Building a Healthier SG

3.01 pm

The Minister for Health (Mr Ong Ye Kung): 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.

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? 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). 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. 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. 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. 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.

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 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. 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. 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. 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. 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. 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. 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".

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. 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. 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.]

Mr Speaker: Members will be glad to know that Parliament Sittings can be part of the Healthier SG range of activities as well. Our heart rate goes up considerably at times. [Laughter.] Dr Tan Wu Meng.

3.39 pm

Dr Tan Wu Meng (Jurong): Mr Speaker, I declare that I am a medical doctor in a public hospital looking after cancer patients.

It has been 57 years since Independence, six decades since MOH was set up during British colonial days – nearly a lifetime. So, we should take stock, and ask ourselves, not just what comes next, but what if. What if we reimagined our healthcare system today, anew? What would we keep? What would we change? What we would we transform?

Healthier SG is an important first step in this reimagining. It is an opportunity for a healthcare transformation, and I dare say, a healthcare revolution.

Earlier this year, during the debate on MOH's Budget, I called for change – a change agenda. Today, speaking on Healthier SG, I will speak on helping residents and helping family doctors to help residents.

Let me start on co-payment. It was a central dogma for public healthcare financing in Singapore for many years, but we must judge policy – not based on dogma but whether it gets the job done, whether it achieves the desired goals.

The original idea for co-payment was to shape behaviour so that people look at the bill, consider what is value for money. But what happens if co-payment discourages some residents from going for medically recommended screenings, medically recommended vaccinations, medically recommended treatments for chronic disease, even if the illness might become a bigger problem some years down the line and cause suffering that you cannot even put a price tag on? The less well-off might well be affected the most.

So, it is an important step to fully subsidise nationally recommended screenings and vaccinations for Singaporeans, to remove the need for cash co-payment when using MediSave to treat chronic disease under the care of a family doctor – as part of an MOH programme.

In short, the behavioural nudge needs to be towards prevention and health, rather than a sludge that makes it harder to do what is necessary to prevent greater problems down the road. We should make it as easy as possible for people to do the right thing. Nudge, not sludge.

Sir, on subsidy, the place of subsidy matters too. In our early days, with a young population, subsidy was very much centred on the acute hospitals. Over the years, subsidy has become more and more decentralised so that care can be delivered with subsidy in the community, for chronic illness, closer to home.

But with our ageing population, with seniors becoming less mobile, some finding it harder to go out, we also need to look at how care and, where needed, subsidy is delivered to patients and residents in the community – seeing through the eyes of our people.

Sir, I visited the funeral wake of my Clementi resident, spoke with her family who told me their story. Ah Ma had been ill for some years – ill with a major stroke, bedbound, could not get out of the home. She was a PG Singaporean with a PG card but because she was not mobile, bedbound, she physically could not get to the polyclinic near her home. That meant she could not access the polyclinic care without a means test. It meant she could not apply her PG card subsidies towards the remainder of the bill without having to go through a means test.

In contrast to an able-bodied Singaporean able to go to a polyclinic, walk in the door, access polyclinic care without means testing, and apply the PG card without means testing.

The family engaged a home doctor from an established voluntary welfare organisation (VWO) for house calls, writing medicines, prescriptions on a piece of paper, a paper prescription. The family would then bring the paper prescription to the nearby polyclinic and pay unsubsidised rates for the medication.

Had Ah Ma been physically mobile and able to get to the polyclinic in person, there would have been no such administrative hurdle.

So, we need to look at cases like this, see if there are ways to deliver care closer to patients' homes, and even have some medically necessary consultations in patient's homes, if needed. And likewise, to see if the funding journey can be more straightforward for such home medical visits, where they are assessed to be medically necessary.

There are also some Clementi seniors who have regular medical appointments at hospitals, needing blood tests. They are wondering if some of these medically necessary tests can be done closer to home, or on occasion, at their homes, while still receiving some level of subsidy. It saves time waiting for some blood tests that may take several hours and it saves a trip back and forth, for blood tests that need to be done a few days before the medical appointment. Because when a caregiver has to accompany a patient back and forth, the burden, the stress, the worry, does not just fall on the patient. It falls on the caregiver who may have to take time-off from work and often it is the less well-off caregivers who have less bargaining power with the employer, less able to take time-off without worrying for the safety of their jobs.

So, for medically necessary treatments, Mr Speaker, we should look at how to bring the subsidy to the patient, if it helps prevent hospitalisations, reduce the burden of suffering, if it reduces the number of visits and the load on caregivers.

Because when subsidy is tied to a physical venue, to a place of bricks and mortar, it can become accidentally regressive because the less well-off – patients and families who are less mobile, they find it harder to get to the place of care, harder to access to the subsidy. And it is these families who also find it harder to apply for private medical transport, to foot the bill, to get to the place of care.

So, I call upon MOH to look closely at this because if the policy intent is to provide subsidy where help is needed, then we have to keep a lookout for physical or systemic barriers.

There is a broader point, Mr Speaker, how do we better support residents, and particularly, long-term patients, who continue living in the community and want to minimise visits to and from hospitals – patients with advanced neurological conditions like motor-neuron disease? I asked a Parliamentary Question in Parliament yesterday but unfortunately; time ran out and I could not ask my supplementary question. For patients with advanced neurological conditions, later-stage kidney diseases or dementia – can we find ways to better empower family doctors who have known these patients for years, family doctors who hope for better support from the hospital clusters, to care for patients in the community?

I call upon MOH to look at forming a workgroup as part of Healthier SG, to look at the issues faced by long-term patients with serious medical conditions living in the community. Look more closely at patient journeys, deeper at the challenges faced by caregivers, healthcare providers, seeing through the eyes of our people.

Sir, I want to talk about Healthy 365. MOH has designated the Healthy 365 app as the "digital window" to programmes by PA, HPB, SportSG and other programmes as well. But what happens for seniors who do not have a smartphone, who are not digital savvy, who are not quite comfortable using a smartphone app?

We must make sure the digital window does not become a digital bottleneck. There must be careful attention to ease of use, understanding what our seniors and elderly need and find easy to use. Technology must serve, adapt and bend to the person, rather than getting people to bend to the technology. Seniors who feel left behind by digital change should not be treated as having fallen by the wayside, or not able to adapt. Just because a senior is not on a digital dashboard does not mean the senior is not there.

Sir, Healthier SG also mentions residents having individual choice of healthcare provider. This must be in practice, not just in theory. I have met Clementi residents asking about what will happen at our national specialist centres that treat heart disease or cancer, for example.

A cancer patient might have lived in Tiong Bahru for many years but chooses to stay with a loved one in Jurong who can be caregiver while they undergo treatment. So, she might want to see a specialist in the west, rather than in central Singapore.

Some Clementi residents have asked: will it become harder to seek specialist care in a hospital outside your own geographical cluster? Will there be obstacles to patients choosing which public hospital they can go to, to receive their subsidised specialist care, once capitation kicks in? Can MOH confirm that patients will not face uphill hurdles – financial or administrative – if they wish to see a specialist at a different public hospital from the Healthier SG cluster near their home?

Sir, let me speak on helping family doctors to help patients and residents. I want to talk about care and how it takes time.

Preventive care, chronic care, holistic care, it takes time. Some of these discussions are as much conversation as consultation. Talking with a patient that you have gotten to know over the years, understanding why they took up smoking, why it is hard to kick the habit, persuading them to make that change, for better health and to save their life. Talking with a senior who has just been discharged from hospital after an illness, helping that senior find hope and confidence again to go back to exercising and leading a healthy lifestyle. Or making that time to be with a patient and a family through a difficult illness that may be getting worse, working through with the patient and family on what might be best in the difficult months and weeks or even days ahead. All these take time.

And so, it is so important for MOH to continue looking at what happens in the real world, understand how much time is needed to deliver holistic care and to support our healthcare workers and family doctors on that journey. Paying family doctors to this important work, recognising the time needed is an important step. It sends a message that the work must be done, is being done and needs to be recognised.

Will MOH also apply these important lessons to our public healthcare system too so that polyclinic doctors and healthcare workers can also be given more time, space and support to deliver that holistic preventive well-rounded care that we continue to work on and aspire to?

I want to speak on enablers. The Healthier SG White Paper mentioned system enablers. We enable by making systems better, but this must also mean easier access, easier to navigate, fewer obstacles.

I want to talk about medical IT, Mr Speaker. Earlier this year, I spoke on how across the public healthcare system alone, we have 14 million consultations each year. Imagine if we save one minute on waiting for computers and apps and technology-related time spent — less time spent waiting for technology or grappling with technology. That would mean 14 million minutes saved every year – 10,000 workdays, or about 27 years of someone working 24 hours a day. It is not a small matter.

And with more family doctors coming on board, connecting with the public sector IT system, it is all the more important that the IT continues to improve – enabling, empowering, not getting in the way.

Even as the healthcare IT is enhanced, there must be attention to ease of use. Sometimes, people prefer paper records, manual processes, not because they are afraid of technology, but because they find that existing technology platforms are more cumbersome, that it takes more time. And in our design and implementation, we must continue looking at this.

I previously called upon MOH to give this the same attention and focus, as the big firms do, like Apple and Google, because today, every patient, every healthcare practitioner knows how a well-designed IT platform from a major tech firm can do things. And people will benchmark ease of use, elegance, against what the big firms do as well.

Mr Speaker, some healthcare workers and family doctors worry about the paperwork and administrative overheads from Healthier SG.

The White Paper mentions submission of patient data. Will MOH look at how the software is designed, how long it takes to fill up a form, whether existing clinic software may become slower and more cumbersome once it connects with the public sector IT network?

Has MOH assessed whether small clinics will need additional headcounts to address the compliance requirements of joining Healthier SG. Will the subvention consider this as well?

For capitation, Mr Speaker, MOH has said there will be a shift to capitation funding where clusters get a pre-determined fee for every resident assigned within a geographical area.

Can I ask the Ministry: will capitation consider that different patients have different needs, some patients having more medical conditions, more illnesses, more complex needs and thereby, more attention and more funding needed to achieve the same healthcare outcome?

Sir, systems and enablers in the healthcare process, it depends ultimately on our workforce, our people. Our people are what enables us to deliver care.

Healthier SG means that the role of family doctors in the community will be ever more critical – doctors drawn from the community, serving, caring, looking after the community.

So, we need to ensure a diversity of backgrounds and journeys in our healthcare workforce, in our medical profession, at every level and in every generation.

Much work has been done. There has been progress, but we must continue giving this much deliberate attention, whether it is flexible work arrangements (FWAs) so that healthcare workers who are parents, who are caregivers to an elderly relative who need more flexible arrangements at work, that they can continue training, developing, growing, progressing on their journey. Likewise, going upstream to ensure that no matter where you start in life, no matter your background, no matter whether your journey took longer or a detour, that your starting point never deters you from stepping forward on that journey.

Mr Speaker, in conclusion, as I said two years ago during the debate on the President's Address, healthcare is about all our lives – your life and mine, the lives of our loved ones, the life of every Singaporean. I call upon MOH and this Government to provide the resources, energy and imagination to do what is necessary to keep our healthcare system fit for purpose today, for tomorrow and for a generation to come. I stand in support of this Motion. [Applause.]

Mr Speaker: Mr Gerald Giam.

3.58 pm

Mr Gerald Giam Yean Song (Aljunied): Mr Speaker, Healthier SG is a welcome new initiative, even though focusing on preventive healthcare is something that has been advocated for over the years.

In February this year, the Member for Aljunied Group Representation Constituency (GRC), Mr Leon Perera, made a very comprehensive Adjournment Motion speech on rethinking preventive health to generate better outcomes. Among his policy recommendations were for the Government to set short- and long-term targets for reducing the incidence of chronic diseases, encouraging more people to go for health screening by providing additional subsidies for MediShield Life premiums and nudging people to buy healthier food products providing a digital currency earmarked for their purchases.

To its credit, MOH is now bringing preventive healthcare to the forefront of healthcare policy, through the Healthier SG programme.

My speech today will focus on managing the cost of healthcare under Healthier SG, and measuring and improving the desired health outcomes of the programme.

Under Healthier SG, MOH will waive the requirement for residents to co-pay part of their bills in cash when using MediSave for chronic care management at their family doctor under the Chronic Disease Management Programme (CDMP). Can I ask the Minister if there will still be an annual MediSave withdrawal limit for chronic disease management?

According to an answer to my Parliamentary Question, in 2019, some 15% of patients reached the $500 withdrawal limit – this is now being increased to $700 – most of whom had complex conditions. Fifteen percent of patients in 2019 translates to about 20,000 patients in absolute numbers. These patients were restricted in the use of their own medical savings for chronic disease treatment. It could discourage them from seeking treatment for their conditions and lead to a further deterioration of their health.

This could necessitate more expensive interventions down the road, like hospitalisations or amputations, which will drastically reduce their quality of life. Given the direction of Healthier SG towards waiving cash co-payment requirements for chronic care management, I would like to call for the annual MediSave withdrawal limits for chronic disease management to be completely lifted, especially for those over 60. This will encourage residents with chronic diseases to see their doctor early and stay on with their disease management plan.

In answer to another Parliamentary Question that I filed, in 2018, about 563,500 local patients were seen at polyclinics for non-CDMP conditions. These patients were not eligible for the full subsidies and MediSave withdrawal allowances under CDMP. Moving forward, under Healthier SG, can CDMP be expanded to all chronic diseases, so that more patients can benefit from it?

Next, on polyclinics. Polyclinic attendance has increased from under 410,000 10 years ago, to more than 550,000 in July 2022. The White Paper acknowledged that many residents, especially retirees who no longer have company health plans, have been switching away from private family doctor clinics to polyclinics for their medical treatment. Cost is a factor in these decisions, with drug prices a key reason why medical treatment is often more expensive at GP clinics.

Under Healthier SG, drug prices at participating private family doctor clinics will be made "more comparable" to those at polyclinics through a combination of enhanced drug subsidies and drug price limits. I also note that a new subsidy tier for CHAS for common chronic drugs will be introduced. Singapore Citizens who are CHAS, PG or MG cardholders can opt to obtain these drugs at the private family doctor clinic which they have enrolled with.

These are welcome changes. However, the words "more comparable" suggest that CHAS, PG and MG cardholders will not necessarily enjoy the same low prices for drugs and medical consultations at private family doctor clinics as they do at polyclinics, let alone the other patients who are not eligible for these additional subsidies.

The Minister mentioned just now in his speech that the basis for computing subsidies for polyclinics and GPs is different, so the prices cannot be equalised to the last cent. However, can the Minister confirm that the differences will only be in cents and not in dollars, or tens of dollars for each prescription? I am asking for these details because any price differentials will be a disincentive for Singaporeans from switching from polyclinics to family doctors.

I note that Healthier SG aims to encourage residents to enrol with a family doctor by "narrowing the difference" in drug subsidies across polyclinics and private clinics. Can the Minister confirm that the "narrowing" of the difference will be brought about only by lowering the price of drugs for patients of family doctors, and not by increasing polyclinic prices to achieve parity? Furthermore, how much can drug costs be brought down, without subsidising private GPs' profits, given that GPs also make a margin from the sale of prescription medication?

With all this in mind, it is my recommendation that residents who currently prefer seeking outpatient medical treatment at polyclinics should not be compelled to enrol with a private family doctor. They should, however, remain with a polyclinic in the same healthcare cluster, so that their medical records can be shared with whichever doctor is attending to them.

If, eventually, most residents enrol with private family doctors, can the Minister elaborate on what will be the role of polyclinics under Healthier SG? Will the Government continue to build more polyclinics or will there be a reduction in polyclinic capacity as Healthier SG gets implemented?

Another area that can potentially reduce healthcare costs in the long term, but was given relatively less attention in the White Paper is maternal and child preventive healthcare. A research study on childhood obesity published in the International Journal of Obesity found that early life risk factors increased childhood obesity. These risk factors included the father's obesity at 24 months after the child was born, the mother's pre-pregnancy obesity and excessive weight gain during pregnancy, short duration of breastfeeding and early introduction of solid foods. The study found that early life and preconception intervention programmes may be more effective in preventing obesity if they concurrently address these risk factors.

Another study by local researchers published in BMC Pregnancy and Childbirth found that women interviewed had poor knowledge of the child health consequences of maternal obesity and were often unaware of reliable sources of health information.

Is MOH looking to take a more preventive approach to maternal and child health? For example, family doctors could take a more proactive approach in advising expectant mothers and young parents on healthy dietary habits for themselves and their children. The Healthy 365 app could also be used to provide more continuous guidance from healthcare professionals to women who are planning, undergoing and recovering from pregnancy.

Many habits are developed from a very young age and persist for the rest of our lives. The benefits in terms of cost savings and health outcomes of preventive health initiatives for expectant mothers and children could, thus, be tremendous in the long term.

I would now like to discuss more about the health outcomes under Healthier SG. What gets measured gets done. Both performance metrics and targets should be set before embarking on Healthier SG. I am glad to see that the White Paper has listed some short-term and long-term metrics. However, it does not provide their targets. Without targets, these metrics hold much less meaning.

I have filed PQs to be answered by the Minister tomorrow on the targets for various short- and long-term preventive health metrics. These include the target screening rates for chronic diseases, the proportion of residents actively using the Healthy 365 app, the obesity rate and the avoidable emergency department attendance rate.

I look forward to the Minister's reply to these questions. The achievement of these targets should be closely monitored, so that adjustments can be made to better achieve them. Given the huge investment in Healthier SG, the public should expect an improvement in both the short- and long-term metrics.

Family doctors that accept enrolment should also be held to a high standard of quality and transparency. They should publish their prices, bill sizes and clinical outcomes. This will allow residents to make informed decisions when choosing or switching to their enrolled family doctor.

Other non-clinical metrics should also be used to gauge them. These include the adoption of IT systems that make it easier for patients to make and change appointments, reducing waiting time and sharing of clinical data with other healthcare institutions. Good service quality would encourage patients to more regularly seek preventive health services.

Last week, I received a phone call from a market research firm doing a survey on behalf of the Government. The pollster asked me to state the extent of my agreement: from strongly agree to strongly disagree, to statements like "Singapore is heading in the right direction", "the Government is managing Singapore well" and "I approve the way the Prime Minister is running the country".

This was not the first time I was surveyed this way. But this time I was also asked a series of questions about healthcare financing, which was an uncanny coincidence given that it was only a week before today's debate in Parliament on healthcare. The questions revolved around whether I was worried about being able to pay for my family's healthcare needs, currently and in the future. I must admit that the questions made me ponder about my own family's healthcare expenses.

Individual healthcare expenses are unpredictable, and a large chunk of the costs are likely to come in the final years of life as a result of chronic conditions, many of which are preventable. Given that the survey was funded by taxpayers, the Government should release the survey results, so as to better inform the public on issues regarding future healthcare spending, and prompt them, as is the objective of Healthier SG, to make the necessary adjustments to their lifestyles and preparations to avert preventable chronic illnesses in the future. Sir, I support the Motion.

