomes. And from there, we will establish the baselines of various indicators and then, determine what targets we want to achieve and by when. While it is important to measure outcomes and targets, those who have run organisations before will know that this is not straightforward. I used to be involved in workers' training, so I interacted a lot with HR practitioners. And HR practitioners always lament – and this is not just for Singapore, it is the whole world. They always lament employees are over-managed but under led. The unions always say that. Because if you are manager and you are in the middle of a big change management exercise, you will likely instinctively say, what are the targets, let us measure the targets, whatever gets measured, gets done.”
“It is in a way, a good problem. It is better than if the feedback comes back as, "We think nobody will enrol". That would be a bigger problem. But if GPs are to over time accept enrolment from the entire population and help keep them healthy, they have got to shift out of some current load. And I am glad that a couple of Members have given a good suggestion. Mr Melvin Yong suggested for employers not to insist on workers producing medical certificates (MCs) whenever they are sick. Many common ailments like cough and cold can be managed with more rest, drinking more water and perhaps some off-the-shelf, over the counter medication, including TCM medication. Ironically, the disease where this is most practised now is COVID-19. But if we insist we want to see a GP, we queue up and see the family doctor in order to get an MC – today, a lot of people practice that – but actually it is not the best use of the doctor’s precious time and resources. Many employers already do not insist on MCs for COVID-19. Mr Melvin Yong mentioned that our healthcare clusters today accept up to three days of sick leave without the need to produce an MC; the Civil Service grants officers up to two days for mild conditions like cough and cold. I hope this can become a prevalent practice. Let me talk about drug prices. Mr Gerald Giam asked a series of questions about our effort to substantively remove difference in drug prices, between GP clinics and polyclinics for residents enroled in Healthier SG. As I said in my opening speech, the basis of subsidy for polyclinics and for CHAS in GP clinics are different. The former, which is polyclinic, takes into account age. But for CHAS in GP clinics, a major factor for consideration is income.”
“Once we can feature TCM in Healthier SG, then the suggestions that the Leader of the Opposition has put forth, I think will be considered. And there will be a certain natural forward movement in our policy thinking. I just have one last thing before I move to another topic. Mr Pritam Singh mentioned psyllium and fybogel. I think it is the same thing. It is not that one is Western medicine and one is TCM, one is funded and one is not – I am not wrong. There are doctors in the House, please correct me. I think it is the same thing. Psyllium is the seed for fibre supplements, fybogel is essentially psyllium with a brand, called Fybogel. Both are not medicine, both are dietary supplements, fibre supplements. But like all things sold in the polyclinic, including the gauze used to dress your wounds, they will all be subsidised, including supplements. But there are doctors in the House; so, please correct if I am wrong. Let me move to the next topic, crowded GPs, raised by several Members. Dr Tan Wu Meng, Mr Yip Hon Weng, Mr Ang Wei Neng, all expressed concerns that if GPs become very popular, residents can get squeezed out by the huge demand. I tried to explain some of this in my opening speech that we will try our best to manage this. We will ask GPs to set a limit on number of residents they can enrol. How many will depend on the clinic and the doctor's own judgement, how many more can he take. So, it will differ from clinic to clinic. We are also implementing enrolment in phases; we will prompt residents to enrol with their usual GPs, the dropdown list, your most frequented GP will be first; and we will encourage residents to enrol early and not wait. I take comfort that we are discussing this because we are worried the demand will be overwhelming.”
“Both disciplines believe that early management of risk factors and disease can stave off problems and complications later on in life. Therefore, I believe, when we focus on preventive care under Healthier SG, we hope TCM can play a role. While we work that out, in the mean time, we encourage TCM practitioners to continue to do what you are good at, advise the patients to take care of their health, pick up good habits, live healthily and take care of their health holistically. But like I said in my Parliamentary reply, TCM is self-regulated, with varying standards of practice. So, over the last year, MOH and the TCM community have established two workgroups. They work on issues such as enhancing TCM clinical training and improving career development. And once completed, this can be a basis to explore how to involve TCM in support of Healthier SG. But I do not think, as one Member suggested, I do not think we should impose the regulation of Western medicine on TCM. I think self-regulation for something that is traditional and cultural, would be more appropriate. But we need to strengthen that self-regulation. We have recently also finalised the succession plan of the Chairman of the TCM Board. This is MOH's partner in the TCM community. Mrs Yu-Foo Yee Shoon has been Chairman for I think at least three terms or more, a lot of contributions. The incoming Chairman will be Dr Teo Ho Pin, another familiar colleague of ours. He has taken up the Chairmanship with gusto. I have had several discussions with him. He understands the big shoes he has to fill, MOH's position and thinking, especially in the context of Healthier SG, and I think he understands his task as the TCM Board Chairman.”
“If you ask a TCM doctor, "This patient need a life-saving, urgent operation, can you replace it with herbal medication?" They would say "No, go for the operation." Most TCM practitioners I know, would say that too. I think they respect each other's space, their strengths and their disciplines. When it comes to regulation, there is a fundamental difference as well. Western medicine is a lot about research, clinical evidence, efficacy, safety. You get the data, then, the drug, the treatment can be approved. It is tightly regulated and by law. TCM is passed down from generations, great-great-great-great grandfather took that and passed down to great-great-great grandfather. Culturally, traditionally, they trust that herbal medicine. And you ask for clinical evidence? They do not have. You want to go for MediSave? Today's rules mean it must be a medicine, it must be certified by HSA with clinical data. For TCM, that is hard to come by. What TCM is very strong in is preventive care. More than 2,000 years ago there was already the saying: 养生三法：“饮食有节、起居有常、不妄作劳.” Very hard to translate, but let me try. Even the literal translation does not capture the full meaning. It means there are three key aspects to health: you eat not just in moderation, but 饮食有节 means you eat what your body requires, you go according to the seasons. 起居有常 means you have a healthy daily routine that follows the rhythm of the day, the month and the year probably, and not to over-exert your body, heart and mind. So, in the area of preventive health, that is where I think Western medicine and TCM share a common understanding. You would notice in my opening speech, I have a symmetry, where I talk about preventive care and how the other side also has been emphasising on it.”
“I thank Mr Pritam Singh for reminding me. I got invited in December to an event by the TCM community and that is why I spoke to them, with the indication that if we focus on preventive care, I think it is an impetus that we can make a breakthrough and feature TCM in preventive care. And that was how the thinking first started. And my last two speeches about TCM, I made quite a few TCM speeches, they are all in Chinese. The coverage has been uneven, so it is good that I have this opportunity now to explain it in English. The two speeches I last made was quite recent, Mr Patrick Tay was there, in one of the events in September last month. In summary, this was what I have been telling the TCM community and what we have been doing. One, MOH has always recognised the tremendous value of TCM and the benefits they have brought to the community. I specifically always mention, during COVID-19 – and the Leader of the Opposition mentioned this as well – I personally wrote to our TCM clinicians to say: "Please advise your patients to take the vaccines." They were a great help and really helped us moved the needle in getting heartlanders to take the vaccine. But, I also explained, we must recognise that Western medicines and TCM, they evolve very differently throughout history. They are two separate systems, complete systems with their own disciplines and their own know-how. They may intersect at some point, they may overlap, but you cannot make one to be like the other. It is not possible. They are two complete holistic systems. Take for example, you ask a western doctor, "how do you balance the five elements of a human body to keep him healthy?" Most western doctors would profess they would not know. We have doctors in the House, I do not think you would profess that you know.”
“Thank you, the speech is slightly long. Mr Deputy Speaker, Sir, I thank the Members for all their questions and my MOH colleagues for answering the bulk of them. In closing, I will address the few remaining issues and then, I will then take a step back and share the broader perspective of the challenge that we are facing concerning healthcare. Let me start with TCM, as raised by several Members and Leader of the Opposition, Mr Yip Hon Weng, Ms Hany Soh, Ms Joan Pereira. Maybe I will start with – we seem to have this mood here where we talk about who made what speeches in the past. Let me give my version. [Laughter.] I came into MOH about a year and a half ago, what struck me was the tremendous amount of groundwork that was done by my predecessor in laying a preventive health infrastructure, the IT system, the three clusters and all the medical protocols. So, I walked into a workplan seminar. As the new Health Minister, I had to speak to the senior doctors and management. At the workplan seminar, it was very daunting. I discussed with three very learned persons, our three Director of Medical Services (DMS), Prof Kenneth Mak, Prof Benjamin Ong and Prof Tan Chorh Chuan. I had in-depth discussion with them, discussed what was the next phase of healthcare and I think we zoomed in on preventive care. The good thing is, so much groundwork has been laid. On 23 May 2021, I think, I made my first speech in MOH. We talked about two topics. One was COVID-19 – Living with COVID-19 and second was preventive care, that was when Healthier SG, was first talked about. But really, thank you to the several Ministers before me and the whole team who laid so much groundwork. Then then we had COVID-19 closures and all that. We did not have many events until December.”
“You are. Thank you very much. And 18 September. A few Members have raised this issue. I will give a fuller response later in my closing speech. Thank you.”
“I thank the Leader of the Opposition. I am glad that he read my Parliamentary answer on TCM and also my December 2021 speech on TCM. I just wonder, last month, I gave two more speeches about TCM and Healthier SG. I just wonder whether he is aware.”