Mr Speaker: Ms Denise Phua.

4.10 pm

Ms Denise Phua Lay Peng (Jalan Besar): Sir, I stand in support of the direction set in the White Paper on Healthier SG. This plan is a strategic move to transform Singapore's healthcare system from one that primarily cares for the sick to one that proactively prevents sickness.

Preventive healthcare aims to prevent illnesses, detect specific conditions early and encourage the promotion of good health. Regular health screens, testing and healthy lifestyle counselling are but common features.

Globally, the incorporation of preventive healthcare in national plans is not new. The United States, for instance, publishes 10-year Healthy People masterplans, five iterations now, to identify public health priorities to improve the health and well-being of the Americans. The latest is the Healthy People 2030 plan. But well-written plans may be, many people in the world, including the US, are still afflicted by poor health.

For the Healthier SG vision to come to pass successfully, we need to get the planning assumptions, strategies and execution right. I have several concerns to which I seek Ministry's consideration and responses.

First, on mobilising a network of family doctors. Sir, the first of the five key features of the Healthier SG plan is to mobilise a network of family doctors. "Lynchpin", as the Minister has just called it. The family doctor will consult, will develop a health plan, will conduct annual check-ins and help residents achieve their health goals. This, in theory, sounds good. But, in practice, most residents only see a GP when they are ill. If GPs are the first to be tapped upon, then their transition from the role of a GP, just addressing someone's immediate needs, chop-chop and go, to that of a family doctor or physician – this transition, this journey cannot be underestimated.

How does the Ministry facilitate the transition, for example, of a GP who sees, say 50 to 60 patients a day, a popular one, to morph into one that is more consultative, holistic and takes a lot more time? Would there be prerequisite skillsets and dispositions that need to be considered? Other than their intrinsic motivation to want to do good for their residents, would the financial incentive that Minister spoke about be sufficient to cover their time and their costs?

Many Singaporeans also visit polyclinic doctors as their first port of call. Working Singaporeans also tend to consult their employer's panel of doctors. How do these doctors become one's family doctor, if they may not be the same doctor who regularly attends to one? These questions need to be answered and looked into. The devil is always in the details.

Next, on developing individual health plans. Developing health plans for enrolled residents is one thing, but following up to ensure outcomes is another. The White Paper correctly states, I quote, "while doctors can prescribe activities, it will only work if residents take personal ownership of their health and their lifestyles, and follow through with their health plans." The same challenges were also voiced by residents in the White Paper, quotes were given and validated also by many of our own lived experiences.

The move to take personal ownership for one's own health is far more complicated than just developing a health plan. There are many theories of behavioural changes from time immemorial. If not thought through carefully, the Healthier SG vision would really just remain a pipe dream.

What could be a highly effective combination of "inside-out", or intrinsic, and "outside-in", extrinsic intervention measures to address the needed change in mindsets and behaviours of residents? How does the Ministry intend to address the first target group who are the senior residents above 60, who may be even more rigid in their mindsets and their behaviours? Why is there little mention of upstream interventions when one is younger, such as those in schools, because that is when behaviours and mindsets are shaped? Surely, upstream interventions in schools, through proper eating, proper exercising and emotional management are an important part of developing good health habits for life.

And then, for the even more vulnerable, what is the Ministry's recommendation for younger Singaporeans who are disabled, who have special needs and who are prone to earlier onset of chronic illnesses due to a lack of education and care? They are best served by healthcare professionals who are a bit more aware, who are more trained of their conditions, such as, for example, Dr Chen Shi Ling and her doctors at Happee Hearts Movement. Who and how does the Ministry propose to include this group of residents and to fund doctors like Dr Chen? Sir, those are the groups that need to be looked at and the details that need to be considered.

Thirdly, on activation of community partners such as the HPB, Agency for Integrated Care (AIC), PA, SportSG and National Parks Board (NParks). I agree totally with the White Paper that "patients' social, mental and physical well-being, are best achieved through community assets and services."

My own lived experience on the ground, trying to coordinate all my well-intended service providers, for example, for the seniors. My experience is that although the different parties are all good community assets, with good hearts, many of their efforts are usually not well coordinated and they are not quite motivated sometimes to really work together. They sometimes even "compete" for the same clientele. Situations of, example, elderly residents being repeatedly served, because they are the ones who are more forthcoming, some are under-served or not even served. Situations like that are quite common.

What would the regional health system player each in charge of about 1.5 million residents do differently? How can they improve the situation? How will they, as integrators, better organise ground efforts without losing the passion and the resources of these precious community partners, for a Healthier SG?

With so many partners and touchpoints, what would the typical experience of an enrolled resident to Healthy SG or the system or a "customer" look like in his healthcare journey? Some clarity would be reassuring.

Lastly, on setting up enablers for Healthier SG. Sir, I find it hard to imagine the size of the beast or the initiative based on just looking at the White Paper. For Singaporeans to appreciate the big shift and the need for greater investments – I think the Minister had just announced as $1 billion for a start and I think $400 million for recurring costs. To justify that, I seek more clarity on the following levers.

One, on human resources. What are the types of jobs, in detail, what are the skills pre-requisites and number of persons required to realise the vision of Healthier SG?

On technology, beyond the one-time grant to assist clinics, if they do convert, to convert to an appropriate IT system, how would the maintenance and upgrade costs be treated? What would be needed to facilitate residents, as Dr Tan just mentioned, who are not tech-savvy, to use apps like Healthy 365, so that this group indeed is not left behind?

On performance indicators – the selection of performance indicators – whether process or outcome indicators, whether lagging or historical or leading indicators – this selection is never an easy task, even in the world of usual management and leadership. What gets measured gets done, as they say. But what gets measured and paid for, gets done even more.

Badly selected measures lead to unintended bad consequences. Resident enrolment rate or health plan completion rates can easily be ramped up through aggressive marketing, without regard for quality or follow up. So, I urge a further scrutiny and discussion on the White Paper's proposed key indicators.

In conclusion, Sir, I highly support the intent of the Healthier SG White Paper. Many countries have done it, many developed countries have tried with varying degrees of success. I have raised issues and concerns from my own lived experiences trying to coordinate ground efforts and from those who are serving in healthcare and the community. I hope the Ministry will seriously consider my inputs.

A transformation of this nature is complicated. But I believe that if any country can succeed in nurturing a healthier people, Singapore would be the one. Sir, I support the White Paper.

Mr Speaker: Ms He Ting Ru.

4.19 pm

Ms He Ting Ru (Sengkang): Mr Speaker, it comes as no surprise that big changes are needed in the way we approach healthcare to keep our care systems sustainable. The plans announced are ambitious and are meant to address the long-term well-being of an ageing Singapore. As always, the actual execution and implementation of these plans and strategies bear scrutiny and discussion, along with the effect that they will have on our doctors, healthcare workers and most importantly, our residents.

Such a shift in approach to put preventive health and our family doctors front and centre of our efforts to improve our population's health and to integrate our care systems in the heart of our communities, requires that a multi-faceted set of issues are tackled. My Workers' Party colleagues have and will over the course of this debate, share our thoughts and positions on important topics relating to financing changes, preventive care, patient responsibility and how we can better integrate the primary healthcare system with our Intermediate and Long-Term Care (ILTC) and social care systems to reduce the burden on care workers, patients and families as we set our foundations to navigate the new golden age of an ageing society.

I will speak today on the measurement of success for the new Healthier SG approach, on ensuring that our family doctors are set up for success and finally, on some care areas that I believe need more attention.

First, an observation: the White Paper most often refers to increases in life expectancy as a measure for good healthcare outcomes. Yet, this obscures the quality of those long years of life.

Thus, we must look at other indicators, such as healthy life expectancy, or the proportion of life spent in poor health, that are more telling of the situation. The Government has alluded to this, attributing the rising costs of our healthcare budgets over the years partly to the increased impact of chronic disease on our population. Our population is living longer, but not necessarily more healthily. I hope that these other metrics start to form the backbone of how we measure good care outcomes.

And today, as we debate a Motion that will see our health and social care systems shift towards placing family doctors at the heart of our care system, I cannot help but remember Dr Goh, who provided exceptional primary care for me and my family from when I was five. It is because of his gentle humour, patience and smiling countenance that doctors' visits never felt stressful – whether it was for a flu infection or a routine follow-up. And his practice nurses too eventually got to know our entire family – including my two ageing grandmothers – well enough to automatically pull out our patient cards without us having to provide our registration details and to chat with us about the latest family updates.

As my father was often away for work, I know that it was a great comfort to Mom to know that she had a trusted team that she could call up and ask quick questions over the phone, whenever she had any medical or even quasi-medical concerns, especially when they related to her two young children. I also remember him nagging Dad to get the usual tests and health checks done, despite Dad's aversion to all things medical.

Of course, I recognise that we lucked out in having Dr Goh and his team there for us, and indeed we hope that more – if not all – of us in Singapore will have the chance to have such excellent care through our various life stages. Indeed, the White Paper notes that just three in five Singaporeans have a regular family doctor and that most relationships between doctors and patients are still largely transactional in nature, with most interactions only happening during acute illnesses or episodes.

The current system does not allow much space or resources for the care team to be able to support a patient's health more holistically and to develop and work out a long-term approach to each patient's care. It is therefore good that we are moving towards institutionalising and formalising that important relationship between family doctors and Singaporeans.

However, as we work on getting Singaporeans more familiar with registering with a family doctor, we must also ensure that this new shift does not end up unfairly burdening family medicine and GP practices and their associated ecosystems and that care workers do not end up bearing the brunt of well-intentioned but unintended consequences, even as family doctors – and I quote the White Paper – "do much more". It also must be noted that in order to deliver the objectives outlined in the White Paper, the paradigm shift in care would mean that family doctors will inevitably end up spending more time with each patient and this would mean longer hours, the number of patients being equal.

At the end of FY2021, the membership of the College of Family Physicians Singapore registered just over 2,600 doctors providing primary care, of whom there are approximately 1,600 doctors holding a graduate diploma of family medicine qualification. MOH previously estimated that in order to implement our plans, 3,500 family physicians are required by 2030 – more or less doubling the number in just seven years. Could the Minister clarify if these targets remain valid?

Given the long time needed for doctors to be trained – five years of medical school in Singapore, plus the five years to serve the bond – would the Ministry clarify how it intends for such an increase in numbers to be catered for by 2030? And could we look at lowering the barriers for foreign-trained Singaporean doctors to come home to practise and serve communities back home here in Singapore?

After all, it was not so long ago that our care systems were heavily strained by the COVID-19 pandemic and many of us would have experienced long queues in clinics and our hospitals, when GP clinics were so overwhelmed that they became unable to answer phone calls from worried patients. And this is despite many Public Health Preparedness Clinics (PHPCs) extending their opening hours to cope with the surge in demand for medical care.

Doctors, nurses and practice staff generally come under extreme stress and pressure, and while grateful, we cannot afford to take this for granted in the future. Indeed, most of our care workers will tell you that they continue to feel the strain today of continuing to work under challenging circumstances and a generally tight manpower situation.

While it is true that the pandemic was a "black swan" event, our experiences in the past couple of years in particular have taught us the severe risks and downsides of operating extremely lean and "efficient" infrastructures, ranging from healthcare to housing and "just-in-time" supply chains. It is therefore an opportune time for us to consider how we can best prepare for such instances and spikes in demand and to ensure that increasing the role of family doctors in a Healthier SG, does not end up placing too much strain and burden on family doctors, nurses and allied healthcare workers.

The danger then is that it not only becomes unattractive for potential new doctors and health workers looking to serve in primary care, but may also end up, meaning the existing workers will resign. This is particularly important during the transition period while both patients and care workers are still getting to know the new approach and as we wait for the efforts of our preventive care programmes to bear fruit. Indeed, the Singapore Medical Journal in an article in 2020 stated that, I quote – "The nature of the (GP) work can predispose them to developing burnout, which in turn impacts the physician-patient relationship and patient care."

In short, we must not forget to care for our care workers, to ensure that they are not burnt out while they care for us. Additionally, concerns about the amount of administrative or paperwork that doctors need to fill in, both to enrol in the programme, and also for each patient visit, need to be adequately addressed.

Coming back to the capacity of our primary care system. The White Paper mentions the need to increase the number of doctors and nurses in primary and community care from the current one-fifth to at least a quarter by 2030. Given that we are now in the final quarter of 2022, this is an ambitious target. While MOH and its various partners will undoubtedly put in much effort to ensure that more will start choosing family medicine as a vocation, efforts are also hampered by what is traditionally seen to be the "lesser status" of family doctors.

I recall a former classmate feeling particularly down when the time came to choose specialities, as she had "only managed to get on a family physician track". At the time, we discussed why she felt this way, despite knowing that being a family physician is, in itself, a speciality and requires a very specific skillset and years of training that may not be any less challenging compared with that of a consultant working in a hospital.

She mentioned that the initial reaction to hearing that somebody is a family doctor is that they "didn't quite make the grade to become a specialist". These concerns are backed up by a pertinent study done by the Lee Kong Chian School of Medicine under the leadership of Prof Helen Smith, which found that while half of medical students would consider a career in general practice and family medicine (GPFM), the perception was that there were less career advancement options. Perhaps of more concern was the finding that students reported having encountered derogatory comments about the area, including doctors in GPFM having "poor clinical competence".

The sentiment that family doctors may not be as well remunerated compared with consultants – particularly in private practice – is also exacerbated by the high costs of setting up a private practice in the first place, when compared with the career option of a senior consultant working in a hospital. Directly addressing and removing such concerns, would be essential in meeting the aims being debated here today and I hope that these are issues that we quickly overcome, to ensure that our very best and brightest medical students and even mid-career doctors see training to be a family physician as a career choice, or even "the" career of choice.

Support for family doctors and their colleagues also needs to go beyond the obvious. Family doctors and particularly solo practitioners are also often effectively running a small business. Many of them operate in the heart of our communities but are also beset by increasing costs, such as increasing rent and higher utilities bills. Solo or smaller practices surely would also end up seeing their financial situation strained in the current environment. I would like to ask the Minister to clarify if the situation is being monitored to see if extra support or grants are needed. This is especially important if we are trying to attract more doctors to provide primary care.

Also, would MOH work closely with the Ministry of National Development (MND) and the Housing and Development Board (HDB) in particular, to ensure that our family doctors are able to easily set up clinics in our heartlands and that their practices remain available and accessible to our communities?

Next, on to the important role that the primary healthcare system will need to play in our nation's efforts to improve mental health.

While the White Paper mentions mental health protocols will be developed, mental health does not appear to be part of the first 12 care protocols being rolled out to family doctors.

A study of Singapore from 2017 found that those suffering from mental health conditions was the second biggest cause for ill health that debilitates residents without necessarily killing them. For our youths in the 10- to 19-year-old age group, in particular, this rises to first place.

Not having adequate treatment or support while suffering from mental health conditions has an impact on all aspects of one's life, ranging from economic output to physical health. So, it is important that our plans to address mental health illnesses are firmly anchored within the primary health care system.

While designing the mental health care protocols for family doctors, I also hope that attention can be paid to the intrinsic complexity of the field and that a "one size fits all approach" will not work. After all, how a practice nurse may approach a 20-year-old patient suffering from schizophrenia would likely need to be very different from approaching an 85-year-old showing signs of depression.

Because mental illness still carries stigma, aside from the different spectrum of mental illness symptoms, adjustments must also be made for different attitudes and cultural nuances that may be applicable to the situation. We must ensure that the doctors and their staff are adequately trained and supported to deal with patients who suffer from ill mental health.

The referral system must also not be overly complicated and doctors, nurses and other allied care workers need to have easily accessible references to know what resources are out there available out there to their patients.

Finally, when we speak about a paradigm shift towards preventive care and a more holistic approach to health, we can better target healthier lives for different groups – be it differentiated by age group, gender or socio-economic status – avoiding a blanket approach to preventive health and social care and ultimately achieving better outcomes. This is especially important in the context of our ageing society where the burden of care is without doubt only going to increase.

My colleague, Mr Leon Perera, who unfortunately is currently isolating at home after a positive COVID-19 diagnosis, in his Adjournment Motion earlier this year called for differentiated indices for health and care outcomes, and I would like to reiterate that call here.

Indeed, a 2020 European study on active ageing constructed an individual-level index of active ageing from people aged between 50 and 90 years old and found that gender-differentiated outcomes are pervasive. Like many other previous studies, it points out that women may live longer but are more likely to suffer from chronic and disabling illnesses and also score higher on levels of pain and depression.

The study also pointed out how problematic gender-blind active ageing policies are as they do not adequately address the different challenges men and women face in old age.

As I mentioned during the April Women's White Paper debate, the gender health gap is also a phenomenon observed here in Singapore. While Singaporean females do have longer life expectancies, a sizeable portion of that extra time is spent in ill health.

A 2017 MOH report in collaboration with the Institute for Health Metrics and Evaluation found that in 1990, the gap between life expectancy and healthy life expectancy was 2.4 years larger for females compared with males and this had increased to 2.5 years by 2017. It was also a finding by a 2011 study in Singapore that it appears that we too suffer from the gender health-survival paradox of women having more morbidities despite longer life expectancies.

Thus far, it appears that we can do more detailed studies and data on this phenomenon in Singapore, and we must make sure that this paradox does not grow, especially since we are still trying to tackle the negative economic effects on women brought about by COVID-19, the gender wage gap and an increased burden of higher CareShield Life premiums.

I, therefore, hope that more research and data can be collected on the nature of this phenomenon in our local context so that policies and targeted measures can both be taken and to allow the success of tackling it to be measured.

The other point I brought up during my speech earlier this year was that research, healthcare systems and treatments and diagnoses have historically tended to leave women out. When it comes to gynaecological issues, it is further compounded by stigma and culturally-ingrained embarrassment.

Issues such as prolapse and stress urinary incontinence due to the weakening of pelvic floor muscles, whether brought on by menopause or childbirth, are thought to affect at least 15% of women here in Singapore, yet embarrassment to discuss such matters even to obstetrician-gynaecologists (OBGYNs) probably means that many women suffer needlessly in silence for what is often a treatable condition.

I, therefore, hope that these issues can be tackled sensitively and effectively by our primary care providers and that the necessary training and resources are given to support the providers to address these areas of concern together with their patients.

To sum up, we support Healthier SG and believe that this approach will benefit Singapore in the long run. However, it is imperative that we quickly address any areas of concern with a positive mindset and start to evolve a national conversation around health that is multi-sided.

It must not be a top-down, patronising approach where experts tell us what is good for us and that we must follow their approach. Instead, it should be a partnership between doctors, nurses, allied care workers and their patients and families.

Good holistic care takes time and the right investments, as does our shift in approach. I hope that this is something we will afford to both our patients and especially our care workers.

After all, we can talk until we are blue in the face about the twin "P"s of prevention and the performance of our care systems, but these will be nowhere without the two most important "P"s of the system – our patients and the incredible people who make the system run. I support the Motion.

Mr Speaker: Mr Sharael Taha.