“I thank Ms Hazel Poa for her suggestion on the sugar tax. We have been very reluctant to look into a tax like that. The principle is not wrong – having a "sin" tax is the policy of this Government. When it is cigarettes, it is something that is harmful, we do tax it. Carbon, we tax it. We do tax sins. The question is sugar causes diabetes, should we tax sugar? The Member, Ms Hazel Poa, has suggested a sugar tax. I assume if you extend it further, you can also tax salt or oil, for example. We are reluctant to do this. First, it affects a lot of people. Sugar is commonly consumed by so many people and so, you will add cost. And also, we consider the equity of the tax. There is equity involved. Because sugar is found in fruit juices, sugarcane, the pearls in bubble tea. So, you start to make such comparison, it is not going to be so easy. Therefore, the implementation will be complicated. Which is why for MOH, we decided against it – notwithstanding other countries having imposed sugar tax. We use labelling and regulation. Senior Parliamentary Secretary Rahayu Mahzam talked about the Nutri-Grade labelling. Once we announced Nutri-Grade A to D, if you have high sugar content for canned beverages, you will be graded D, immediately, the beverage companies reformulated. As a result, today – I do not have the data with me – but we are achieving a reduction in sugar consumption as effectively as the UK with labelling and without a sugar tax. But thank you for that suggestion.”
“Between 1 January 2021 and 31 December 2021, around seven million invoices were issued to patients of public hospitals. Of these, approximately 6.7 million, or 96%, were issued within 30 days of the care episode and 6.8 million, or 98%, were issued within 90 days.”
“The nursing intake numbers in the Institutes of Higher Learning (IHLs) have remained relatively stable between 2017 and 2021, after growing by around 20% in the five years before that. Each year, about 2,100 students are admitted into pre-registration nursing courses at the Institute of Technical Education (ITE), Nanyang Polytechnic (NYP), Ngee Ann Polytechnic and National University of Singapore (NUS) combined. Employment outcomes for nursing graduates have also been strong over the same period. Based on the annual Graduate Employment Survey (GES) conducted by the IHLs, 83% were in full-time permanent (FTP) employment within six months after graduation. Of those in FTP employment, nine in 10 were working as nurses.”
“Based on data from public hospitals, the average number of pregnant women diagnosed with gestational diabetes in our public hospitals from 2017 to 2021 was approximately 2,950 each year. Women can lower their risks of gestational diabetes by achieving an optimal weight gain and adopting a healthy lifestyle before and during pregnancy. Pregnant women can access the Health Promotion Board (HPB)'s Parent Hub portal for resources on maintaining a healthy Body Mass Index (BMI) through exercising regularly and adopting a healthier diet. Gestational diabetes screening is offered to pregnant women between 24 and 28 weeks of gestation. Women with gestational diabetes will be closely monitored and managed with lifestyle interventions and may be referred to nurse counsellors for advice. Some may require medication or insulin injections for blood glucose control. It is estimated that four in 10 women with a history of gestational diabetes develop diabetes or pre-diabetes when measured four to six years after delivery. As such, between six and 12 weeks post-delivery, they will be screened for diabetes. If gestational diabetes has resolved, they will be recommended to continue lifestyle interventions and attend diabetes screening every one to three years. Post-delivery, women of any age with a history of gestational diabetes are eligible for subsidised diabetes screening under the existing Screen for Life (SFL) programme package. The Agency for Care Effectiveness (ACE) has recently updated the Appropriate Care Guide (ACG) in August 2022 on recommendations for screening, diagnosis and follow-up for gestational diabetes to provide the latest evidence-based guidance to support clinicians better.”
“Between 2017 and 2021, arrears by foreigners constituted less than 0.1% of the total bills issued by Public Healthcare Institutions (PHIs). This includes foreigners residing and working in Singapore, as well as some short-term visitors. The Ministry of Health (MOH) does not have data on arrears specifically for Long-Term Visit Pass (LTVP) holders. Government healthcare subsidies are, generally, accorded to Singapore Citizens (SCs) and Permanent Residents (PRs), in line with the broader Government policy of differentiating benefits by citizenship status. While LTVP holders are not eligible for medical subsidies, some may be covered by their sponsors' employee medical benefits or other private medical insurance plans. SCs and PRs may also tap on their MediSave to pay for the medical expenses incurred by their immediate family members, and this includes those who are LTVPs. LTVP holders who face difficulties affording their healthcare bills may approach the medical social workers at the public healthcare institutions to apply for assistance. PHIs may offer payment instalment plans or provide assistance using charity funds based on their medical social workers' assessment.”
“Hospitals do not routinely track referrals to private general practitioners (GPs) by diagnosis. Nevertheless, since 2018, some private GPs have organised themselves into Primary Care Networks (PCNs) to provide more holistic and team-based care and take on patients previously attended to by hospitals. Based on available information from public acute hospitals, about 10% to 20% of diabetic patients seen in these hospitals are referred to primary care doctors between 2018 to 2021. With Healthier SG, more patients with chronic diseases, including diabetes, will be treated in GP clinics and we expect caseloads to continue increasing.”