4.36 pm

Mr Sharael Taha (Pasir Ris-Punggol): Mr Speaker, Sir, by 2030, one in four Singapore residents will be above 65 years of age, up from one in six today.

Statistically, the elderly is more likely to fall sick or suffer from disabilities. Age aside, there is a prevalence of chronic diseases amongst our population – 32% of our population has hypertension and 37% has hyperlipidaemia. If left untreated, high blood pressure and high cholesterol will lead to significant health problems.

Shifting our approach from reactively caring for those who are sick to proactively preventing individuals from falling ill is an applaudable move by the Ministry.

It is understandable that we first focus on onboarding the elderly with regular checkups and promoting healthy lifestyle choices. However, we must not forget the other age segments of our population and address lifestyle habits that are also of growing concern.

In the March sitting last year, I asked the Minister for Education on the number of vaping cases that has been reported in schools since the ban on e-vaporisers in 2018. I also asked how we can educate our youths on the dangers of using electronic vaporisers and what action can be taken against those who supply such items to our school-going children.

Unfortunately, there is no specific data point for vaping amongst students and the Ministry replied that it will continue to monitor the trend.

Though we do not have specific data on hand, conversations and anecdotal sharing all point towards a worrying rising trend on the use of these illegal electronic vaporisers with our school-going youths and young adults.

One of our Pasir Ris-Punggol resident volunteers shared that it is prevalently used by her schoolmates in polytechnic and it is not uncommon to hear cases of students in secondary school possessing illegal vapes.

Vaping is not harmless. As of 18 February 2020, vaping has been linked to 68 deaths and over 2,800 cases of lung injury related to vaping – now more commonly referred to as EVALI, E-cigarette or Vaping product use-Associated Lung Injury, in the United States.

When CNA did a special on teenage vaping a week ago on 23 September, confiscated vapes were sent to Health Science Authority for lab testing. The results of the chemical content in the liquid were shocking. Among the chemicals found was formaldehyde, a cancer-causing agent used in the process of embalming, nicotine levels which surpassed a stick of cigarette and juice laced with tetrahydrocannabinol (THC), the main psychoactive compound found in marijuana. According to the CNA report, Dr Aneez Ahmed, senior consultant surgeon for thoracic surgery at Mount Elizabeth Novena Hospital says he is starting to see cases of teen vapers with inflamed lungs.

Despite its ban since 2018 and its harmful effects, vapes continue to be popular and is accessible even to our young. According to the report, one of the teenagers, Kelly, who started vaping at 16 years old, explained to the interviewer that it was simply much easier for her to get hold of a vape than to buy cigarettes from a shop as she is underage. Anecdotal conversations with youths disturbingly surface the ease in which they can obtain vaping instruments online or through Instagram chatrooms, with the product delivered within an hour to a day upon order.

Mr Speaker, Sir, this lifestyle habit of vaping, especially amongst our youths and young adults, is a worrying trend. Although it is illegal, our youths still have access to it.

While Healthier SG focuses on inculcating proactive preventative care and healthy lifestyle choices for our elderly and rightly so, we should not turn a blind eye to other emerging worrying trends too. We must do more to educate our youths on the dangers of vaping, and prevent and enforce the illegal sale of vapes, especially to our school children.

With the ease of purchasing vaporisers, the anecdotal evidence suggest that our youths are exposed to this unhealthy lifestyle habit at a young age which may be detrimental to our vision of long and healthy lives for Singaporeans as the Motion exerts.

There may also be other unhealthy lifestyle habits that we need to be aware of. Strong partnerships amongst stakeholders in the community can help to promote healthy lifestyle habits and choices instead. This brings me to the second point on building strong partnerships within the community.

In the White Paper, the National Healthcare Group (NHG), National University Health System (NUHS) and SingHealth (SHS) will step up as regional health managers to look after the health of approximately 1.5 million residents in their respective sectors each and work with family doctors and other partners to reach out to as many residents as possible.

Funding model will shift from a workload-based model to a capitation-based model where clusters receive a pre-determined fee for every resident assigned to them on geographical boundaries.

How do we ensure the clusters reach out to its residents effectively? Being able to reach out to residents should just be one of the metrics for healthcare clusters to consider. What other metrics will be given to healthcare clusters to ensure that they are successful at engaging the residents and able to drive significant changes to reshape health and lifestyle choices amongst the residents?

In the White Paper, while we have explained the role that residents, family doctors and community partners such as ActiveSG and PA can play, one community partner that is significantly missing are employers. Getting the involvement of employers is very important, considering we spend a significant part of our day working.

Other than employers encouraging their company panel doctors to participate in the Healthier SG enrolment programme, how can employers also be incentivised and recognised for participating in the Healthier SG programme? Is there scope for employers to be incentivised to provide healthier meals at the workplace, for example, or even provide healthier lifestyle options such as weekly or hourly time off for exercise breaks?

One of the best ways to incentivise and encourage healthy lifestyle habits is to have family members supporting each other.

Dieting, exercising and visiting the doctor can be a lonely and challenging task for many individuals, especially when it is done alone. Different family members may also be at different stages of their health transformation journey and at times may accidentally do things that may not exactly help one another.

I am sure many of us here have tried to be on a diet and have had a good day of controlling food intake, but the achievement is short-lived the moment a family member invites you to have a late-night supper or offers you that delicious plate of nasi lemak, nasi rawon or char kway teow which you simply cannot refuse!

At the heart of Healthier SG is the relationship between family doctor, patient and the health plan.

How can Healthier SG adopt a family-oriented model and place family support at the core of motivating individuals? Can the Ministry consider allowing or encouraging family involvement in reviewing and following a prescribed health plan? Can we also look into ways we can increase family engagement as part of Healthier SG, perhaps find a way to introduce gamification where families score points when they take part in an activity together? With enrolment starting for those aged 60 and above in the second half of 2023, will Healthier SG be rolled out to the rest of the population and if yes, when do we expect that to happen?

As we look towards our vision of long and healthy lives for Singaporeans, I would like to briefly touch on the support for dementia patients and caregivers. A nationwide study in the Well-being of Singapore Elderly (WiSE) found that one in 10 seniors above the age of 60 suffers from dementia. Today, 60,000 people aged 60 and above live with dementia. By 2030, it is projected that 90,000 residents will be living with dementia in Singapore. That is a 50% increase.

In a recent visit to Apex Harmony Lodge in Pasir Ris, a home specialising in dementia care, I was thoroughly impressed by the level of care for our dementia patients in the home. The home, led by Chairman Mr Gan Boon Jin and CEO Ms Soh Mee Choo, has invested in upskilling its staff and introducing new technologies to provide the best care for its patients.

However, such healthcare for dementia patients does not come cheap. The cost of taking care of a dementia patient is above $40,000 per year and continues to rise. In the lodge, more than 90% of the residents enjoy subsidised care, some even fully subsidised. However, Apex Harmony Lodge has a current capacity to accommodate 200 dementia patients, which is really a small fraction of the expected 90,000 elderlies with dementia by 2030. How are we preparing to provide sufficient healthcare support for the growing number of dementia patients in the future that require either full board or day care services? Mr Speaker, in Malay, please.

(In Malay): [Please refer to Vernacular Speech.] By 2030, one in four Singapore residents will be above 65 years of age, up from one in six today. Statistically, the elderly is more likely to fall sick or suffer from disabilities. Many Singaporeans also have chronic illness. For instance, 32% of our population has hypertension and 37% has hyperlipidaemia. If these conditions are not treated at an early stage, it will lead to significant health complications.

As a community, we must give more focus towards preventive care and tackle health issues and lifestyle choices before it is too late. Therefore, we must certainly focus on the elderly, by encouraging them to watch their diet, for instance, by reducing their salt and sugar intake, exercise and to also stop smoking.

However, as we focus on our seniors, this does not mean that we can allow other worrying trends to become prevalent amongst our youths.

We have often heard about how easy it is to get e-cigarettes, also known as "vape" and there are those among our youths who partake in this unhealthy habit. We must do more to educate our youths on the dangers of vaping and prevent the illegal sale of vapes, especially its sale to our youths.

Building a healthier Singapore will require the participation of all levels of society, especially families, which must form the core support that ensures Singaporeans make the best health and lifestyle choices. I would like to suggest that Healthier SG be launched with a family-oriented model and that family support is also placed as the core of individual motivation.

More can be done to encourage and support active participation of our family members to take good care of their health. Community partners will continue to provide support, and together, we can all become a healthier, happier and thriving community.

(In English): Notwithstanding the points and clarifications above, I support the Motion.

4.49 pm

Mr Dennis Tan Lip Fong (Hougang): Mr Speaker, according to the Healthier SG White Paper, all residents will be encouraged to enrol with a family doctor or a family physician, who, I quote from the White Paper, "will serve as the point of contact to holistically manage the residents' health", focusing on providing holistic care, prevention and to improve chronic care. Each family doctor will develop an appropriate health plan for each enrolled resident and would also administer the appropriate health screenings and vaccinations.

Mr Speaker, I agree with the intent and merits of having a specific family doctor to holistically manage each resident's health. Needless to say, any doctor would be familiar with his or her regular patients over time. I believe there are already many Singaporeans who have the habit of seeing the same GP over a long period of time each time they fall ill or need prescription and appreciate the benefits of a GP who is familiar with their medical history over time. I have known my current family GP since I was in secondary school.

The proposed requirement of a family physician having to develop an appropriate health plan for each enrolled resident and having an annual check-in with each enrolled resident, to find out how the resident is doing in terms of his health or how he or she is adhering to his or her health plan should be a significant departure beyond the current common practice of only seeing the doctor when we do not feel well or when we require prescriptions.

I agree with these proposals, but the devil is, of course, in the details. The health plans, screenings and annual check-ins will, hopefully, provide a sufficiently regular opportunity for the doctor to be able to help us to pick up any signs of any health issue earlier before it manifests into something serious or chronic.

That said, it is important that such health plans are appropriately developed for residents of different age groups and dealing with prevention of a range of diseases and health conditions. Beyond the mentioned first three chronic illnesses, may I ask the Minister to elaborate more on the 12 care protocols and the time it is expected to take for the care protocols to be fully rolled out beyond the first year of Healthier SG?

The White Paper also mentioned that mental health and end of life will subsequently be covered. I hope that mental health will certainly not be at the end of the queue, but some priority be given for its earlier introduction. The White Paper itself gave a "special mention" of mental health at page 52. The family physician will, certainly, be ideally positioned to help residents with regular checks on their mental health and, importantly, early detection of any problem.

May I ask whether the Inter-Agency Taskforce on Mental Health and Well-Being has been specifically tasked to integrate the new plans under Healthier SG? Will the task force consider how the family physician's role in managing the mental health of their residents can be enhanced? Will the task force help to integrate the family physician's new role alongside other resources and stakeholders which are already part of the task force's efforts to date?

Mr Speaker, in order for the proposed programme under Healthier SG to work, it will also require the cooperation of all enrolled residents, to be able to adopt the right attitude in adhering to the health plan developed for them and to be actively concerned for their health, and physical and mental well-being. Everyone must be willing and able to accord it priority alongside other demands of their everyday life and treating the plans and the appointments with the family doctor seriously and taking full advantage of them. In the hustle and bustle of modern living, I am not sure everyone may be able to do so.

I do hope MOH will have an appropriate public education campaign not just to encourage enrolment, but to encourage enrolled residents to take this programme seriously and be diligent in adhering to the health plans and recommendations and advice of their family doctors, and to make full use of what is provided under the programme.

Mr Speaker, I also believe that for this programme to work to the best benefit of most Singaporeans or residents, we need to ensure that as many people will enrol under this programme. I am aware that many Singaporeans currently visit GPs or clinics which are on the panel of their employers' corporate medical insurance plans. These GPs are often not their usual family GPs. When employees change employment or if their employers change their insurers, the GPs or clinics may also change.

I would like to ask how does MOH intend to harmonise this situation with its proposed programme under Healthier SG to have more people stick to one regular family doctor? Would MOH also engage different stakeholders, including both the medical practitioners and the insurance industry, to see how corporate medical insurance plans can be tweaked to enhance the Healthier SG objective of having more people stay with one family physician?

There are also many people who have regularly gone to see GPs in polyclinics, ostensibly for reasons of cost and subsidy. Can MOH give an indication of the size of this group of Singaporeans?

Besides MOH's plans to make available more prescribed drugs under CHAS subsidy in GP clinics, how will MOH ensure that the cost of consultations and prescriptions with the family physician will not discourage Singaporeans from switching to Healthier SG?

Following the introduction of Healthier SG, how does MOH see the role of GPs in polyclinics with respect to primary care and would MOH be reviewing the role of GPs in polyclinics?

The Healthier SG also proposes to allow for a change of family doctor once each year. While I understand there may be a need for some flexibility, for example, when a resident changes his or her place of residence or even changes his employment, allowing changes of doctors within a short period of time may not be conducive for the greater goal of Healthier SG to get more people to have one family doctor to manage their health.

Mr Speaker, the White Paper also mentioned that the number of eldercare centres (ECs) will be expanded from 119 to 220 by 2025 and that under Healthier SG, the offerings for eldercare centres will be expanded as follows:

(a) eldercare centres will serve as a community connector for seniors to help them follow through with the lifestyle interventions as recommended by family doctors;

(b) eldercare centres will offer community-based monitoring of vital signs, such as blood pressure in between their visits to the family doctor, following care protocol requirements to be worked out under Healthier SG;

(c) eldercare centres will also help to roll out health screenings and other healthcare initiatives.

I welcome the above, but I do see that this must come with additional manpower as well as IT resources. I would like to ask the Minister whether and how will MOH help with the provision of additional manpower, IT, training and other necessary resources and support for both the eldercare centres as well as the family physicians' practices. More assistance may be required by both stakeholders in managing the additional responsibilities as well as ensuring that all interventions, screenings and other measures recommended by the family physicians are well coordinated.

Mr Speaker, I do appreciate what the eldercare centres, the senior activity centres and, indeed, the day care centres in Hougang Single Member Constituency (SMC) are doing to take care of the seniors under their charge. It is not an easy task for the eldercare or senior activity centres to reach out to all seniors within their designated cluster and try to ensure that the seniors are in good shape and that help can be given if required. The response of our seniors may vary between individuals.

While many are happy to know of the support they can reach out to and many also get involved in activities in eldercare centres and welcome being connected to such centres, some seniors may not be open when eldercare centres try reaching out to them. Some may not want to keep in touch with their eldercare centres. Some keep to themselves and may not socialise with others. Some of these seniors live by themselves and may not have family members at hand to keep an eye on them in their homes.

I am concerned that for this group of people, the family doctors under Healthier SG may also experience difficulty in reaching out to them or ensuring their committed participation. I hope MOH can study how outreach efforts can be improved to such seniors so that all can actually benefit from these programmes under Healthier SG and, most of all, their health and well-being can be enhanced.

Mr Speaker, the Healthier SG White Paper is silent on dental care. While I understand the White Paper may focus on chronic care management and prevention of chronic disease, dental health is important. Good dental and oral health can also enhance our overall health and prevent complications to other areas of our health, including prevention of certain chronic or other diseases. Moreover, there is some overlap in similar lifestyle factors causing problems to dental/oral health and to other aspects of our health, for example, consumption of sugary products.

In my view, a similarly structured programme akin to Healthier SG may also help to promote better dental and oral health. I would, therefore, like to know whether in the future, if MOH will also look at extending Healthier SG to the coverage of dental and oral healthcare.

Still on the topic of dental health, recently, a resident provided some feedback to me about the cost of dental treatments not covered by MediSave. Payments through MediSave can only be made for treatments where surgeries are involved. Dental clinic treatments like tooth extraction, root canal treatments and affixing of crowns, while not necessarily regarded as under the category of surgery, can be relatively expensive to many people.

For retirees, the outlay in cash for dental treatments can be a burden, especially if they have recurring issues. While there are subsidies available for limited categories of CHAS and other card holders, my resident wishes that the Government can consider making MediSave available for at least some of the treatments and/or consider increasing the extent of CHAS subsidies currently available for these treatments, for example, for orange CHAS card holders and even beyond. If need be, the Government can look into including more measures to deter possible abuses by minority practitioners.

Mr Speaker, before I end, I would like to touch briefly on the issue of resourcing. Under Healthier SG, family doctors have new responsibilities towards the care of residents enrolled under them, regardless of age. While they will be paid a fee per enrolled resident, if the patient numbers do not reduce for any family doctor, what is the expectation of MOH on the effect of the additional work or additional patient loading brought about by Healthier SG? And how are the doctors expected to cope with the additional work and responsibilities? Mr Speaker, in Mandarin, please.

(In Mandarin): [Please refer to Vernacular Speech.] Mr Speaker, I support the recommendations in the Healthier SG White Paper that every Singaporean chooses a designated family doctor to provide medical services and manage their overall health.

To implement Healthier SG smoothly, we must ensure that the participation of the majority of Singaporeans and that participants have a positive attitude towards the health plan set for them.

In addition, I hope that the mental health aspect mentioned in the White Paper will be given priority and included into Healthier SG as soon as possible.

The White Paper also plans to increase the number of existing eldercare centres from 119 to 220 by 2025. These centres will take on more responsibilities and services and work closely with GPs. I hope that the Government will provide more manpower, technology training and other resources for the various parties to support this new model of cooperation.

At present, apart from ensuring the health of the elderly and providing them with assistance, eldercare centres also need to reach out to and communicate with the elderly in the area in different ways. This is a meaningful but challenging task.

Many seniors are glad to learn that the centres are able to provide the necessary assistance and are happy to participate in the activities organised by the centres. However, there are still some elderly folks who choose not to contact the centres or participate in activities organised by them.

This trend will pose some challenges to the Healthier SG programme. For example, how GPs can effectively engage and persuade this group of seniors, especially those living alone, to participate in the programme is an issue to look at. I hope that MOH will look into improving outreach to this group of seniors so that all Singaporeans can benefit from Healthier SG.

Mr Speaker, although oral health is not currently covered under the Healthier SG White Paper, dental and oral care has implications for the overall health of an individual, such as helping us avoid other chronic health conditions. I hope that oral health will also be included in Healthier SG.

(In English): Mr Speaker, notwithstanding the concerns I raised, I support the Motion.

Mr Speaker: Ms Mariam Jafaar.

5.03 pm

Ms Mariam Jaafar (Sembawang): Mr Speaker, I declare that I am a Managing Director and partner of a management consulting firm that does work in the healthcare space.

The rising cost of healthcare is a threat to our Government budgets and to our economy. It is a growing financial and emotional burden on our families. It has already been cited as the reason why we have to do the unpopular choice and raise GST, despite the political cost. It is, in a word, unsustainable for Singapore.

It is unsustainable for Singaporeans like my Woodlands resident, Mr Z, whose wife suffers from diabetes. Mr Z comes to my Meet-the-People Sessions (MPS). He has problems – how to cover the cash co-pay for her next hospital visit, how to pay for the bags and other consumables that are not paid by MediSave, how he is going to push her in her wheelchair to the NKF centre for her dialysis treatments, these days, often in the rain, when the growing arthritis in his bones sends waves of pain up his legs and back.

It is for my resident, Ms N, who has worked hard to build her career. But one illness to her aunt who lives here on a Long-Term Visit Pass (LTVP), has wiped out a huge chunk of Ms N's savings, and continues to take a chunk out of her take-home pay every month.

It is why my resident, Mr T, refuses to go for check-ups, let alone screening. "If they find something, I do not have the money for treatment. So, better do not know", as Minister Ong said. It was exactly what Mr T said.

Sir, we have a healthcare system that is admired. We are living longer.

And, at this point, I want to react to the comment by the Member Ms He Ting Ru who stated that we are living longer but not healthier and that MOH tends to look at life expectancy rather than more healthy indicators. For this speech, I did look at that data. And she may want to know for the specific datapoint on health adjusted life expectancy (HALE), MOH has actually tried doing that and it has been increasing year-on-year. And based on the global finding, our HALE at 73.9% in 2019 is the highest in the world.

So, I just wanted to give the credit to MOH that our hospitals do a great job at treating the sick.

But could we have done more to avoid people getting sick in the first place? Could we have done more in taking more decisive, holistic actions on preventive care, on a national focus on population health, that permeates everything we do in our daily lives, from the food we eat, the exercise we do or do not do, the amount of screen time we allow our kids that might have helped us prevent the rise of chronic diseases – diseases like diabetes, hypertension and lipid disorders?

So, for these reasons, Mr Speaker, I say that Heathier SG is not just a good idea. It is necessary and overdue. Too much has been spent on acute care, too little on prevention. More people are getting sick and living with chronic illness. They are getting sick earlier in their lives and will require medical care for a long time. Add to that an ageing population and rising costs and we have no choice but to make this work.

HPB has worked hard to promote healthy living, but HPB cannot do this alone. It is time we recognise and ensure that incentives, norms, practices, data analytics and policies must be aligned to the behaviours we want to drive across the system. Not only behaviours of the doctors, nurses, hospital administrators, everyone in the healthcare delivery system, but also of the community, of patients and currently healthy citizens, to take charge of our own health.

There are many things to like in the Healthier SG White Paper – mobilising GPs, removing co-pay, free vaccinations, cheaper drugs at the GP, social prescriptions, leveraging community assets and solutions. Colleagues have talked about it today.

I would like to focus on three enablers to making Healthier SG happen – healthcare financing, IT and manpower as identified in the White Paper. But before I go into the enablers, I would like to frame them in the context of what it is that we are trying to achieve.

How do we frame the objectives? The ultimate objectives must be better health outcomes, at lower cost. And indeed, this is the objective of healthcare reforms around the world, towards a model commonly known as value-based healthcare.

But when we look at the key performance indicators (KPIs) for Healthier SG, many of the KPIs, especially in the near term, are process indicators, things like enrolment rates, screening rates, vaccination rates and health plan completion rates, while health outcomes like disease prevalence and control, mortality, re-admission rates, frailty, start to figure only later.

Mr Speaker, there is a whole body of knowledge that has emerged in the field of value-based healthcare around health outcomes measurement, such as the US' Centers For Medicare and Medicaid Services and its Meaningful Measures initiative, as well as the International Consortium for Health Outcomes Measurement and its range of condition-specific standard sets of outcomes, for different age groups and different demographics, including clinical and patient-reported outcomes. Patient-reported outcomes includes measures of quality of life, for example. Do they feel pain, their ability to perform activities in daily living, sense of control, their moods, loneliness?

So, why all this effort? Quite simply, it is because without measurement and transparency of outcomes, we would not know whether what we are doing and paying for is having an impact and how much. Doctors and clusters would not have the data they need to make better decisions and drive innovation, teamwork and best practice sharing.

We need outcomes that are measurable, effective and standardised across clusters. It takes time to identify, find ways to measure, and to show the value to everyone in the care delivery chain so it is not simply administrative overhead. This is not something we can leave to the clusters. I repeat, not something we can leave to the clusters. MOH leadership is needed.

So, I call on MOH to consider including, as another pillar of Healthier SG, a drive to accelerate the identification, measurement and transparency of health outcomes.

It is very true that there is a big risk in a transformation as fundamental and complex as Healthier SG to expect too much too soon. But the evidence from successful value-based healthcare systems has shown that meaningful health outcomes can, in fact, be achieved sooner, but for defined patient segments, particularly at the intersection between primary care and the secondary and tertiary space, such as at the point of discharge from hospital.

For example, a general nutrition education takes a long time to payback. But Oak Street Health, a relatively young and innovative US primary care provider, found that making sure elderly patients with diabetes are eating properly when they are first discharged from hospital is very rapid payback in terms of lower re-admission rates.

Another example, in Sweden, the Stockholm County Council launched a value-based payment programme for hip and knee replacement in 2009, led to a rapid shift of care from acute care hospitals to cheaper specialty clinics. In the first two years, complications decreased by 18%, re-operations by 23%, and revisions by 19%, cost per patient declined 14% in terms of resources used by providers and 20% in terms of money paid out by the Council.

Finally, the Lumos programme, an initiative to integrate healthcare data in Sydney, Australia, developed a model that shows the high value impact that can be obtained through early detection in primary care specifically. When a patient is diagnosed with diabetes early in primary care, and has regular GP visits forthwith, their diabetes journey is much more likely to be managed over time in the community setting.

In contrast, when the diagnosis is done later and in a hospital setting, and he does not engage much with primary care, this could result in poorer management of diabetes and increased re-admissions. But here is the good news. The Lumos data also suggests a GP visit within one week of discharge of an unplanned re-admission can substantially reduce the risk of an unplanned hospitalisation in the five to 12 weeks following discharge. This is data that we can act upon and do something about.

The common thread in each of these examples is "think big but start small" – focus on a specific population group and patient segment, for example, people over 60 with diabetes and identify a subset of outcomes for that patient segment, and set the system to work to track and improve those outcomes and make this visible.

And I stress to focus first on managing and tracking and doing something with it. I am a little bit more ambivalent about the suggestion by the Member Mr Gerald Giam to put a target on every KPI, especially with some of these KPIs, as the Member Ms Denise Phua said, it is very easy to achieve them, can set some perverse incentives. What is important is to identify the right KPIs, measure them and actually use them to make our system better.

So, I urge MOH to consider a real push to measure health outcomes from the beginning. And with this lens of focusing on outcomes, I turn now to what it is going to take to make Healthier SG work.

First, healthcare financing, an area that will undergo significant reforms in Healthier SG, with a move towards capitation funding.

The drawbacks of our current model of a fee for service are clear. It motivates doctors to take on more and more patients, even if they do not have time, to order that extra MRI, even if it is not necessary, to prescribe the most expensive drug instead of a generic that does the job. It feeds off a very human trait – love, the love that makes us willing to try anything, spend anything, if we believe it might keep our loved ones alive. And trust me, I know how that feels.

But, Mr Speaker, more expensive care is not necessarily better care. More treatment is not better care. This is why healthcare systems around the world are implementing payment reforms, with mixed results. There are different forms – pay for performance, bundled payments, capitation and they can be used in combination, but the fundamental logic is the same – pay for quality and value rather than volume.

Capitation, in particular, gives healthcare providers a powerful incentive to manage total systems costs. Most capitation systems are geared to encourage providers to focus on prevention and early detection and intervention. One successful example is CMS Medicare Advantage in the US, where Medicare pays private insurers a fixed risk-adjusted payment for the total cost of care for a patient. Then, it is up to the insurer and its provider partners to figure out the best way to invest that money to provide the care. Insurers, such as Humana, have built their own or partnered provider networks to help them create more value-based models.

Oak Street Health, which I mentioned earlier, is one such Humana partner. Oak Street clinicians are given the autonomy to do whatever drives best outcomes for the patient. Working in multidisciplinary teams of GPs, nurses, specialists, nutritionists, they take input from the patient and caregiver, and also consider the patient's social determinants of health, such as food security and social support.

This holistic approach often drives new insights and innovation. So, if the patient needs a surgery to be healthy, they will make the referral. If he needs food delivered to him to make sure he eats healthy, that is what they do. Or if it takes a house visit to make sure that the home does not have hazards – a stray rug or slippery tiles that could cause him to trip and fall, that is what they do. Or if they think the most meaningful thing is to have someone put their arm around him to be comfortable with his life situation, that is what they do – and they are achieving good outcomes.

Another example is Kaiser Permanente, also in the US, where transparency about outcomes and costs encourages the clinical teams to avoid low-value care and right-site care within its integrated network of hospitals and primary care providers. A system of incentives encourages clinicians to work together and share best practices and always driving continuous improvement.

These successful models point to a few prerequisites for capitation to be truly value-based. It needs to be organised around defined patient groups and population segments, adjusted for risk, and linked to quality thresholds or improvement in health outcomes. Otherwise, capitation could create incentives for "cherry-picking" of healthier patients or for limiting access to required care or what we call "rationing" behaviour.

To that end, can the Minister clarify the capitation model envisioned under Healthier SG, including how will the payments be risk adjusted based on patient profiles in the cluster? Will there be bonus payments for achieving better health outcomes? How will health outcomes be shared across the delivery value chain to encourage people to work together? How much autonomy will be given to the clusters and clinical teams to do what they believe is right to deliver better care, informed by care protocols and outcomes? Can there be participation payments for tracking and reporting health outcomes? How will adjustments be made at the backend when someone uses healthcare services outside his or her own cluster?

Second, healthcare IT. The enhanced National Health Electronic Records system under Healthier SG is much needed. We should not need to tell every new doctor or specialist we see about our medical history or our prescriptions or to have to repeat expensive tests and x-rays or to repeat information needed by our medical social worker at every hospital you or your child goes to.

Digitising and automating processes, leveraging mobile apps like MyHealthHub and Healthy 365, all these make sense, though implementation is non-trivial, as some colleagues have raised.

The hon Member Tan Wu Meng has made the point that digital solutions must be easy to use and reliable. I absolutely agree. To change behaviour though, doctors and patients alike must be excited and willing to use these tools.

Here is where the lens of outcomes pushes us to go even further and, that is, data – clinical data, pharmacy data, health screening data, health app data, cost data, but also data about the individual and how he likes to be engaged.

Can we use all that data and analytics to identify risky individuals for whom we can have the right conversations and make the right targeted interventions in order to make a meaningful impact? Can we engage patients and physicians, not only with apps and technology and tools but with data – data that tells them where they stand in comparison to others and advises them with personally relevant information of actions that they can take, including, of course, working with community partners? I think the role that data and analytics can play in driving outcomes for Healthier SG is incredibly interesting and I would suggest doubling down on the capabilities to do this.

Last but not least, healthcare manpower. I have spoken a number of times in this Parliament on the adequacy of healthcare manpower, including the shortage of nurses and the need for healthcare manpower transformation in preparation for a future that is much more focused on value-based care and prevention.

For Healthier SG to work, we not only need more nurses, we need enough good family doctors, nurses, allied health professionals, pharmacists and care coordinators. They must be comfortable dealing with a wider range of complex conditions, working with data and technology, working in multidisciplinary teams, including specialists, and new ways to engage patients.

We need everyone in the healthcare delivery system to be rewired around prevention and putting care in the right place.

This will not come naturally. Today, they are not trained in that way, they are not compensated in that way, and let us face it, their intellectual respect – our intellectual respect – is not for prevention. Our intellectual respect is for the surgeon who pulls off a complicated surgery. So, we need to respect family doctors a lot more.

If Healthier SG is to succeed, we have got to get this rewiring right. I believe that, for most clinicians, the language of health outcomes is an inspiring and powerful one versus administrative tasks. It can underpin the enormous change management effort that will be required.

Mr Speaker, MOH has implemented a series of individual reforms in recent years. Healthier SG is a fundamental and comprehensive transformation that will require institutional commitment to work things out, considerable investment and new organisational and people capabilities and ways of working.

They say, "health is wealth". To put our healthcare system now on a more sustainable footing and to get a healthier Singapore and Singaporeans – for Mr Z, Ms N, Mr T and millions of other Singaporeans like him – we cannot fail. I support the Motion.

Mr Speaker: Order. I propose to take a healthy break now. I suspend the Sitting and will take the Chair at 5.40 pm.

Sitting accordingly suspended

at 5.21 pm until 5.40 pm.

Sitting resumed at 5.40 pm.

[Deputy Speaker (Ms Jessica Tan Soon Neo) in the Chair]

Mdm Deputy Speaker: Mr Gerald Giam

5.40 pm

Mr Gerald Giam Yean Song: Thank you, Mdm Deputy Speaker. I just want to make a clarification to Ms Mariam Jaafar. She mentioned that she was concerned about setting targets to accompany the KPIs because she mentioned that the hospitals could game the system. I just want to clarify if that is what she said, because the KPIs that I mentioned were all KPIs that were mentioned in the White Paper. So, which are the KPIs is she not concerned that the hospitals will game?

Mdm Deputy Speaker: Ms Mariam.

Ms Mariam Jaafar: Thank you. I think I am just making a general point that we have seen in multiple studies, that sometimes target-setting too early when you do not actually have a good base behind it can create a lot of perverse target-setting. I am not saying that hospitals will do it, not saying that doctors will do it, but I do not think we need to take that risk and instead focus on the measurement, identifying the right ones in the first place, measuring, and then also making sure that we keep doing better and better in those KPIs.

Mdm Deputy Speaker: Mr Gerald Giam.

Mr Gerald Giam Yean Song: So, is Ms Mariam Jaafar saying that we should not set targets right now even though we have the KPIs, or is she suggesting that there is a certain time frame later on that we should set the targets and so when will that be?

Mdm Deputy Speaker: Ms Mariam Jaafar.

Ms Mariam Jaafar: I think we would need to look at different KPIs. Some KPIs, maybe you can set the target. I believe we need to walk before we run. This is a very major transformation and like I said, we should scrutinise the KPIs on the page first to make sure that those are the right ones that we want to measure. I cannot say when the right time is to measure it, but I expect that will come in future once we have more data, I think it is important to do this based on a good fight, based on data.

Mdm Deputy Speaker: Dr Lim Wee Kiak.

5.42 pm

Dr Lim Wee Kiak (Sembawang): Thank you, Mdm Deputy Speaker. First, let me declare my interest as a member of the medical profession – I am a practising ophthalmologist in the private sector.

I would like to also commend and congratulate Minister Ong Ye Kung and the team over at MOH for a very bold and forward-looking Healthier SG White Paper. You know it is a good paper when many, many Members suddenly rise to the occasion and start to claim credit for it. So, everybody would quote their own previous Adjournment Motion, COS debate and so on. At this juncture, I think I would like to join them as well. Let me claim credit for putting forward the suggestion that there must be an adult immunisation schedule.

This paper itself will transform our health care system into one that is preventive. It is a paradigm shift. A paradigm shift because most of us, most of the patients, only when they are ill, will they see a doctor. If you are not ill, you should not see a doctor at all. Most of the doctors will only see patients when they are ill. If the patients are well, they do not see the patients. So, it is very, very different. I am not sure if we should even call them patients in the first place because now, they are not ill at all. So, it is a complete paradigm shift. Maybe clinics will have to change their name, they should not be called clinics, they should be called wellness centres, because they are there for wellness, they are not there for the sick.

In the transition, that is the difficulty. To have a paradigm shift, you have to change the mindset of both patients, as well as the GPs, as well as the population. I think that is the enormous task that MOH have now, ahead of them.

First, let me just congratulate MOH for taking this very bold step, one small step ahead, but it is bold step for the nation. I totally agree with the White Paper and support the White Paper. All those proposed initiatives are commendable, but there are many areas of concerns, like my Parliamentary colleagues have raised. The details are always in the execution and the problems are always there.

I would like to focus my speech on two areas – the "One Resident, One Doctor" scheme and how this will potentially affect the patient, as well as the GPs.

Like many of my Parliamentary colleagues, I do have my family doctor, Dr Tan in the Nee Soon Clinic that looked after me and my family when I was young. I am very grateful for that. That one GP clinic looked after my entire extended family – my grandmother, grandfather – he was the one who came and signed the death certificate for my grandfather, and for my grandmother as well. So, I think we are quite familiar with the relationship of one good GP to a family and what a good family physician can do.

The current White Paper now dictates that it should be one family doctor to one resident. I think it is a good idea. But our current GP practices now are no longer like those which were in Nee Soon village. They are no longer solo practices. Most of them are in group practices now. In fact, they are big group practices whereby doctors always change. So, you may not see the same doctors all the time.

If the scheme now is to be attached to the clinic, then does it defeat the purpose of this White Paper, in the sense that you do not build a relationship between the doctor and patient, but it is just between the clinic and the patient. So, I am not sure how that changes the paradigm.

It is very similar to the current polyclinic system now, whereby my residents always complain that when they go to the polyclinic, they see different doctors all the time.

The only thing that held everything together is good medical records. When you have good medical records, then it makes a big difference. So, I think the key thing now is your IT. It is to make sure that the medical records are seamless so that patients do not need to repeat everything, doctors do not need to look through a lot of other records in order to find out how to manage this particular patient or resident.

In established healthcare systems in developed countries like the UK and Switzerland, access to healthcare starts from a regular GP or family doctor. When doctors have a good long-term working relationship with their patients, they can harness the power of these relationships to solve problems beyond what may be too complex for other healthcare professionals, such as those pertaining to social and lifestyle challenges as well.

As a doctor with regular patients, I can certainly attest to the effectiveness of such working relationships where both parties have mutual respect, trust and confidence, which is the most important.

As I mentioned earlier on, many GPs are now in group practices. GPs rotate themselves between clinics. If patients are enrolled with a particular doctor, they may find it very difficult to reach this doctor at the preferred location on certain days or certain times. Under such circumstances, of course, the patients would be attached to the clinics instead.

If the enrolment is based on the clinic and patients see different doctors, then the question, of course, is what is the value of the doctor-patient relationship?

Some patients would prefer doctors who are not in their health cluster – not within their area of residence. I think the Minister has mentioned that they can switch GPs. If the patient can switch GPs, can they also switch cluster? That is the next question.

Can the Minister also help clarify whether GPs in a particular health cluster can refer patients to specialists in other clusters, especially for existing patients who have been seeing a doctor at a particular hospital for a long time? This is important as patients may want to exercise more choice over their preferred specialists.

The reverse is also true, in the sense that with specialists, can they refer patients now to GPs or polyclinics within their health cluster for step-down care? If the patient requests to go to their preferred GP, will this cross-referral and transfer of medical history be conducted seamlessly? Will cross clustering further complicate funding of the programmes as it is funded by clustering?

Then, there are the patients who go to their company's medical group to utilise their company's medical benefits. Employees these days are spending fewer years working with the same company. This means that it would be very difficult to forge the long-term relationship that we hope to achieve through this "One Resident, One Doctor" scheme if they are switching doctors every few years under the company's scheme. How does the Government plan to counter this?