“Kidney dialysis is required for patients with End-Stage Renal Disease (ESRD), where their kidneys can no longer function adequately. The increase in the number of ESRD patients on dialysis is driven mainly by Singapore's ageing population and the prevalence of chronic diseases, particularly, diabetes and hypertension. The ESRD, or kidney failure imposes a heavy personal and social cost. It is also a significant burden for the healthcare system. The Ministry of Health (MOH) has not done an estimation of the socioeconomic costs. "Dialysis" is commonly understood to mean haemodialysis (HD). This is the more common mode of dialysis, but peritoneal dialysis (PD) has been shown to be more cost-effective and produces clinical outcomes comparable to HD and is done at home, providing convenience and independence for patients. Hence, MOH has adopted a PD-preferred strategy for medically suitable patients. MOH also provides higher subsidies for PD to encourage uptake and aims to raise the percentage of PD uptake amongst new dialysis patients from 19% now to 30% by 2025. In working towards this target, MOH works with stakeholders on a set of pre-dialysis counselling, training and educational materials to help patients to perform PD independently at home. In April this year, MOH launched the National PD Home Support Programme, which provides home visits and more targeted counselling and support to help patients and their loved ones to gain confidence to perform PD at home. MOH also provides means-tested subsidies to patients receiving HD and PD treatment, including those receiving PD home support. Patients can also use MediShield Life and MediSave for their dialysis treatment, and there is also charity assistance for those who face affordability concerns.”
“Severe infections and illnesses, particularly those requiring intensive care, can result in acute kidney injury that necessitates dialysis. This has also been observed for COVID-19 patients who had become severely ill. Otherwise, COVID-19 has not been established to directly cause an increased risk of end-stage kidney disease requiring long-term dialysis. Likewise, there has been no established link, locally or internationally, between COVID-19 vaccines and kidney disease.”
“But there is also the concept of population health where healthcare, social support systems and societal habits – plus personal responsibility – come together to make a population healthy. It is a higher level of health outcomes, going beyond what medical personnel alone can do but what a whole-of-society can achieve. There is a similar concept in Chinese medicine. It is well summarised by Tang Dynasty doctor Sun Simiao (孙思邈) who said, "上医医国, 中医医人, 下医医病". The saying, essentially, without translating it in detail, differentiates the outcomes of curative care, preventive care and population health. If all of us come together to make Healthier SG work, we will progress towards the holy grail of healthcare – healthy longevity. That is when the number of years we can live healthily approximates the number of years we can live biologically. Mr Speaker, Sir, I look forward to the views and suggestions of Members of the House. Mr Speaker, I beg to move. [Applause.]”
“There are two systems: one that emphasises the treatment of the disease and the individual, and the other, which is the population health system, seeks to improve the health of the nation. So, both Western and Asian cultures have such concepts. Healthier SG is a long-term strategy that spans over many years. It is an important turning point in Singapore's national healthcare policy. For MOH, this initiative is a heavy responsibility with far-reaching implications. Its success requires the cooperation and effort of Singaporeans and the entire country. (In English): Sir, let me conclude. Healthier SG involves a mindset change in the way we look at healthcare. I would like to quote a passage in the White Paper. Quote: "we need to do things differently. Clinicians will need to constantly think of ways to prevent residents from falling sick, against instincts trained to treat as many suffering patients as possible. When conducting...health screening, we will have to deploy less precise but more scalable solutions, to identify residents...who have higher risks of falling ill." "Policy planners need to develop and evaluate programmes and initiatives across a multi-year Budget cycle, consciously investing in preventive care now to avoid years of pain and suffering later." "Every player needs to work closely, increasing the extent and depth of integration of their services." Unquote. Only by doing things differently and collectively can we achieve results beyond what traditional healthcare can deliver. In Western medicine, there is a distinction between different levels of health systems. The traditional understanding of healthcare comprises primary and acute care – ICUs, hospitals, clinics.”
“Some people might think that going for check-ups, receiving vaccinations and seeing a doctor regularly are not necessary. We often hear stories about individuals, for example, a friend who smokes a packet of cigarettes a day and consumes fatty meat every week, but still lives to a ripe old age of 90. This is a "lottery" mentality. The "winners" who lead unhealthy lifestyles without suffering from health issues are definitely in the extreme minority, who "struck the lottery". But we all know that out of those who bet on the lottery every week, the vast majority would lose money and only the rare few wins something. In general, those who live unhealthily tend to end up as "losers", and the risk of falling ill is high. So, we should not gamble with our health and our lives. In an earlier Lianhe Zaobao report, I came across a quote from Sun Simiao, a famous Tang dynasty physician, which I thought is very meaningful, and worthy of sharing here. To him, a lower-skilled doctor can only treat a person's illness, a mediocre doctor can take care of a person's health and a superior doctor would be able to improve the health of the entire nation. Sun Simiao also said that an extremely capable doctor treats illnesses before they surface, a mediocre one treats an illness that is just starting, while a lower-skilled one treats an individual's known illnesses. This is a meaningful saying. What Healthier SG aims to achieve is the vision of improving the health of the entire nation. Healthcare should not only depend on medicine but also on our lifestyle habits; it should not rely on hospitals but also the community; it should not just rely on doctors, but also on individuals and families. Western medicine also has similar views on healthcare.”