The enrolment of one-to-one GP will still allow patients to use their CHAS card at other GP clinics and this does not allow for "stickiness" to one GP and patients will still go GP-hopping. This is the feedback that I got from my GP colleagues. Of course, GPs are GPs. There will be GPs that are very popular. I am afraid that when this enrolment starts, the very popular GPs will be all fully booked out. Just like the good schools, MOH may have to start a balloting system for patients to book their favourite GPs.

Last of all, can GPs choose their patients? Are they allowed to reject patients who choose them in the first place? If that is the case, then, yes – by right, GP groups and GPs can cherry-pick. They can choose patients who are well, who do not need so much care, who are much more cooperative, compared to those who are not so cooperative.

As for the age of entry, disease prevention, especially for chronic diseases, is the focus of the White Paper.

I was wondering why the Ministry choose 60 and above as the entry age for the programme. In fact, 60 and above is where chronic diseases start.

At 60 and above, like what my Parliamentary colleague Sharael Taha just mentioned, one out of 10 will be having early dementia. It is a bit too late. If you want to prevent dementia, you should encourage them to start walking at 40 years old. If you walk 4,000 steps a day, it reduces your risk by 20%. If you walk 10,000 steps a day, it halves your risks straightaway. In that case, you do not need to build so many expensive dementia management centres if you start the programme early.

So, the question is – of course, ideally – that the implementation age should be 40 years old and younger – not older. The earlier you start, the easier it is to manage chronic diseases. In fact, we are here not to manage chronic diseases, but trying to prevent chronic diseases. By the time you hit 60, you are actually managing chronic diseases. So, there is a difference there.

The essence of the White Paper is to prevent disease from forming. Of course, we also want to make sure that chronic diseases are well managed, they do not progress to become more serious in the first place.

Last of all, is encouraging participation. Free medical checkups and vaccinations are, undoubtedly, attractive for boosting participation, yet there will be residents who are unconvinced.

Even for our free COVID-19 vaccination programme, which it comes to their mind, there are people who will refuse the vaccination. There are also regular functional medical screenings via Project Silver Screen that is held in the heartlands, free for seniors over 60. Not everybody will sign up. I have older folks who do take care of their health through good lifestyle habits like regular exercise and eating healthily but there is an aversion when it comes to asking them to go for medical screenings or seeing a doctor, especially when they are not feeling unwell.

Preventive healthcare does require commitment on the patients' part. It is unlike a simple medical consultation where patients see the doctor because they have symptoms. After they have their symptoms seen, they get treated, they go home with a medical prescription and that is the end of the transaction, whereas preventive healthcare is a long-term journey. The concept itself is relatively recent. What else can you do, as a Government now, to encourage the active participation of the population in preventive healthcare because it is really a big paradigm shift for all our residents.

A big part of it is funding. I shall talk a little bit on remuneration for GPs. This, I must, first, not take credit for myself. I must credit my GP colleagues who have emailed me when I asked them for their feedback on the Healthier SG White Paper. The first thing they asked me was, "How is the funding model?"

Many GPs are concerned about the remuneration model as they believe that the new scheme will add considerably more workload for them.

MOH has announced that there will be an annual service fee for each enrolled resident, which will vary according to the risk profile, scope of care as well as progress made. The fees are based on the patient's progress rather than service, which I think could be challenging to measure objectively. I think the argument on what KPIs to set, how to measure, has already started in this House.

A younger patient who is more receptive to advice will naturally make more progress than an older patient with more chronic health problems and who may be more resistant to changing their lifestyle. Can the Ministry provide a clearer outline on how GPs will be remunerated?

While I believe that most doctors want to make a difference to their patients' lives. However, if they feel that they are not compensated reasonably for their time and effort, some will choose not to participate in this particular scheme. In short, my concerns are how do we empower GPs and how do we make sure that GPs do not cherry-pick at the end of the day? That is the tough part, the tough balance that you have to make.

In terms of drug pricing – drug pricing to be made comparable to polyclinics needs to be handled carefully as GPs do earn from the sale of proprietary drugs. The uneven rollout of drug pricing by January 2024 may lead to residents preferring to be seen in polyclinics instead of GPs. That is one feedback that I got from most of the GPs.

I also want to voice the concerns from my GP colleagues about the IT-enabler for GPs. The incentive for GPs may not be worth the extra time and effort because, in July 2023 – that is, next year – the solo GP and his clinical assistant must do an enormous amount of work. While clusters can help him and his patients to connect to the social and community partners, he still has to see patients in an efficient and timely manner and ensure outcome indicators as well.

This can be a daunting task for many GPs. They will not receive payment for their work right away, it may be a year later. So, we need to walk this journey with the GPs and scope this launch very carefully.

The next topic I want to talk about will be the participation from the healthcare clusters.

I note that the three healthcare clusters will be involved in keeping the resident population healthy and will be step up as regional health managers. Can the Ministry share what are the specific KPIs for the health clusters and how will these KPIs be tracked?

I would also like to raise the concern that small GP groups as well as independent GPs may find themselves at a disadvantage, compared to the big groups which have clinics spanning all three clusters, because their market will be very limited.

Last of all, is preventing GP burnout. I echo some of my Parliamentary colleagues here. In the UK's National Health Service (NHS) system, GPs form the bedrock of their entire healthcare system. The healthcare journey for every patient starts with the GP first. In recent years, GP practices across the UK face significant and growing strains with the declining number of GPs, rising demand and struggling to recruit and trying to retain staff as well. This translates into longer waiting times and poorer service for patients.

According to data from the British Medical Association (BMA), the overall number of GP partners has been on the decline in recent years. Since 2017, the number of GPs working full-time hours or more in GP practice-based settings has been steadily decreasing. More GPs choose to work part-time as they have better control of their hours and workload, to improve work-life balance and reduce stress and burnout.

Besides loathing the heavy workload and long hours, NHS GPs have expressed their unhappiness with how their contributions and abilities have been undervalued, compared to specialists. They also face increasing abuse from patients as well.

We must learn from these countries with similar models and recognise the benefits but see how we can avoid the pitfalls. For the shift in our healthcare policy to be successful, we need adequate GPs to be working regular and reasonable hours to minimise burnout and to ensure that all our patients will be able to receive timely and adequate care.

How will MOH monitor the situation to ensure that GPs are well-equipped to deal with increasing workload? Will there be a support channel for both patients and GPs to share feedback? This is not to encourage patients to complain, but for MOH to seek meaningful feedback and to provide necessary support if the clinics are facing difficulties coping. The last thing we want is for the national care standards to drop and patients to be left in the lurch.

Will MOH now require GPs enrolled under this scheme to operate a certain number of hours on specific days or specific times of the day? There are clinics that are open only half a day on certain days of the week. Many do not operate on weekends and public holidays.

What will happen to patients who require medical care when their GP clinic is closed? What is the contingency plan if the GP is away for an extended period of time, be it for professional or personal reasons? Are enrolled clinics required to have more than one GP? Would they have to hire a standby and inform MOH if they will be away? Will there be a backup – a first-line GP and a second-line GP? Instead of appointing one, you have to appoint two, which means that one is on standby.

To get a clearer picture on the GPs' interest in the "One Resident, One Doctor" scheme, we need more statistics. Currently, how many GPs are practising on a part-time basis? These GPs may not be able to accept major cases or cases requiring commitment for long-term follow-up. How many GPs are participating in the Primary Care Network? What percentage of GPs nationwide does this constitute?

In conclusion, Mdm Deputy Speaker, good health is our personal capital asset. Responsibility for health should be a collaborative effort among individuals and the society that we live in. We all have to look after our health.

At the same time, many may not be well-versed in healthcare matters and would greatly benefit from having a healthcare professional by their side to walk them through this healthcare journey. We cannot put this plan into execution without strong support from our GPs.

During the pandemic, widespread burnout caused an exodus of healthcare staff around the world. Singapore experienced our highest turnover rate of healthcare workers over the past two years. Yet, even before that, healthcare workers have voiced their discontentment with long, inflexible working hours, and the abuse and disrespect they faced from patients. The pandemic has pushed the stress faced by healthcare workers to a breaking point. As we recover, we must ensure that Singapore continues to be a safe, conducive and inviting place for all our healthcare workers, including our GPs.

With that, Mdm Deputy Speaker, I support the White Paper.

Mdm Deputy Speaker: Dr Tan Yia Swam.

6.00 pm

Dr Tan Yia Swam (Nominated Member): Mdm Deputy Speaker, as President of the Singapore Medical Association (SMA), I have been involved in some prior discussions on Healthier SG. MOH has been actively engaging the College of Family Physicians and the SMA; and is aware that doctors broadly support this move. We support the shift in emphasis from treating disease to prevention and to strongly support the individual's health in primacy care via the family doctor and community support.

I speak now to raise specific concerns and hope that these will be considered as we embark together on Healthier SG. I would like to remind everyone, that we must consider the whole healthcare ecosystem, and not strictly segregate primary versus specialist care, or restructured versus private sectors when problem solving.

First, some context and background. I am a general surgeon who has worked in several restructured hospitals, before stepping out to private practice as a breast surgeon three years ago. And, as Dr Lim pointed out about wellness, I am registered as "Breast Friend Surgery and Wellness" because I advocate strongly for prevention of breast cancer.

During an administrative briefing many years ago, I once saw patients described as "clients" and doctors are called "service providers". I was saddened and devastated. That is when I decided – I will do what I can to reclaim back the doctor-patient relationship, for all of us. It is demeaning to think of healthcare purely as a business, or a transaction of payment for services rendered. Those of us who have enjoyed good doctor-patient relationships – and I have been on both sides – understand the world of difference it makes.

Having a good family doctor provides that strong anchor – to look after you and your family, and in turn, refer you to the necessary and relevant specialists for additional care. In real life, the difficulties and limitations of logistics, insurance panel restrictions and personal preferences will affect the flow of care. I have spoken on the problems with the Integrated Shield plans previously and I am glad to report that there has been some progress made.

What other broad challenges exist now for healthcare workers? Three things: one, IT support; two, manpower; and three, the elephant in the room, respect for healthcare workers.

Let me elaborate. The newspapers have reported on the national downtime affecting electronic healthcare systems in restructured clusters and this House has had updates from MOH on investigations.

As SMA President, I received feedback on the struggles that healthcare workers face on the ground. Complaints and angry patients aside, what we are more worried about is the potential lapses of care, as back-up manual paperwork is done during downtime, and then healthcare workers have to stay back to load the relevant information back into the electronic system.

Duplicate documentation – can you imagine how many man-hours are wasted, rather than focusing on actual patient care? As much as we understand the need to make things electronic, most healthcare workers are wary and cautious of the roll-out of the National Electronic Health Record (NEHR). I thank Minister Ong for acknowledging our concerns and recognising the need for good IT support and adequate monetary reimbursements.

May I also suggest that we need legislative support, in the event of unexpected complications in trying to implement the changes, for example, in the cybersecurity of electronic health systems, be it the clinic's own records or the national system?

I also propose that there should be education and encouragement for patients to take ownership of their own health records in HealthHub and to actively share relevant information with their attending doctor. Why is this mindset important?

I, personally, would like some of my medical information to be private. Just, as an example, if I had a previous miscarriage and abortion, mental health issues, I would not like every healthcare worker to know about them. I will choose to inform my attending doctor on what I feel is relevant, or, if they ask, I will question, is this information going to make a difference to my current condition?

I value confidentiality and privacy. In conjunction with Healthier SG, let us remember to educate individuals on the importance of personal care and responsibility.

Next, manpower issues may not be solved just by hiring more healthcare workers. It is not just the number of staff but the experience of each staff. Losing one nurse with 10 years of experience and intensive care unit (ICU) training, can she be replaced by five new nurses?

Look to the retention of staff – for senior, trained doctors to stay in public sectors; for experienced nurses and allied health to want to stay in Singapore. It is good that there are more training and new hires for Singaporeans and for foreigners, but how do we actually retain them?

Exit interviews should be taken seriously to evaluate systemic problems or work culture differences. For my own exit interview some years back, the schedule was changed a few times and eventually, it was a new HR staff who met me to take back the staff pass and sign some papers as a formality. I hope MOH continues to engage all stakeholders on a regular basis and take our considered feedback. The Tripartite Committee looking in the welfare of our junior doctors is a positive step. How about other groups?

Why are the foreign nurses, who have worked and trained here for years moving on to work in other countries? Is it purely about matching the salary, or struggles with setting up a family and their childcare needs? What are the subsidies available for foreign staff in the childcare centres? I take note that certain kinds of leave are eligible only if the child is a Singaporean Citizen.

How may we help them to find a home and be willing to be here long term? Would it be possible to consider offering permanent resident (PR) status for the healthcare worker after one to two years of working here and maybe even extending PR status to the immediate family after a longer period of work, let us say, five years? I do not know.

Specialists have raised concerns about the capitation model in particular, will there be funding for complex cases, such as transplants or if a routine case runs into complications?

The feedback from senior specialists in restructured hospitals is that, should there be a decrease in the number of complex cases, it will affect the training of our younger specialists. In the long run, we worry that the quality of care will be affected adversely as well as our standing as a leading medical health hub.

Finally, I address the elephant in the room – respect for healthcare workers. After the hurrah of healthcare heroes during COVID-19, we now struggle with a backload of "business as usual" cases, long waiting times and general unhappiness.

Perhaps, the average layperson does not quite understand how complex the healthcare system is. In having team-based care, with nurses and allied health taking on so much of the healthcare needs, it should be recognised, by having the patients know that these are all professionals, who are trained to deliver specific interventions and health outcomes.

As an example, I perceive that sometimes, patients do not understand the importance of physiotherapy after surgery and neglect to keep the range of movements, resulting in a frozen limb, and then, wrongly blaming the doctor for bad surgery.

For patients who come to the hospital for the first time ever with end-stage organ failure; I am deeply saddened. Why the years of neglect? Was it a lack of awareness or lack of resources? How about the role and responsibility of the immediate family in reminding the elderly loved one to go for regular check-ups, advise compliance with medications and to take active steps to modify this.

On the one hand, we see some patients who have chosen not to know anything about their own bodies. On the other hand, we also see some people who Google non-stop and take bits of information with inadequate context, even to the extent of arguing with healthcare professionals about what is correct medical care. I wonder, do people argue with lawyers or bankers this much in legal or financial matters?

What is the right balance? I always believe that education is key: good basic health education and understanding of how our body system works, how the body gets ill – is essential towards keeping oneself healthy.

Establishing a good doctor-patient relationship and having mutual trust in each other gives much better patient outcomes and satisfaction. The rise of badly-written Search Engine Optimisation articles is severely detrimental to the doctor-patient relationship. So many articles share half-truths and myths, even fear mongering. As a council doctor of the SMA, I will continue to advocate for this public education and allowing doctors to do our work well, with adequate support.

Each and every one of us here has to play our part well, in taking responsibility for our own health. In the launch of Healthier SG, I look forward to the shift of care to a community-based care and truly embody "prevention is better than cure".

Mdm Deputy Speaker: Ms Hazel Poa.

6.09 pm

Ms Hazel Poa (Non-Constituency Member): Mdm Deputy Speaker, I welcome the plans outlined in the White Paper to bring about healthier Singaporeans.

I have a number of questions on the funding model and manpower requirements, which I hope the Minister can provide answers to.

Firstly, on the funding model for healthcare. I welcome the change in funding model to incentivise efforts towards preventive and early intervention measures and better health outcomes. Since we are paying the GPs and regional health managers on a capita basis, and learning from the SportsHub experience, will there be provisions for clawback of fees paid or termination for non-performance? What are the KPIs for family doctors?

I note from the White Paper that MOH is still in the process of working out the KPIs for the healthcare clusters. I would like to request for these to be presented to Parliament once they have been worked out, as they will be of much interest not only to the Members here, but also to members of the public.

Apart from KPIs based on the performance of the healthcare clusters at the regional level, I hope to also see KPIs based on outcomes at the national level as well for the regional clusters. This will provide incentives for the regional clusters to cooperate with one another for a better outcome at the national level. After all, the outcome at the national level is of greater importance to us and the KPIs should reflect that.

Apart from KPIs for the healthcare organisations, the performance appraisal and reward system of key personnel should also be revealed for the same reasons.

For the service fees that the Government will be paying to GPs and healthcare clusters, will there be any difference between foreigners and locals? Would there be any financial reasons for GPs or healthcare clusters to lean more towards one group?

Next, I have some questions on the manpower requirements. What are the number of doctors, nurses, and other healthcare professionals now and projected in the next decade? How does MOH intend to reach those numbers? Would it be via an increase in enrolment in relevant courses at our universities, polytechnics and other training centres? If so, what is the planned enrolment for these courses in the next decade? How many is expected to be via recruitment from outside Singapore? And does MOH plan to change the terms and conditions of these healthcare professionals to attract and retain them?

I also have some questions on chronic diseases. The White Paper showed that the rate of diabetes has fallen slightly, while that for obesity has risen slightly. However, the rate of high blood pressure and high blood cholesterol has risen sharply.

Unbalanced diet and low level of physical activity were cited as reasons. These two reasons would, however, cause rises in all four categories. And since the magnitude of change is so different, could there be other contributing factors apart from diet and exercise? For example, would stress levels and poor work life balance be contributing factors? Can MOH also provide more details on what ways is our diet unbalanced?

The White Paper also mentioned that the prevalence of chronic diseases have risen across many age groups including the young. Can MOH provide the prevalence rate with breakdown by age?

Lastly, I have a couple of suggestions for the Minister to consider. I have raised this before and I will raise it again. MediSave can currently be used for hospitalisation and limited outpatient treatment. I have heard anecdotes of how some people chose inpatient treatment for something that can be treated as an outpatient and at a lower cost, because the former can be paid via MediSave while the latter require cash outlay. Therefore, demand is skewed towards the more expensive inpatient treatment due to MediSave rules.

In line with the efforts outlined in the White Paper to move our healthcare more towards preventive and primary healthcare, will MOH consider allowing MediSave to be used for all outpatient treatment?

Secondly, healthier food tends to be more expensive than unhealthy food. Can we find ways to make healthy food less expensive compared to unhealthy food? One option to consider is a tax on unhealthy food that goes towards subsidising healthy ones.

Mdm Deputy Speaker: Dr Wan Rizal.

6.14 pm

Dr Wan Rizal (Jalan Besar): Mdm Deputy Speaker, I declare that I am an academic staff focusing on health and wellness at an Institute of Higher Learning (IHL).

I welcome the announcement of the Healthier SG White Paper. The push toward preventive health is an area that I have advocated throughout my career, from being a Physical Educator and now, through research and programme design. I am supportive of the plans laid out by the Ministry, which have been on the agenda for many years. And now, with the fundamentals in place, we are taking this necessary step to improve our healthcare further.

Madam, despite my support for the Healthier SG White Paper, I do have some concerns that I would like to put forth.

Firstly, different constituencies have different demographics that may require specific considerations and attention. For example, as a whole, in my constituency at Kolam Ayer and Jalan Besar GRC, there are higher proportions of elderly residents and notably, there may be fewer GP clinics in the vicinity too. Therefore, concerning resources, both in terms of quantity and quality, will there be enough GPs and community partners that can support our elderly?

Secondly, for the elderly who are less mobile or immobile, regular visits to the doctor may be challenging. How does MOH intend to engage and support them? During the COVID-19 pandemic, I was encouraged by the efforts on the ground to visit the elderly who are less mobile to provide vaccinations for them. I hope that similar efforts may be made to engage and support them.

Thirdly, the elderly may take a longer consultation time. How does this impact the GPs daily workload and operations? And collectively, how will this impact the quality of support for the elderly?

My fourth point revolves around the caregivers who selflessly tend to the elderly. Would it be possible to allow the caregivers to be enrolled with the elderly in their charge? This would allow the doctor to plan a more holistic and inclusive approach for both of them.

Finally, with regards to the enhancement and usage of digital tools, our elderly have come a long way in getting themselves digitally ready. Nevertheless, some are concerned with how fast technology and apps have evolved. Moreover, the thought of being scammed, too, may hinder their usage of digital support. How, then, does the Ministry plan to address these concerns?

Madam, throughout my stint in Parliament, I have continually raised the importance of mental health and how we should treat mental health just like physical health. Thus, I would like to ask the Ministry: how does mental health fit in the Healthier SG initiative? This would be more pertinent when Healthier SG is rolled out to the younger generation, who are more open to mental health issues and understand the importance of mental well-being.

Nevertheless, the elderly are not spared too. Issues like dementia or depression due to social isolation remain pertinent issues. Therefore, concerns like whether there would be enough mental health trained GPs and, if so, how would these GPs engage and manage consultation time, bearing in mind that consultation times may differ in complexity, require deeper attention and may take a longer time. I believe Healthier SG is an opportunity to address the issues that I have raised previously related to accessibility and screening. GPs now would naturally increase the nodes for accessibility, and I hope health screening can also include aspects of mental health.

Madam, through Healthier SG, collaborations and partnerships are increasingly emphasised. However, I was unable to find the roles of IHLs. Practice-based research efforts are expanding and courses that provide lifelong learning regarding public health have grown.

IHLs play an important role within the public health system. To educate and train; conduct basic and applied research in disciplines pertinent to public health; and engage in the community and professional service. Of course, IHLs are not the only institutions that provides education, research, and service. However, it would be useful to tap on IHLs as additional resources. Madam, in Malay, please.

(In Malay): [Please refer to Vernacular Speech.] In my English speech just now, I touched on several matters that I hope the Government can clarify. This includes the matter of our seniors.

In Jalan Besar GRC, for instance, where many of its residents are senior citizens, I am concerned about their health. And I hope that they will make full use of the Healthier SG initiative.

I hope that MOH can provide some clarification on the issue of resources, both in terms of doctors and community partners, who are able to support our seniors. I hope that the quantity and quality of these resources will not be affected.

Second, for senior citizens who are less mobile, frequent visits to doctors may prove to be challenging. So, how does MOH intend to engage and support them?

During the COVID-19 pandemic, I was grateful that many of our seniors, who have difficulty getting around, could be visited by doctors and get vaccinated. I hope that the same effort can be made to support them.

Third, consultations for senior citizens may require a longer time. Therefore, I am concerned about the impact on the quality of support for our seniors.

Fourth is about the caregivers of the elderly who have worked wholeheartedly and tirelessly. I hope they are allowed to register the elderly under their care. This will enable doctors to prepare a more holistic and inclusive health plan for both of them.

My final point is related to the use of digital devices. Our seniors have gone a long way in preparing themselves digitally.

However, some are worried about the rapid advancement of technology and applications that continue to evolve.

In addition, many are also anxious and afraid of online scams. So, how does MOH plan to address their concerns?

Finally, I have frequently highlighted in Parliament about mental health issues and how mental health is just as important as physical health. I hope that the Minister can elaborate on the role of mental health in the Healthier SG initiative.

(In English): Madam, please allow me to end by sharing a personal anecdote. Last December, I had a health scare and I conceded that at 43 years old, I just could not catch up with my children. I consulted a doctor friend and after analysing the results, he assured me that I was just too exhausted but highlighted that it is time I put my sports science knowledge into practice.

So, I started the New Year with a simple goal of being more active, having a healthier lifestyle. To shift my BMI category from overweight to something more acceptable and lowering my body fat percentage from 25% to 20%. This means shedding about 10 kilogrammes off my deceivingly "okay-looking" frame. I am glad to share that I have met the objectives, but there are a few lessons learnt.

The first lesson is looking okay or feeling okay, does not mean one is healthy. Thus, the importance of screening cannot be underestimated. It not only gives me a peace of mind knowing the results of my screening, but nudged me towards preventive health too. My initial commitment to physical exercise and increased physical activity then manifested into other aspects of health. For example, I became more conscious of nutrition, cutting down on salt and sugar and eating more vegetables. I also began to be conscious of my overall well-being, like cutting down on screen time and making sure I have enough sleep.

So, lesson number two is health is not just about physical health. A holistic, balanced, sustainable approach to self-care, based on the numerous dimensions of health and wellness, is important – like mental, social and spiritual health.

Notably, the people around me became the catalyst and motivation. Family members, friends, colleagues and even my grassroots leaders, were more receptive to my healthier lifestyle. For example, simple things like a healthier food spread, more family activities at the park and shorter meetings in the evenings, makes a lot of difference to our health. These allow me to maintain my newfound healthy habits and encourage others to pick up healthier habits too.

So, lesson number three – it is always better together. I hope that MOH and community partners like PA plan activities for all the communities – activities that revolve around families. Studies have shown the elderly who stay connected to the family and participate in regular recreational physical activities benefit from a longer life expectancy, better immune system and better mental health.

Madam, preventive health is a commitment that each of us must make, but it is often easier said than done. In this regard, an individual's commitment and the whole community must move towards a healthy lifestyle and make preventive health happen.

The Government alone cannot make it happen. However, I do hope that the plans laid in place will nudge and ease Singaporeans to control and begin a healthier lifestyle. Notwithstanding my concerns shared earlier, I support the Motion.

Mdm Deputy Speaker: Ms Janet Ang.

6.25 pm

Ms Janet Ang (Nominated Member): Mdm Deputy Speaker, thank you for the opportunity to participate in this debate on the Healthier SG White Paper.

"For a nation to truly prosper, its citizens must have good health. Those who enjoy good physical and mental health, report high levels of well-being. An effective health infrastructure is critical for sustaining per capita income. Poor health keeps people from fulfilling their potential." That was a quote by Baroness Philippa Stroud, CEO of Legatum Institute, a thinktank in London. Legatum Institute ranked Singapore number two in the world for the Health Pillar in their Legatum Prosperity Index (LPI) 2021.

According to the World Health Organization (WHO), a well-functioning healthcare system requires a steady financing mechanism, a properly trained and adequately paid workforce, well-maintained facilities and access to reliable information to base decisions on. The WHO's global study assesses healthcare systems around the world and Singapore was ranked sixth in the world, and the highest rank for countries outside of Europe.

And, as reflected in Figure 1 in the White Paper, Singapore has been able to achieve good health outcomes, improving our healthcare system, without incurring substantially higher levels of healthcare expenditure. It is not by chance that Singapore has been able to come out of the COVID-19 pandemic with relatively low deaths. How we have emerged from COVID-19 reflects the resilience of our healthcare system, of our institutions and most of all, of our Government and our people. Kudos especially to the generations of healthcare professionals and policy-makers who have strategically enabled us to more than survive COVID-19, and to emerge from COVID-19 stronger together.

The Healthier SG White Paper, which is being debated in the House today, is timely. Singapore is faced with a rapidly ageing population, and we can expect, therefore, an increase in the proportion of people living with diabetes, hypertension and other chronic diseases.

As the saying goes, "Prevention is always better than cure." We need to shift our emphasis from reactively caring for those who fall seriously ill, to proactively preventing individuals from falling ill. Therefore, health screening, a healthy lifestyle and education are the key pillars to disease prevention. We got to add to that discipline.

At the same time, we need to sharpen our focus on the value of care, recognising that there is a cost to care. Dr Brent James, a renowned clinician and Doctor of Medicine who was the Chief Quality Officer for over 30 years at Intermountain Healthcare and a senior advisor with Health Catalyst as well as co-author of a book, "To Err is Human", suggests that Value of Care = [Clinical Outcome + Patient Experience] divided by cost. Prevention and going upstream has been proven to be the best way to improve clinical outcome.

The community also plays a part in the reshaping of our healthcare model toward one that involves every resident and not just when they become a patient. Allow me to share two initiatives where I personally witnessed the community in action, and the impact on the health and well-being of the seniors as well as the volunteers.

GoodLife! Makan at Block 52 Marine Terrace is a programme by Caritas' Montfort Care Family Service Centre (FSC). Seniors in the neighbourhood are encouraged to come together at the GoodLife! Makan community kitchen to prepare, cook and share their meals with one another, and more importantly to listen to one another's stories and to learn and support each other.

SHARE A POT® is another community initiative which brings seniors together around a pot of hot nutritious soup for them to enjoy, and also to rally each other to grow stronger and live well with broth and brawn. During COVID-19, SHARE A POT® went online and did its part to help seniors to stay connected. These kinds of initiatives can become a part of the Healthier SG community partnership.

I applaud Healthier SG for the comprehensive holistic approach that it has taken. There is a lot to be done but we will need the whole of Singapore to be committed to act for a healthier Singapore. Continued dialogue with all stakeholders to clarify issues and collaborate on solutions as we take this forward will be imperative.

For the rest of my speech, I will cover three areas.

First, going upstream with resident and family physician relationship. For example, at Intermountain, they incentivise the Primary Care Network to keep people out of hospitals as much as possible. For their diabetic population, they invested additional 4% of their budget in this group and achieved a decrease in hospital admits by 22% and a decrease of 21% for other avoidable visits and admissions, resulting in overall improvement in value of care and reducing overall costs over time. So, prevention is certainly better than cure.

Healthier SG is enlisting the primary care providers to play the central role in this healthcare model. This will cement the place of family medicine in delivering holistic and coordinated healthcare to all patients, reduce doctor and clinic hopping and have the potential to ultimately improve rationalisation of specialist care by public hospitals.

Everyone I have spoken with agrees that this is certainly a step in the right direction, but cautions that as in all things, the devil is in the details. How to implement and to implement it right from the start is the big question. Here are some of the questions which we hope MOH can clarify.

While it is good for a patient to come under a fixed doctor or clinic, it may not always translate in practice. For example, patients seen at polyclinics often do not get to see the same doctor at every visit. Likewise, some GP groups employ locum doctors. Can MOH clarify if the intended enrolment is with a GP practice/clinic or is it with a named doctor?

Can a resident be enrolled with more than one GP so that there is a second opinion or a back-up doctor in case the enrolled doctor is on vacation or at a conference? How does the enrolment work for the family paediatrician, the family dental surgeon, the eye doctor and others? By the way, will health screening include regular eye screening and dental screening?

What happens to the residents who do not enrol? How will it work for residents with company provided or insurance provided panel of doctors? Can the employees consider the GP clinics of the healthcare partners as their enrolled GP?

Phased approach is the pragmatic way to implement. I am above 60, and so am in the category – but after listening to hon Members speak about it, I do hope that MOH can consider enrolling the students in Institutes of Higher Learning (IHLs) and the National Service (NS) groups as well as reduce the starting age to 40, because usually it is the 40-something who will bring the 70-something to the doctor. So, I think it is good also for research – comparing the different groups, how they adopt and enrol themselves into such a programme.

Next, the plan to use technology to help implement this programme is laudable and should be explored. I love the idea of using the HealthHub app as a digital reminder to patients. To close the loop, there can be digital reminders in-built into the electronic medical record system, which prompts the doctor to check on the progress of the healthcare plan and ensure timely implementation. To take it one step further, appointments with relevant care team members can also be considered to be implemented online.

Therefore, the IT system, the health communications network and the National Electronic Health Records system are critical for the successful implementation of this initiative. MOH has done very well as it is in this space but will need to continue to invest as more still needs to be done to ensure system up-time, efficient sharing and update of the patient's health records while ensuring data is secure and personal data duly protected.

There will also be a need for trained doctors, nurses and staff to engage, educate and support the patients in the enrolment and transition journey. What help and support will MOH provide to help the GPs and clinics transition to the level of digital that will enable them to perform their role in this healthcare model?

According to Dr David M Eddy, the father of evidence-based medicine, it is now well studied and clear that "complexity of modern medicine exceeds the capacity of the unaided expert mind. Solo reliance on the craft of medicine is scientifically untenable."

It has been found that the best way forward is to develop evidence-based best practice protocol, blend it into clinical workflow, embed data systems to track protocol variations and strongly advocate that clinicians apply the protocol but subject the protocol to continuous improvement based on patient need, and thereby improving the protocol in a continuous loop applying Deming's Lean Six Sigma principles. Clinicians globally have found this approach to improve clinical quality and drive better clinical outcomes over time.

I read from the White Paper that our Singapore medical and clinical professionals are exploring such best practice methodologies and I applaud it.

Let me speak briefly for the digital naive, the vulnerable elders and the foreigners. In spite of the best efforts of the Infocomm Media Development Authority (IMDA), GovTech and their volunteers, there is still a large group of seniors who may not be digitally savvy. How will MOH onboard this segment of citizens who are digitally naive and who are likely to be from the lower-income households? Will we consider similar initiative like they did in Japan where the neighbourhood postman becomes the point of contact for this group of vulnerable seniors?

For vulnerable elders, will home care and support for end-of-life be part of this programme? End-of-life care is expensive and underdeveloped. We will need to enable the caregivers and the elderly themselves to transition with dignity and with comfort.

Lastly, considering that we do have a sizeable number of people in our community who are permenant residents (PRs) and employment pass holders or work permit holders, how will Healthier SG apply to them?

In summary, the initiative is an excellent one. In the long run, it would lead to Singaporeans leading healthier and more productive lives. At the same time, there is opportunity for Singapore to create an innovative model of value-based care based on strong population health expertise with a robust digital health platform, an extensive telehealth network and a compassionate and engaged community. We all need to play our part.

Let me close with some advice from my mother-in-law, Mrs Lily Cheah, who is 99 years old, going on 100. Whenever she is asked, "What is your secret, Auntie Lily, for a long and healthy, happy life?", Mom's answer is "Use it or you'll lose it." Mdm Deputy Speaker, I support the Motion.

Mdm Deputy Speaker: Deputy Leader.

Debate resumed.

Mdm Deputy Speaker: Mr Xie Yao Quan.

6.38 pm

Mr Xie Yao Quan (Jurong): Madam, in 2020, I said in my maiden speech in this House, during the thick of COVID-19, that while we worked on the immediate task at that time of flattening the epidemic curve, we also needed to keep our sight squarely on our longer-term health care challenges and bend our long-term healthcare cost curve.

Today, we are debating a new health and healthcare strategy for Singapore, laid out in the White Paper on Healthier SG.

The last time MOH published a White Paper was 30 years ago. That paper was on affordable health care and it was a landmark paper that went on to define the development of our healthcare system over the last 30 years.

Thirty years on, we have this White Paper on Healthier SG. And I believe it will be no less of a landmark paper, providing an additional strategy – a strategy reboot – for a vastly different population with very different needs and against the backdrop of a Government healthcare budget that has increased many times in the last 10 years.

This White Paper shows how urgent and important our challenge of bending the healthcare cost curve is. I stand in support of the Motion. I had two key considerations in mind as I prepared this speech.

First, because the challenge before us is so important and so urgent, we must take a thorough and critical look at every piece of the Healthier SG strategy and leave no stone unturned. In this regard, I will make quite a number of points in my speech. But second, I will focus only on the strategy – and the key strategic pieces – and set aside for now questions that are of a more operational nature, even if there are a number of these.

With this preamble, let me lay out my views on the White Paper on Healthier SG.

First, Healthier SG must be inclusive because it goes to the heart of our social compact, and our social compact must, in turn, be for all Singaporeans. On this point, I have three key questions.

How do we ensure Healthier SG is inclusive socio-economically? We know the lower-income segment has poorer health outcomes and a lower propensity for health-seeking behaviours for various reasons. Therefore, I wished the White Paper had included specific mention of how we plan to support our lower-income segment through additional, differentiated measures to remove the particular barriers to health-seeking behaviours that this segment faces.

For example, because travelling distance may be an especially salient barrier for this segment, do we need to be particularly deliberate in ensuring proximity of family doctors in both GP clinics and polyclinics to our rental communities?

How can we improve seemingly basic things like nutrition, sleep and smoking cessation through targeted interventions for this segment because these things may not be basic for them?

How can we help this segment find time and cognitive bandwidth to exercise, when time and cognitive bandwidth may be particularly scarce for this group?

Because the social needs of this segment are especially high, how can we be particularly deliberate in enabling GPs to work with community partners to address such social needs?

How can we better bring Social Service Offices and social service agencies into the framework of healthcare clusters and Primary Care Networks so that we strengthen and tighten the nexus between social services and health for the low income? Who will have primary responsibility to pull all the assets together to wrap around the enrolled person?

I wish the White Paper had provided some insights to these questions.

The second question that I have is how do we ensure Healthier SG is inclusive digitally? The Healthy 365 app will be the "digital front door" for citizens to enrol with a family doctor and Healthy 365 will also be the "digital front door" for capturing individual behaviour, for tracking progress and for generating healthpoints in exchange for rewards.

But we know that a number of seniors have dropped out of exercise groups when these groups went onto Healthy 365 for the sign-up and bidding of slots. They dropped out because they did not know how to do this on Healthy 365.

Seniors have also given lots of feedback about polyclinics and their recent shift towards more and more of an appointment-based system in lieu of walk-ins. Seniors wonder how they go about booking polyclinic appointments online or on mobile? If they call the hotline, what number should they call? How long do they have to wait for their calls to be answered? A "digital front door" in Healthier SG can well become a "digital gate" for some and we have to avoid that.

The White Paper further mentions HealthHub as the second "digital front door" for every individual's health action plan. But each of the three healthcare clusters also has its own app – its own "digital front door". So, put together, these could add convenience to users but they may also confuse them.

The point is: while digital is essential and we must have digital channels, we have to also preserve traditional touchpoints. In other words, we must provide optionality in the key touchpoints of Healthier SG. Optionality by providing both traditional and digital options rather than substituting the traditional with the digital. We need optionality as a core design principle of key Healthier SG touchpoints.

The third question I have is, how do we ensure Healthier SG is Inclusive for All Healthcare Professionals? I did a word count. The word "doctor" was mentioned more than 160 times in the White Paper, unsurprisingly. Compared to "nurse" and "nursing", which were mentioned 22 times, "pharmacist" was mentioned six times and "allied health", seven times. So, the doctor appears overwhelmingly to be the centre of gravity in the Healthier SG strategy, but what about the roles of a nurse, a pharmacist and an allied health professional?