“The key components are described below: First, and most importantly, we need to ensure that every Singaporean visits a dedicated family doctor or clinic. As to which doctor or clinic, they will have a choice. They will also have the flexibility to change doctors after enrolment. I would also like to clarify that family doctors under Healthier SG are not limited to those from private clinics but will also include doctors from polyclinics. Seniors who currently visit polyclinics regularly can continue to do so and there is no need for them to transfer to a private clinic. Second, the Government will increase subsidies for preventive care. These include subsidies for MOH-recommended screenings and vaccinations, and consultation fees for regular preventive care services. The Government will provide full subsidies for these healthcare services. This means that you do not have to pay; the Government will pay in full for you. Third, many Singaporeans already have chronic illnesses, and they use their MediSave to pay for the relevant treatments. Under the current regulations, they have to co-pay part of the fees. Under the Healthier SG system, we will do away with the cash co-payment for the treatment of chronic illnesses. Fourth, we will also utilise the Healthy 365 app to expand the scope of rewards for adopting a healthy lifestyle. Many Singaporeans are already actively participating in the National Steps Challenge. Besides walking, if individuals engage in other activities, such as ball games, dancing, gardening or other workouts, they will also be rewarded. With digital technology, there will also be rewards for eating healthily. In Hokkien, we say this is "wu jia go wu gia", which means "to have something to eat and also something to take away".”
“They may have to see their GPs periodically for advice, moderate their food and sugar intake, which actually saves money, and take some medication as needed. But when the disease is allowed to go out of control and dialysis is required, it costs about $25,000 a year. Taxpayers and donors have to help them foot the bill. But the bigger cost, and what we are most concerned about, is the personal suffering. Some residents say, "I prefer not to do preventive care now. I prefer not to do health screening now. Better not to know. Because if I know, I need to do something about it and the bill can be expensive". I really hope we do not have such a mentality because even if you choose not to know now, the disease will make sure you know later. And when the disease makes sure you know later, it will be even more expensive – not just in monetary terms, but in suffering, for you and your loved ones. Mr Speaker, Sir, let me now say a few words in Mandarin. (In Mandarin): [Please refer to Vernacular Speech.] Mr Speaker, since March this year, MOH has engaged more than 6,000 individuals through various channels to garner their views on Healthier SG. These have contributed to the final White Paper. When we consulted the public, we did not start from scratch. We presented our thinking and implementation concepts on the Healthier SG strategy, and sought the public's views on their concerns, questions and suggestions. Through this process, we also realised our blind spots. And from the public feedback, we were able to ensure that the plan will be more comprehensive, more effective and more practical. I would like to sincerely thank everybody for their comments and support. The White Paper articulates how we will help Singaporeans to become healthier through various ways.”
“With Healthier SG, in the coming few years, we will, and we want to grow this, perhaps to double the share of total healthcare spending. In making these investments, our primary motivation is to reduce disease burden and the suffering of people and their loved ones. Will there also be a financial payback, in terms of reducing healthcare spending in future? It will be good if this comes about, but it is too early to give a realistic estimate. Because any impact in health of people would not happen immediately. The impact will, perhaps, be discernible eight or 10 years down the road. Even so, we cannot reverse the rise in healthcare spending. It is not possible with an ageing population. What we can hope for is to slow down the rate of increase of healthcare spending. Today, our national healthcare expenditure is expected to be about $22 billion a year. This is the annual medical bill for the whole nation. We are expecting it to almost multiply threefold, in the coming 10 years, to $60 billion in 2030. If this national medical bill, instead of tripling, doubles in the next 10 years, we would have saved much more than what we are planning to spend on preventive care. At the heart of Healthier SG is a philosophy of how we choose to live our lives. If we put in a small effort every day, a bit of discipline every week, a bit of restraint every week, we can avoid big, life-changing suffering later. We can illustrate this logic from a personal perspective. Earlier on, I talked about the kidney dialysis patients at NKF and how they regretted not taking preventive action earlier. If they had practised preventive care, it would have cost them very little, in terms of effort and money.”
“And the fee will be similar or higher than the current Care Plus fee, depending on the health conditions of the enrolled residents. We estimate that in the coming few years, Healthier SG service fees and revenue from subsidised services can grow as more residents enrol and become a significant component of the GPs' annual revenue – maybe a quarter or a third. Hand on heart, MOH has always been a very fair and prompt as a service buyer and I assure GPs that we will continue to be so. What MOH may not be very good at, is to minimise your administrative workload. It is unfortunately inevitable, as we need medical data of patients to be captured in our national health record system and paperwork is needed for payment claims. We will try our best to ease this administrative workload. Some GPs also do not have IT systems to support Healthier SG. Some are still largely using pen and paper. MOH will also provide a grant to each GP clinic to help them be IT-ready for Healthier SG. Mr Speaker, Sir, let me now move on to elaborate more about the finance and budget implications of Healthier SG. Healthier SG requires a lot of effort and resources to set up. We need new IT systems, ground support capabilities, give GPs one-time support for the necessary IT enhancements and capability-building to bring them on board. So, we estimate a set up cost of over $1 billion over the next three to four years. Beyond that, there will be recurrent costs. This includes all the support measures for residents I talked about earlier and the annual service fee for GPs. This is estimated to be another $400 million per year. We spend about 6% of our healthcare budget on preventive care annually, such as to fund HPB.”