Is there room for more equal roles, more co-leadership to shape preventive care in the community? Because, let us pin the flag squarely on the mast. The focus of Healthier SG is chronic diseases. Prevent chronic disease onset in the first instance and if disease is inevitable, manage these diseases well. So, it is not complex medicine per se, but medicine that is person-centred, relationship-driven and certainly high-value. And in this respect, nurses are very good at titrating medication and at engaging, motivating and cajoling. These are key activities in preventing chronic diseases and in managing chronic diseases, that nurses can be very good at.

And in comparison, what is more exclusive to doctors is the gestalt to diagnose diseases and to provide prognoses of disease trajectories. So, I wish we had a fuller articulation of the vision for nurses, pharmacists and allied health professionals, including medical social workers, in the overall Healthier SG strategy – all practicing at the top of their respective licenses in the community, alongside doctors, to prevent and manage chronic diseases across our population.

And I think we also need a mindset shift in our population, from a doctor-centric view to one that respects all healthcare professionals including nurses, pharmacists and allied health professionals, and what they can do.

In summary, my first broad point: our Healthier SG strategy needs to be inclusive socio-economically, inclusive digitally and inclusive for all healthcare professionals.

My second broad point is that manpower planning will be key in Healthier SG. The most natural question in this regard is how many family doctors, nurses and so on, would we need to fully realise the strategy, but I prefer to leave this to MOH's COS debate next year. I think that would be the best time to discuss manpower numbers.

Today, I would like to raise some other points about manpower planning.

First, for the public healthcare sector, we need stability to become a key principle in manpower planning. Family doctors and physicians in our public polyclinics will take on a significant portion of the Healthier SG workload even as we enable GPs to step up and to do more. So, within the polyclinics, I would like to ask what happens to enrolment arrangements when family doctors and physicians within these polyclinics move, get rotated or cross-deployed, as they routinely do. Do patients move with the doctors? Fundamentally, are Singaporeans going to be enrolled to a polyclinic or to a particular doctor within the polyclinic?

May I boldly suggest that we need less rotation and more stability in our manpower planning for all polyclinics across all three healthcare clusters in order for Healthier SG to work as it should?

On a related note, may I suggest even more boldly, that clinical manpower recruitment, posting and deployment in general across our three healthcare clusters, should be centralised at the Ministry level going forward? Currently, the healthcare clusters have principal responsibility for this strategic manpower function. Taking this responsibility off the clusters and moving it to the Ministry level will ensure a coherent manpower planning strategy nationwide in support of national desired outcomes, and as importantly, this would free up strategic bandwidth within the clusters for them to step up to their very important new roles and responsibilities as regional health managers under Healthier SG.

Besides clinical manpower planning, we would need equally robust manpower planning for our cybersecurity and healthcare IT talent. As the White Paper noted and many Members have noted, IT is a critical enabler and quite often a pain point. But the competition for tech talent has never been more intense and will probably intensify further. So, how does the Ministry plan to manage the competition and secure the healthcare IT and cybersecurity talent it needs to deliver on Healthier SG?

We need to get this right, because this is about securing public trust in the protection of their healthcare data, and it is also about securing the trust of professional users in the usability and inter-operability of our healthcare IT systems.

In summary, my second broad point about manpower planning for Healthier SG: we need this to enhance clinical manpower stability in polyclinics, we need to free up strategic bandwidth for healthcare clusters and we need to secure critical IT talent.

My third broad point is: let us remember to integrate downstream even as we look to integrate upstream. It is timely and apt that Healthier SG emphasises upstream interventions, primary care, preventive care, collaboration between GPs and community partners to promote health. All this is good, but we also need to pay an equal amount of attention to integrating much more downstream. In other words, strengthening the integration between GPs and specialists that are based largely in our hospitals.

GPs have spoken of the need to become more equal partners in care, vis-à-vis their specialist counterparts. GPs want to feel that after a referral is made to a specialist in a hospital, there is tight two-way communication and the loop is closed, and GPs do not feel like they are losing their patients to the system, and in the system. Of course, details about such integration between GPs and specialists ought to be worked out by the healthcare clusters but I wished the White Paper had made a stronger mention of our larger, strategic intent in this regard.

For Healthier SG to really tackle chronic diseases across our population, we need to integrate much more, both upstream and downstream, across the health and healthcare value chain and address all archetypes, including those with more advanced diseases and requiring more specialised care.

My fourth broad point: on healthcare financing, our reforms can go further to truly drive integration. Ideally, capitation funding to GPs should flow through the healthcare clusters rather than from MOH, as is currently proposed in the White Paper. Capitation funding to GPs through the clusters will drive fuller integrations between GPs and the clusters as regional health managers. We should aspire to – as many Members have mentioned – the UK model for example, where GPs can eventually refer patients for direct admission to a hospital within a healthcare cluster, without the need to go through an Emergency Department, for clinically appropriate cases.

I hope as we progress in this multi-year Healthier SG journey, we will keep pushing the boundaries on healthcare financing as a key lever to drive integration and what is currently described in the White Paper will not be become our eventual end-state.

My last broad point on Healthier SG: in certain aspects of the strategy, let us avoid optimising at the margins, only to blunt the tip of the spear. What do I mean? The Motion before us today has only three limbs and community-based programmes are one of the limbs. In fact, the White Paper also emphasised that, "good health is sustained through everyday choices and habits, which take place outside healthcare facilities" – outside the clinic. So, community-based, health-promoting programmes are a centre of gravity of Healthier SG.

These programmes in the community are what I would call "the tip of our Healthier SG spear" and as Minister mentioned in his opening speech, they occupy that space and the time between the visits to the clinic, to the GP, so they are really important. They are the tip of our spear and we must keep it sharp. Keeping it sharp means amongst other things, ensuring that there is adequate funding to this part of the strategy, and as importantly, we need to rethink how we measure effectiveness and efficiency of such funding.

For example, exercise groups by HPB had emerged with a vengeance since we opened up and residents have really welcomed this. But recently, there has been concerns amongst residents that some of the exercise groups by HPB could be cut or consolidated away because they are not hitting and maintaining a certain attendance rate. If the purpose of these exercise groups is simply community programming, then I would agree with this approach because we need to be prudent.

But if such community exercise programmes are so important in Healthier SG, if these programmes are the tip of our Healthier SG spear, then we need a different approach. We need to have K-pop classes available in the mornings and evenings on weekdays and on weekends. We need to have Zumba and Stretch Band and HIIT classes equally available, mornings or evenings, weekdays or weekends.

We need each and every local community to be abuzz and completely teeming with community exercise groups and health promoting activities catering to the entire range of needs and lifestyles within the community. This will really bring Healthier SG alive in the community and send a strong signal to residents that we want them on board, even if this may mean some redundancy or unused capacity at the margins.

Mdm Deputy Speaker : Mr Xie, you have one minute to round up.

Mr Xie Yao Quan : Indeed, we should welcome such redundancy and it could serve as a useful buffer. If we focus instead on optimising capacity and funding efficiency at the margins for these programmes, we will blunt the larger intended purpose of the programmes under the Healthier SG strategy.

I will make one last point about the community and that is eating and food choices in the community. Member Ms Hazel Poa suggested taxing unhealthy food to subsidise healthy food. And I would just like to ask her for clarifications about her specific ideas for taxing unhealthy food and in the larger spirit of Healthier SG, having heard the essence of the strategy, whether she feels that, an intervention like taxing unhealthy food would cohere with the overall spirit of the strategy and is still a good idea.

Madam, let me conclude. In the White Paper —

Mdm Deputy Speaker: You have two seconds.

Mr Xie Yao Quan: — one family doctor was quoted as describing Healthier SG as "our great leap forward for primary care and preventive care for chronic conditions." But a "great leap forward" may not end up in success. So, I prefer to see Healthier SG as a "moonshot" for SG Healthcare.

And when JF Kennedy resolved to send a man to the Moon, he said, "We choose to go to the Moon in this decade and do the other things, not because they are easy, but because they are hard." Indeed, Healthier SG entails hard work ahead for us in this decade, very hard work. But this is precisely why we must do it, and we will do it together to secure a better and healthier future for all Singaporeans.

Mdm Deputy Speaker: Mr Abdul Samad.

6.59 pm

Mr Abdul Samad (Nominated Member): Mdm Deputy Speaker, as a union leader and representative of fellow workers, I rise in support of this Motion to drive towards Healthier Singapore.

This Motion clearly emphasises the need for and the importance of living healthily to start at a young age. This will then pave the way for healthy daily living and mobility as we grow old to enjoy the fruits of our hard work during our early age. Furthermore, unions also want to ensure that our fellow workers can continue working beyond the retirement age, knowing that one of the criteria is about the medical condition of the worker.

My speech today will cover the role of unions in strongly focusing on preventive care and building strong partnerships with community partners to support our fellow workers who are taking care of their own health and wellness.

Madam, I am not sure how many in this House or members of the public know the complete suite of benefits our unions provide in supporting our fellow workers. While many may be aware of the workplace grievances handled and social benefits provided by our NTUC social enterprises and affiliated merchants, unions do so much more than that. Of the many cases that unions handle, only about 10% are on workplace grievances. Hence, we need to provide unique, value-added services to the remaining 90% of our members, one of which is to provide support and subsidies for our members in terms of health and wellness.

Unions continuously innovate to serve our members better because, for the unions, it is "Members First, Workers Always".

Allow me to enlighten the House on the three different ways that our unions and our leaders have supported members and workers in the preventive healthcare journey.

This role is not new to the unions. Minimally, we encourage our management partners to provide regular complimentary health screening for our members and workers. Regular health screening is critical to identify any symptoms of sickness that each worker has, and they could then be provided with the necessary early intervention measures before the sickness worsens.

While providing these complimentary health screenings looks simple, mobilising and encouraging workers to take part is never an easy task. There were times when some management partners wanted to discontinue this, due to the low take-up rates, but our union leaders rejected strongly and worked with management partners, to maximise outreach efforts to increase and optimise participation.

Allow me to share some examples of two unions that have gone beyond what their management partners do for their workers.

First, is the Union of Security Employees, in short, USE, which has set up a healthcare advisory booth provided by the HPB at their customer service centre for any member to walk in and request for assistance. These members take the opportunity to know and understand health advisories while waiting for their turn to be called up.

Another example is one of mine, the Union of Power and Gas Employees, in short, UPAGE. We started this movement many years ago with one of our management partners. Initially, our members were offered $50 if they chose not to take any medical leave for the year. We have replaced that with an annual health screening worth close to $150.

We are happy to share that most of our represented companies today provide basic complimentary health screening for our workers either at their workplace or at a designated healthcare or medical centre to provide that flexibility for the workers.

In addition to this, UPAGE started to provide additional subsidy since 2018 to encourage our members to go for additional testing during their health screening. This subsidy ranges from $50 to $100 per member, depending on the cost of additional tests that our members would like to take. We are pleased to share that we have supported more than 2,200 members with a total subsidy of more than $150,000 as of today and we intend to reach out to more members. We are only able to do this because of our close partners' strong support and generosity for workers in the power sector.

Please note that this subsidy applies to UPAGE members only, not for all. With so many support measures and subsidy provisions, I always believe that the union membership fee would be beneficial to all, if not many.

Hence, I would call on the Ministry to acknowledge and work together with the Labour Movement and our affiliated unions as one of your community partners to reach out, engage and encourage our fellow workers to strive for a healthy lifestyle. This will then align with the Government's vision of Healthier SG.

At this juncture, I would like to put forward four requests to the Ministry.

First, can the Ministry provide a guide on the kind of medical checks that everyone should prioritise for their own well-being at different age groups?

Next, can the Ministry provide more designated centres for our fellow Singaporeans to do their health screening?

Can the Ministry also allow an individual to use their MediSave for additional medical checks that they want to do for their own well-being?

Finally, can the Ministry provide an enhanced infographic that not only states the risk of poor health but one that instils the importance of starting a healthy lifestyle at a very young age? Madam, I will speak in Malay.

(In Malay): [Please refer to Vernacular Speech.] This Motion, that calls us to strive towards a healthier society, is the right move. It will help us to achieve a healthier life compared to a situation where we have to suffer in pain, regardless of whether we are young or old.

Among the challenges that our society faces are diabetes and being overweight, just like me, which can lead to various other diseases. However, this must be changed from early on. We must gradually change our eating habits that always crave for sugary drinks and fatty food, so that we will choose less sugary drinks and healthier food, as well as consume lesser portions.

I have personally witnessed family members, relatives and friends who had to live in pain at a young age, as early as their thirties, suffering from various diseases, such as diabetes, high blood pressure and so on. There is an Arabian proverb which says that every disease has its cure except death, but that does not mean that we should let ourselves go until we get sick, and then we start to get medication.

It is certainly very challenging to change our unhealthy habits into healthy ones. However, we must accept that this change is meant for our own good. We also do not want to trouble our children when we get old, whereby, they need to take care of their sick parents and have difficulty leading their own lives. Let our old age be full of healthy activities, such as playing with our grandchildren and taking care of them, being able to walk to the mosque and so on.

All these can be achieved by ensuring that we lead a healthy life from a young age. It is true that death can happen at any age, but a healthy and active body and mind will be more beneficial for us. Let us not leave our twilight years to chance, but instead, we ensure that we remain healthy for ourselves and for our loved ones.

(In English): Madam, many of us would acknowledge that good health is the real wealth. It is one where we can enjoy benefits of our hard work, instead of sacrificing our savings and wealth to pay for our medical costs.

Let us work together to eat healthier food and adopt a healthy lifestyle so that we can all achieve our mission towards a Healthier SG. In conclusion, I support this Motion.

Mdm Deputy Speaker: Mr Edward Chia Bing Hui.

7.09 pm

Mr Edward Chia Bing Hui (Holland-Bukit Timah): Mdm Deputy Speaker, the Healthier SG White Paper is timely and critical for all Singaporeans today and augurs well for our long-term sustainability. The White Paper has set a bold direction and has completely redesigned the way we deliver healthcare – from one that is reactively caring to one that is proactively preventive. This is a sea change.

As we are more user-led in solutions, we will be better able to identify patterns and similarities where solutions can be scaled up. Prioritising those above 55 is crucial, given that about one in four Singaporeans will be 65 years old and older in 2030.

This White Paper shows our ability to turn a potential adversity of the silver tsunami into a possible silver lining.

We cater to our seniors first and eventually scale this to a nationwide system for those above 40. In time, I hope this would be scaled up to all Singaporeans.

Most importantly, Singaporeans now know that this Government will co-design a preventive health plan with them. This partnership will require every Singaporean to play their part in co-solutioning. I rise in support of the White Paper on Healthier SG.

Gathered ground sentiments largely welcome this initiative. Many are pleased with the preventive measures in place. To enhance this White Paper, some came forward to share their opinions, which will be categorised into two main sections.

First, I will share concerns from the perspective of the individual Singaporean, following which, I will touch on ecosystem partnerships that are required to scale up Healthier SG.

I will now touch on the ground sentiment from residents I have interacted with. With regard to the national enrollment programme, it was stated that Singaporeans will be allowed up to four changes in the initial enrollment period but it was unclear how long the enrollment period would be. Furthermore, would there be a need for Singaporeans to indicate a reason for wanting to switch clinics?

Given the increasing levels of tech literacy, Singaporeans are also turning to virtual doctor appointments and companies are offering such services as part of their medical benefits. Would the Government consider this group of GPs in terms of medication subsidy and capitation funding?

Whether it is changing GPs or being able to access virtual clinician services, it will be very important for this programme to allow Singaporeans to make choices at key life stages.

Indeed, while the GP would be the critical first touchpoint in this relationship, it would be ideal for individual Singaporeans to have a fitness coach who can journey with him or her on a regular basis. A little exercise goes a long way and the new Singapore National Physical Activity Guidelines launched by national bodies Sport Singapore and the Health Promotion Board rationalise official guidance towards healthy activity.

Having access to fitness coaches would allow for a deeper collaboration between MOH with SportsSG, HPB and People's Association, especially with the vast range of community fitness centres that the Government has invested in for Singaporeans over the years.

By understanding that every Singaporean will need a fitness coach or ambassador or advisor nearer to where he or she lives to execute this preventive health plan, we keep our communities close to our Singaporeans. Much like the relationship between a resident and a GP is a personal one that takes into account individual preferences, so will the relationship be with a fitness coach.

To provide Singaporeans with greater choices, would MOH look into collaborating with private fitness service providers? As these service providers are all across the island in different fitness centres and gyms, they are well-placed to provide community care. MOH could also consider engaging self-employed persons (SEPs) with domain expertise as Healthier SG ambassadors and health coaches.

Such approaches will, in turn, encourage diversity of offerings to cater to different individuals and tap on expertise and knowledge in the private sector. It would be a missed opportunity if we do not harness the choice private sector and self-employed individuals provide to Singaporeans.

This will keep Healthier SG relevant to our citizens' preferences and also enable new innovative services like digital clinician services to participate.

At the systems level, designing this programme to have high inter-operability with innovative delivery models will enable Healthier SG to tap on the private sector's ability to discover leaner and effective models of preventive healthcare. This will ensure longer-term success, especially with the backdrop of manpower constraints and rising costs.

Next, I will touch on the ecosystem partnerships that are required to scale up Healthier SG.

As shared, employers are providing employees with medical care plans. Healthier SG's proactive, preventive approach needs to harmonise with employers. The strong support of the Singapore Business Federation and the Singapore National Employers Federation will be needed to help companies to remodel corporate health plans with this new approach.

One question for clarification will be how the Ministry intends to work with employers in assisting their employees to enrol in family doctor national enrolment programmes. Many Singaporeans rely on the provision of medical benefits from their employers and are restricted to a fixed panel of doctors. Also, in some cases, such services are provided by corporatised clinics where doctors are less rooted to a specific clinic or location. Another added complication is when an employer changes healthcare providers or when an employee moves to a new company.

While Singaporeans can choose to see the panel doctors for episodic care despite enrolling in the national programme, it derails from the core idea of keeping to one primary care doctor, limiting the true benefit of having a dedicated family doctor.

The area of interest of Singaporeans will be the co-payment or full payment by their employers under their existing employment contracts. Employers need to embrace Healthier SG so that every Singaporean feels assured that this is in line with their personal healthcare journey.

This is all part of an evolving workplace environment and, as such, MOM needs to work very closely with MOH for this initiative.

Another key ecosystem partner in the provision of healthcare is insurers. MOH and the monetary Authority of Singapore (MAS) should encourage the Life Insurance Association to find sustainable ways to integrate this to an individual's MediSave-related policies.

Such preventive efforts need to be rewarded and if our insurance actuaries can understand the percentage of population making serious efforts to live better, their calculations of risks need to take this into consideration. For example, those with committed healthier plans should not be paying as much when premiums increase with age. Such co-related pricing will make our Integrated Plans relevant and useful. This would provide another incentive for individuals to take charge of their preventive health plan.

Mdm Deputy Speaker, the business model enabling the provision of healthcare services is still largely based on reactive care. As we take the bold step to shift the model to one of preventive care, we will need to engage various aspects of society, including employers and insurers, to recalibrate various cost calculations and incentives.