“Hence, from the time we conceived Healthier SG, we were very mindful that it should not take business away from GPs. So, GPs will continue to attend to their existing patients and prescribe medication to them. What Healthier SG does is to enlarge their client pool, through enrolment for preventive and chronic care consultations. In line with this, GPs should be fairly compensated by MOH for their effort and advice in delivering preventive care. MOH will, therefore, extend an annual service fee payment for each resident who enrol with them. This service fee is what we will describe loosely as a "capitated payment". That means we do not pay the GP for every consultation, every test, every prescription and every service they provide. Instead, we pay them a standard fee, which is a base, per enrolled patient for maintaining a long-term relationship with the patient. It will cover the regular check-ins, ensuring the residents adhere with their health plans, the associated administrative work and also, reviewing the health plan annually. This is over and above subsidies for health screening and medication, which are separately funded. For the Government, this method of payment and subsidy is not new. It is largely how we fund education, where polytechnics and universities receive a standard amount of budget per student. Even though some students take more classes or some students participate in more subsidised activities than others, we pay an average standard budget. For GPs, it is also not a new concept. GPs who assist our healthcare clusters to manage complex chronic patients get a "Care Plus" service fee payment today of $100 per patient. Healthier SG will broaden such schemes to cover preventive care for large segments of the population.”
“So, you take a picture of your char kway teow and then, it will match against our database of different food and your calorie intake, and will monitor your calorie intake. But you have to take honest pictures – do not just keep taking photos of vegetables! We have also made Healthy 365 compatible with more popular digital health apps like Apple Health Kit, Fitbit and Samsung Health – all these are already compatible. We will try to link it up with other commercial digital health apps. That way, your lifestyle data captured by these commercial apps can be ingested into Healthy 365 and you can claim Healthpoints. I should mention in this House that I do notice some of our Members have become a lot fitter visibly. I noticed Mr Desmond Choo over the months, big change. Dr Wan Rizal, amazing change. And my Second Minister for Health Masagos Zulkifli. I think they should be Healthier SG ambassadors. So, what do we have? To summarise: a dedicated doctor, a health plan with social prescriptions, full subsidy for nationally recommended vaccinations and health screening, full use of MediSave for chronic disease management, enhanced subsidy for common chronic drugs at GP clinics, more community lifestyle activities, more Healthpoints for leading a healthy life. They all come together, complement each other, to support residents to take personal responsibility and action to embark on their healthy life journeys. The second important group of stakeholders are our family doctors, from both polyclinics as well as private GP clinics. They will find themselves at the centre of this strategic long-term healthcare transformation plan. GPs need to earn a living by running their clinics. We must make sure that Healthier SG works for them.”
“But we will substantively remove the current difference in drug prices between the two for individuals enrolled in Heathier SG. Fifth, we have roped in important community partners, such as PA, SportSG, HPB and others, to organise more health-related activities for residents, from ball games and brisk walking; to Zumba classes and community gardening. So, while you may see your enrolled doctor only once or twice a year, outside of the clinic, you are not alone. We are enhancing public infrastructure like sports facilities, parks and park connectors, and community partners will support your active lifestyle. Sixth, we will award Healthpoints to help encourage residents to adopt and sustain a healthy lifestyle. Many residents who already participate in the National Steps Challenge and the Eat Drink Shop Healthy Challenge are familiar with the Healthy 365 app. It is your virtual champion to nudge you to be healthy. The app awards Healthpoints for living an active lifestyle and making healthier food purchases. It does not just clock steps but also tracks physical activity through your heart rate. You may be dancing, lifting weights, doing community gardening, doing Zumba, Healthy 365 do not exactly know what you are doing, but it knows your heart rate is higher and from there, it derives that you are physically active and will award Healthpoints accordingly. Healthpoints can be exchanged for a range of rewards, such as public transport and many participating merchants. The reward is not large, but it has a way to give us psychological satisfaction that, "I have accomplished this exercise". And it is a very effective nudge, especially when gamified. We will be enhancing Healthy 365. For example, it will be able to track your calorie intake.”
“The third way to support residents – if you are using MediSave to pay for the treatment of your chronic illness, you are no longer required to co-pay 15% of the bill using cash. You can just use your MediSave. These changes are somewhat of a departure from most Government subsidy schemes, where some co-payment from residents is often required to reflect the sharing of responsibility and uphold the concept of individual effort. Here, we have decided that since preventive care is very fundamental to healthcare, further subsidy is justified. It does not contradict the principle of personal responsibility, because in the context of preventive care, personal responsibility and action are needed to make changes and lead a healthier life. Fourth, we will enhance the subsidy for common chronic disease drugs at private GP clinics. Many residents gave feedback that there is a significant drug price differential between the GP clinic and the polyclinic. So, even if they wanted to stick to one family doctor at a GP clinic, when it comes to taking medications, they will go back to the polyclinic where medication is cheaper. To help residents anchor with a family doctor of their choice, we intend to level this price difference, by introducing an additional subsidy tier to Community Health Assist Scheme (CHAS) for common chronic drugs and also set drug price limits. This benefit will be available to all enrolled Singaporean CHAS card holders, including Pioneer Generation (PG) and Merdeka Generation (MG) card holders. I should add a small caveat, which is that the basis of calculating subsidies at polyclinics and for CHAS are different. There is a technical reason, but we will not be able to equalise the price down to the last cent.”
“But please choose one to be your dedicated family doctor whom you trust, who knows your conditions well and can work with you to practise preventive care. In the same vein, some residents are worried that their regular GP may become so popular that they get squeezed out by the demand. We will try our best to manage this. In the enrolment process, there will be a dropdown list. The doctor you regularly visit will be at the top for you. So, that will give you an edge over your "competitors". And we are working with GP networks and polyclinics to let us know who their regular patients are in order to facilitate this. We are also doing this in stages, so that enrolment demand will not be so overwhelming, overnight. You may also want to enrol early when the time comes to "chope" your regular GP. The second area of support is that once you are enrolled with a family doctor, the Government will fully fund the most important aspects of preventive care. Hence, annual preventive care check-ins with your family doctor, nationally recommended vaccinations, such as influenza and pneumococcal vaccinations and health screenings will be free. Health screenings will include three very common chronic conditions – type 2 diabetes, hypertension and hyperlipidaemia, and three cancers: breast, cervical and colorectal. These are recommended for the general population and will be free. Those with specific risk factors may be referred for further tests. And there are more complex screenings, like colonoscopy, which is an invasive procedure and not appropriate to be made a standard screening for everyone. Although it is not free, it will continue to be heavily subsidised at our hospitals.”
“We can still enjoy many things in life, especially the good food – the char kway teow, the prata, the mee rebus, the occasional bubble tea with less sugar – just everything in moderation and without overindulging. And we will find joy in exercising, especially with friends. We will be able to snub out smoking or Juuling and not miss them. The support to residents – we must support residents to do all these. And it comes in several ways. Let me just describe how we are supporting residents. The first and most significant form of support is your long-term relationship with the family doctor. And research has shown people with a dedicated family doctor are much less likely to develop serious illnesses. Your enrolment with a dedicated family doctor is, therefore, a critical first step. However, since the release of the White Paper, there have been a few concerns on enrolment, and I might as well clarify them in this opening speech. Some residents are worried that once you choose a doctor, it is a final decision that cannot be reversed. Not to worry, we recognise that there are times when a resident needs to change their doctor, either because they have moved houses, or have found a more suitable doctor. And so, we have provided the flexibility for residents to change your enrolled doctor. Nevertheless, when the time comes, please make your choice carefully and consciously. Other residents are worried that once they enrol with a doctor, they cannot see other doctors – banned – including specialists that they are now seeing because of their chronic illnesses. So, please be assured that this would not happen. You are free to continue to visit all other doctors, including your specialists.”
“They are in the background, but a lot of work has gone into these and they are extremely important. What will all these mean to people? Let me start with the most important stakeholder group – residents, whom we represent here. The greatest impact is that residents will receive much stronger support to stay healthy and prevent any existing illnesses from worsening further. And we are making a big effort to support you, because it is almost human instinct to not do the right thing because of instant gratification. "Have a puff to destress now, worry about health later"; "eat the cheesecake now, worry about sugar later"; "eat the fried chicken now, it is very nice"; "laze around instead of exercising"; "binge watch Korean drama instead of having a good night's sleep". All these instant gratifications. Everyone is smiling. We are all guilty. Nothing bad will happen immediately or next day, but they accumulate to cause serious diseases, or can aggravate existing illnesses later. Every grain of sand you keep dropping will become a bucket. And, by then, it will be a big burden. It can cost us, our organs, our limbs, our minds, our lives. I visited the National Kidney Foundation (NKF) recently. They told me that every day, six more patients in Singapore require dialysis – every day, six more. To be on dialysis means you need to visit the NKF centre three times a week, each time five to six hours. Your life is totally changed. And the staff told me, that most patients there at NKF regret not correcting their diets and lifestyles while they could. But now, it is too late to reverse. They have to live with dialysis the rest of their lives. So, let us try to live without regrets.”
“Three, I will speak more about its budget and financial implications, as this is only briefly covered in the White Paper. One, to recap, there are five key components to Healthier SG. First, family doctors. They are the lynchpin of Healthier SG. We want to mobilise them to build strong relationships with their patients and play a bigger role in preventive care. Two, health plans. These will be developed between doctors and patients. The health plan comprises an overview of the health status of the resident, the health goals to achieve and an action plan, which can include going for essential health screenings and vaccinations, and changes to your lifestyles. This whole area is what we call "social prescriptions". And doctors are saying that "social prescriptions" are often more important than drug prescriptions. This brings us to the third component, which is community partners. It may not be easy to follow diet or exercise advice and improve lifestyles by ourselves. Many of us have tried, but to no avail. So, we will draw on the effort of agencies such as Health Promotion Board (HPB), People's Association (PA) and SportSG. They are organising many health-related activities on the ground, to create that supportive environment to help us change. And once the first three components are ready, we embark on the fourth, which is the national enrolment exercise. And this will commence in the second half of 2023 next year, starting with residents aged 60 and above. Then, each resident chooses the family doctor or clinic you wish to build a long-term preventive care relationship with. And from there, we begin our journey towards better health. Finally, enablers. We need the right IT systems, manpower and financing structure to make Healthier SG work. These are invisible.”