Mdm Deputy Speaker, I have touched on two main sections in my speech.

First, on the micro level, let us place individual Singaporeans first in this journey by providing virtual doctors and fitness coaches by tapping on the private sector for more options.

Second, at the macro level, let us engage employers and insurers in recalibrating benefits, costs and incentivise them to better align with our model. The easier we make this to follow, the more we can guide Singaporeans to a society where we can all keep costs sustainable, maintain a comfortable standard of living and, most importantly, age well in the decades to come.

Mdm Deputy Speaker: Ms Ng Ling Ling.

7.18 pm

Ms Ng Ling Ling (Ang Mo Kio): Mdm Deputy Speaker, I would like to first declare my role as an independent consultant in healthcare transformation projects.

Madam, I give apples to Jalan Kayu residents at every house visit from the start of this year. This gives me an opportunity to share with them about healthy living, a key theme that I promote in Jalan Kayu besides sustainability and intergenerational bonding. An apple a day keeps the doctor away – this 19th century proverb sounds simple, but it is not always easy to follow.

In my COS speech in March, I spoke about my concern for the increased prevalence of chronic diseases, such as high blood pressure, high blood sugar and high cholesterol in our population, not just amongst our seniors but also in some of our younger people.

I recognise that our national Budget for healthcare will inevitably have to increase in order to create better health and quality of life outcomes for our people. But I also suggested to manage the workload on our healthcare professionals by empowering Singaporeans to take more ownership of our own health and participate whenever possible with our healthcare professionals on our treatment or health plans.

I thus read the Healthier SG White Paper with great delight, that we are, indeed, embarking as a nation towards a much healthier way of living, with stronger emphasis on preventive care, building relationships and trust with our family doctors to maintain our health, supported by each of our own community, right in our neighbourhood. This is a transformative healthcare policy, in my view.

It will also require a transformative mindset from our people to fully reap the fruit of this healthcare policy breakthrough. But we can take heart that we will have our neighbours to walk the journey ahead with us together. For my Jalan Kayu residents, you have your Member of Parliament who will walk this journey with you.

All good policies can only be as good as how well they are implemented. That is when the tyres hit the road, so to speak.

I will focus my speech on clarifications with MOH on three implementation considerations. One, awareness of subsidised preventive health screening; two, enhance community partnership and participatory approach to collective health; and three, enabling seniors through simplifying healthcare technology.

Firstly, I would like to know how MOH will be tracking and reporting the usage of the enhanced subsidies provided under Healthier SG to encourage Singaporeans to adopt more preventive health behaviours. The White Paper outlined MOH's plan to fully subsidise nationally recommended vaccinations and screenings as well as an onboarding health consultation with their chosen family doctors upon enrolment.

I would like to clarify what types of vaccinations and screenings will be fully subsidised. Are they those that are under the existing Screen for Life programme or will there be more added under Healthier SG? What is the participation rate for Screen for Life for Singaporeans above 50 years old currently? And what improvement does MOH aim to achieve under Healthier SG?

From my Meet-the-People (MPS) experience, whenever I asked my residents in need about their awareness of Screen for Life programme, I will usually draw a blank look. For the handful who may be aware, they would admit to me their fears of finding out illnesses that will cost them more to treat and affect their jobs.

I believe for preventive health behaviours to improve significantly in Singapore, MOH must invest more in creating the right awareness and assurance of benefits of preventive health screening and a follow-through care that Singaporeans can expect. This should be done in more mass media and vernacular languages, including even some dialects, to correct the misinformation that screenings will lead to more problems.

Secondly, I would like to propose strengthening the community participatory approach so that our busy family doctors, whether they are practising in the GP clinics or polyclinics, would know and have quick ways of connecting with their community, sports and social service counterparts when they see patients that need support beyond medical treatments.

The White Paper proposed to rally a group of community care partners to support residents in leading healthier lives. The White Paper mentioned the People's Association (PA), SportsSG and Agency for Integrated Care (AIC)'s Silver Generation Office (SGO) to help organise healthy living programmes for residents. It also mentioned plans to tap on the eldercare centres to serve as the community care connectors for seniors, to help them follow through the recommended lifestyle interventions prescribed by their family doctors.

Although I am fully supportive of this approach after speaking with a few GPs in my Jalan Kayu constituency since the release of the White Paper, I noted their concerns on the bandwidth to activate such community partnership to care for their patients who are my residents. There were also questions on seniors who are living in the private estates, such as those who are living in the Seletar Hills East and Jalan Kayu private estates where some of my older residents live. The existing eldercare centres are usually located nearer to rental blocks of each constituency. I would like to ask how MOH will also support the social prescriptions by family doctors for the senior residents living further from eldercare centres, including those living in the private estates.

Lastly, I understand that enrolment will start next June, beginning with our older residents aged 60 and above first. This is good as we should always prioritise the health of our seniors first, given their higher risk of developing health challenges.

The White Paper proposed the HealthHub app and Healthy 365 app as the digital front doors of Healthier SG to encourage and nudge residents to adopt healthier lifestyles. I understand that the HealthHub app will have a digitally enabled health plan where residents can access and check their health outcomes. This will be complemented by the Healthy 365 app which allows tracking of physical activities and diets, as well as supports their access to community activities.

Like fellow hon Member Dr Tan Wu Meng, several studies that were published between 2020 and 2021 shared that there is lower interest in adopting mobile health applications and digital health services amongst seniors despite the convenience that it presented during the COVID-19 lockdown.

Thus, I would like to clarify with MOH on the current adoption rates for these two apps by the senior population above 60 years old. And if the take-up rates have been low, similar to my fellow hon Member, Ms Denise Phua, I would like to ask how MOH intends to help our seniors utilise these two apps after they have enrolled with their family doctors under Healthier SG. Mdm Deputy Speaker, please allow me to say some words in Mandarin.

(In Mandarin): [Please refer to Vernacular Speech.] Prevention is better than cure. Not only does this phrase demonstrates our understanding of preventive care, but it is also the core concept of the Healthier SG White Paper.

Through preventive care, we can help every Singaporean improve their health and quality of life. In our ageing society, preventive care can also reduce the cost and burden on the healthcare system and individuals. If you want everyone to be healthier, we must empower them.

Therefore, I strongly support the initiatives put forward in the White Paper.

At the same time, I would like to make three suggestions to the implementation of Healthier SG to help residents better accept preventive care measures to improve their health.

Firstly, I hope that MOH will provide more public education and information on benefits of preventive screening to encourage residents to undergo screening.

MOH currently has the Screen for Life programme which covers chronic illnesses and some common cancers, for example, colorectal cancer. I hope that MOH will further strengthen public education under Healthier SG, and even use Malay, Tamil or even dialects to reach out so that more Singaporeans, especially the seniors, will understand the benefits of preventive health checks.

Secondly, I also hope that MOH will work with the GPs and the community partners to empower residents to complete their own health plans, using more of the Community Participatory Approach.

In the community, we should also have the regional health system to help identify common illnesses in each local constituency through the coordination of the three regional healthcare clusters, and work with Government agencies such as the People's Association and SGOs, as well as the residents, to organise healthy activities that benefit the residents. In this way, residents will be able to take ownership of their own health, making it easier for them to accept preventive care. This will also help to strengthen the Healthier SG ecosystem.

Finally, I hope that MOH will be able to improve the HealthHub and Healthy 365 mobile apps to make them more accessible for the seniors under Healthier SG. I also hope that MOH will work with IMDA to promote HealthHub and Healthy365 apps through the IMDA's Senior Go-Digital Scheme and teach the seniors how to use these two apps and introduce their main functions. I hope that when the seniors experience the benefits of using these apps, they will help promote Healthier SG through word of mouth.

[Mr Speaker in the Chair]

(In English): In closing, I would like to speak up for a group of healthcare professionals who have become my friends in my four-and-a-half years of involvement in the healthcare sector. They are the family doctors working both in GP clinics and public polyclinics. They are a group of highly intelligent, motivated and committed healers in our community.

The falling ill of one family doctor in a busy polyclinic can mean the rest taking up a much higher patient load for the day, sacrificing lunchtime or even any breaks in that day.

I hope that MOH will continually invest in helping them reduce unnecessary administrative workload.

To the Minister for Health Mr Ong Ye Kung, I agree that administrative work that is required for claims is very necessary, but I think we should study some of the areas in which we can maybe reduce for the professionals. This can include doing away with the need for issuing medical certificates (MCs) for mild acute illnesses, like coughs and colds, which my fellow hon Member Ms Mariam Jaafar has raised earlier in the Parliamentary speech she made.

While this will require the support of the Ministry of Defense (MINDEF), the Ministry of Education (MOE) and MOM, countries like the United Kingdom that have practised doing away with MCs for absence from school and work due to common colds and coughs have not seen students or employees abusing such a move.

Also, more use of telehealth, that can augment and take away some of the family doctors' repetitive tasks, should continue to be invested in and subsidised by MOH.

There is no doubt that Healthier SG will take time – I think at least a decade – before we can see a healthier population coming to fruition. Nevertheless, as a strong advocate of healthy living and active ageing, I commend MOH for taking this bold step towards reshaping Singapore's population health.

With the collective and united efforts of all Singaporeans, we will get there. Notwithstanding my considerations raised, I strongly support the White Paper on Healthier SG.

Mr Speaker: Ms Joan Pereira.

7.32 pm

Ms Joan Pereira (Tanjong Pagar): Mr Speaker, Sir, I support the Healthier SG initiatives and look forward to the expected benefits as this new healthcare model nudges Singaporeans to focus more on active self-care.

All of us as individuals need to consciously take steps on a daily basis to minimise the risks of illnesses and diseases, with care and guidance from our doctors and their teams of support professionals. Many of the things we can do are quite achievable, though not always easy for some of us, such as taking the necessary medications on time, watching our diets and exercising. Following up with doctors familiar with our health histories regularly will help to introduce some discipline into our lives, as we have to be accountable to them too.

One of my concerns is regarding the funding model that will be partly based on health outcomes.

The White Paper states that service fee payments for family doctors will be partially based on "the progress made in terms of preventive care or chronic diseases management". While I understand the intent of this clause, the reality is that there will be some patients who have difficulties being compliant and it is not reasonable to expect the doctors to control their patients.

I would like to know how the Ministry will help such patients. Will there be situations where doctors may choose not to continue with the management of very challenging patients?

Another question is regarding the additional administrative and IT set-up and maintenance requirements necessary for this scheme. The White Paper states that in the initial phase, the Ministry will provide a one-off IT support grant. Going forward, inputting data and maintaining the IT system in a clinic will need more manpower and IT knowledge, particularly to ensure a high level of cybersecurity. While MOH has stated that it will support the GPs in this aspect, what will happen if a patient's preferred GP chooses not to join the network due to the clinic's constraints?

Yes, patients can select another doctor but it is not so easy, especially when a strong relationship has been built and, more importantly, the doctor's medicine works well for the patients. This would then mean that patients have to doctor hop before finding the right one that suits them.

Some residents are also concerned that more costs for the GPs will be involved and they worry as a result, the medical costs will be higher for residents who see GPs under this Healthier SG initiative. How would the Ministry ensure that costs will be kept in check?

I applaud the decision to narrow the difference in drug subsidies across polyclinics and private clinics through a combination of enhanced drug subsidies and drug price limits. However, there may be some non-generic drugs which will continue to be priced above the limits. Will patients be given a choice to opt for such drugs via personal top-ups and MOH to provide greater subsidies because these drugs work well for them?

Last, I would like to ask about the role of TCMPs in the Healthier SG model. TCMPs have been playing a significant role in helping residents, particularly the elderly, to better manage their health over the long term. Traditional Chinese Medicine (TCM) methods often emphasise holistic care and can be complementary to our current system.

If the Ministry is concerned about the standard and consistent TCM healthcare delivery, how about setting up a system similar to our present Western medical framework and ensure its integration into our healthcare system? Sir, in Mandarin.

(In Mandarin): [Please refer to Vernacular Speech.] Last, I would like to ask about the role of Traditional Chinese Medicine Practitioners (TCMPs) in the Healthier SG model.

TCMPs have been playing a significant role in helping residents, particularly the elderly, to better manage their health over the long term. TCM methods often emphasise holistic care and can be complementary to our current system.

If the Ministry is concerned about the standard and consistency of TCM healthcare delivery, how about setting up a system, similar to our present western medical framework, and ensure its integration into our healthcare system?

Mr Speaker: Ms Hany Soh.

7.37 pm

Ms Hany Soh (Marsiling-Yew Tee): Mr Speaker, I speak in support of this Motion. I concur that prevention is undoubtedly better than cure, not only because the former can be easier and more affordable as compared to the latter but also because individuals and their loved ones can minimise the risk of experiencing a lower quality of life that comes with chronic diseases.

It is well understood that prevention of chronic diseases is achieved by addressing risk factors before falling sick whether through healthy living, better dieting or exercising regularly. Although doing so seems simple and straightforward, these actions are easier said than done.

Many of us are used to long working hours, a sedentary work life, late nights and, for better or worse, various cuisines within easy reach whether day or night – all of which contributes to a less than healthy lifestyle.

With that said, it is possible to return to good healthy habits, but it will take some time, effort and some encouragement.

Similar to the Singapore Green Plan, I view the Government's initiations of Healthier SG as a whole-of-nation movement which seeks to rally bold and collective actions, to transform our healthcare system and to encourage all Singaporeans to come together and take steps towards better health.

The funding support from the Government and community partners will come in vital to kickstart this project and steer it towards the right direction.

Similar to the concept of SG Eco Fund, I hope that the Ministry can consider setting up a SG healthy fund to support projects that champion healthy living and involve the community. A steering committee can be set up comprising representatives from the 3P sectors, retired grassroots advisors, sports athletes as well as healthy lifestyle experts to manage this fund and monitor the progress of such projects.

In addition, this committee, with extensive community experience and networks from its members, can also provide useful guidance for healthy lifestyle clubs, thus further advancing the objectives of Healthier SG.

One example of how such funds can be utilised would be to encourage GPs to organise community outreach events to foster lasting relationships between residents and their family doctors. The GPs can be the first line of support for many Singaporeans living in our heartlands. Many of these neighbourhood GPs have served the community for years or even decades and earned the trust and reputation of being the resident experts in all health-related matters.

As such, to foster more of such GP-patient relationships, with trust being built up and utilised to deliver the message from Healthier SG, one suggestion would be to consider providing funding support for GPs to conduct health awareness talks for the community, educating our residents about the benefits of preserving one's health with good habits.

Additional funding support can also be considered to encourage organising the follow-ups on the health awareness talks, such as one-time complimentary health screening and consultation sessions for attendees at their neighbourhood GP.

Other funding support can go towards encouraging more community organisations to set up healthy lifestyle interest groups and for its champions to form strong, sustainable partnerships with the community to promote healthy lifestyle activities.

Over the years, in my capacity as a community volunteer and subsequently as advisor, I have witnessed many inspiring examples of how healthy living has been promoted among residents through health awareness and wellness programmes initiated by the grassroots, such as the Northwest CDC's qigong, dance fit and brisk walking clubs.

The provisions for support for these interest groups and their events will empower them to further enrich the lives of many of my residents in Woodgrove by providing a wider range of healthy activities to choose from.

In addition to that, allocating funding support for passionate and committed healthy lifestyle champions, such as instructors and coordinators would also help grant a renewed sense of purpose for retirees looking to making a positive effect.

These individuals are more than just active participants in their programmes of choice. They also serve as the glue within their own communities. Through them, I have seen many friendships forged among the members and their trainers. Even outside training, they will gather to organise potluck sessions, sharing healthy cooking tips.

In Woodgrove, our active dance fit club members often help to bring more joy to events organised by the Residents' Committees, such as by choreographing a dance performance with them donned in special handsewn costumes.

Mr Speaker, while there is much we can do to ensure that Healthier SG can further encourage more Singaporeans to lead a healthier lifestyle, we should also capitalise on its ability to provide additional benefits outside of its main scope of objectives.

Picking up healthy living tips and sports can be interesting and enable the creation of more family bonding opportunities.

One such example is the Woodgrove Badminton Clinic, which was jointly organised by our Woodgrove Community Sports Club and the Singapore Badminton Association, with support from Horlicks. During the event, apart from inviting our national team's shuttlers Crystal Wong and Jing Yujia to coach our little ones and their parents on badminton strokes, a health talk was also carried out by Horlicks, sharing tips on possible diets to follow before and after exercising.

Next month, Woodgrove will also be collaborating with ActiveSG to organise a community sports day at the Woodland Stadium, encouraging families to participate in various sporting activities such as air badminton, table tennis, Zumba and K-cardio.

In our Marsiling-Yew Tee GRC, the recent launch of the Healthy Living card game in Marsiling's "Living The Life Carnival" was also received positively by elderly residents and their families. In this game, players are supposed to collect cards depicting good health habits in order to win. Through playing the game, these cards will serve to inculcate players with these healthy living habits.

Good health habits begin at a young age. As a community effort, Woodgrove is working on expanding the reach of this Healthy Living card game by encouraging our youngest residents to play with their families, hopefully inspiring them to a healthier lifestyle while promoting family bonding opportunities at the same time.

For a start, the nine PCF Sparkletots centres across Woodgrove will be procuring additional sets of these playing cards and distributing them to all of our K2 students in 2023.

One way to encourage healthier eating is to educate the public about new healthier alternatives. One good example of this would be the recent introduction of the lower sodium salt campaign. I believe that the public may find it useful to learn more about the science behind these healthier options from credible sources, such as HPB, so that they may be better informed about the food choices to make.

Disseminating the information through mass media will be very helpful in this regard. Although we can achieve much by encouraging residents to pay more attention to their health, more help can be provided by influencing their dietary habits, such as reducing the cost of healthier food items, which have a reputation for being more expensive than the standard options.

As such, in order to make the Healthier SG movement of success, there is a need to call for a mindset shift. Not just among the ordinary residents, but businesses that serve the community as a whole. This includes calling on fast food chains, film theatres and supermarkets, to just to name a few, to explore ways to incentivise offering of healthier options. In Mandarin please, Mr Speaker.

(In Mandarin): [Please refer to Vernacular Speech.] Last month, Woodgrove division, in collaboration with Sian Chay Medical Institution, organised a free health talk, sharing with seniors tips on healthy living and post-recovery from COVID-19. Many participants shared with me that they prefer to see a TCM doctor first when they are not feeling well. The reasons vary, including cheaper consultation fees, for example, Sian Chay and Chung Hwa Medical Institution provide free or low-priced consultation and treatment.

Generally, seniors tend to prefer opting for TCM to improve their vitality and address underlying root causes of health concerns in a holistic manner. I believe, we should look into combining Western and TCM medicine in terms of treatment as well as increasing awareness.

To me, both Chinese and Western medicine offer benefits, integrating both would bring a win-win situation. In conclusion, I support the Healthier SG Motion.

Mr Speaker: Leader.