“What are the details that matter? How to make it work? What are the potential pitfalls? It is an important process to make sure that we design the system right. And we got many useful inputs, which we have tried our best to incorporate in this White Paper. So, I want to say a few thank yous. First, thanks to all our stakeholders for their contribution. They took the engagement very seriously. And I think they realised that this is a very important exercise, a very important reform, possibly the most significant in decades. And I want to especially mention about 50 family doctors. They are from the College of Family Physicians Singapore, Singapore Medical Association, our Primary Care Networks, polyclinics and the National General Practitioners Advisory Panel. They devoted a lot of time and energy in working with us in designing Healthier SG. They meet almost every week, over weekends, on top of running their clinics. I would also like to extend my appreciation to the many healthcare practitioners and partners. They range from nurses, allied health professionals, pharmacists, people who work for community organisations, unions, grassroots leaders, employers. They shared their views and contributed their ideas. Last but not least, I also want to thank the officers of MOH, who did a lot of the coordination, the staffing, the drafting and the preparatory work. I know they are very proud of being part of this co-creation effort with all our partners. Today, I will do three things. One, I will go through, very briefly, the salient features of Healthier SG as a recap. Two, explain what this means to the two most important sets of stakeholders – residents and General Practitioners (GPs).”
“Second, our COVID-19 response showed that as a people, each of us are prepared to do our part, have each other's backs and work together to fend off the pandemic. The things we do during the pandemic – vaccinations, tests, self-isolation – and these are all preventive care in action. We found ways to integrate preventive care with acute care in hospitals, in our treatment facilities and with home recovery. And if we can replicate that whole effort in our fight against debilitating chronic illnesses, especially those that come with ageing, then we would have made a big difference in the coming 10 years. And that is why we developed the Healthier SG strategy, which I announced in the Committee of Supply (COS) earlier this year. It is a fundamental re-orientation and reform of our healthcare system, focus on preventive care instead of curative care, emphasise on health instead of sickness, to shift the centre of gravity of care away from hospitals, into the community, to rely less on doctors for health, but to depend on communities, our families and ourselves – and live up to the name of Ministry of Health (MOH), not Ministry of Sickness. During COS, I said that we would seek the inputs of stakeholders, as we flesh out our proposals, and then we will come back to Parliament again. So, here we are. And since then, MOH engaged more than 6,000 members of the public, including 1,000 healthcare professionals. We did surveys, focus group discussions and in-depth one-on-one interviews as well. In this engagement, we did not present our stakeholders with a blank canvas and ask them what we should do to improve health. Instead, we presented a broad plan, a concept of what we planned to do. And then, we asked them – looking at this, what is missing? What are your concerns?”
“Mr Speaker, I beg to move, "That this House endorses Paper Cmd 19 of 2022 on 'White Paper on Healthier SG' as the basis to transform our healthcare system by (a) focusing strongly on preventive care; (b) fostering lasting relationships between residents and family doctors; and (c) building strong partnerships within the community, so as to support individuals taking care of their own health and wellness and strive towards our vision of long and healthy lives for Singaporeans." Sir, COVID-19 has put all healthcare systems in the world under stress. It exposed the shortcomings and weaknesses of the systems. On the other hand, it made practices that used to be impossible, possible now. It was a jolt to the core of all our systems. As the pandemic dust settles, many health authorities are now in a reflective, in a soul-searching mode, rethinking how to improve their healthcare systems. For example, for Indonesia, I am constantly in touch with the Health Minister and they are making a big effort to strengthen the accessibility to healthcare services throughout the archipelago. New Zealand is strengthening central national healthcare planning, to reduce the pressure on specialist and hospital care on the ground. The UK is making a renewed push in integrated care between social and healthcare organisations. And just yesterday, we just heard Hong Kong is also doing a deep healthcare reform effort. As for Singapore, we are embarking on a long-term and profound reform effort. And there are two important considerations in driving this reform. First, our society is ageing rapidly. To reduce the disease burden and preserve the quality of life of our people in the coming years, we have to become healthier.”
“Patients can use up to $500 or $700 a year from their MediSave for the treatment of mental health conditions under the Chronic Disease Management Programme (CDMP), depending on the complexity of their condition. In 2021, about nine in 10 of all patients who withdrew MediSave under the CDMP did not reach their annual $500 or $700 limits. These limits therefore remain adequate. Under Healthier SG, the 15% co-payment requirement will be waived when patients use MediSave for CDMP treatment at the clinic they enrol with. As always, patients who face difficulties paying for their medical bills may also apply for financial assistance such as MediFund at public healthcare institutions.”