Building a Healthier SG

Resumption of Debate on Question [4 October 2022],

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. – [Minister for Health].

Question again proposed.

Mr Deputy Speaker: Ms Sylvia Lim.

1.02 pm

Ms Sylvia Lim (Aljunied): Mr Deputy Speaker, as Members of Parliament, it is not unusual at our Meet-the-People Sessions (MPS) to encounter residents with serious health or mobility issues. For them a short trip to the MPS is, itself, a difficult journey. Some of them are around my age. As I learn more about their circumstances, I often ask myself whether the quality of their lives might have been drastically better if they have had the correct interventions and advice at an earlier stage. I tend to see this particularly in residents of less means.

On today's Motion on the Healthier SG White Paper, I wish to focus my speech on three areas: one, the potential of Healthier SG: two, clarifications around capitation funding; and three, to conclude with the importance of a whole-of-society buy-in.

First, the potential of Healthier SG. A key thrust of the Healthier SG White Paper is that residents will be encouraged to enrol with a family doctor even when they are well so that they may benefit from advice regarding social interventions to adopt healthier lifestyles. It is envisaged that the doctor will take charge of the overall well-being of the resident for a period of time, rather than to treat the patient on an episodic basis. This holds much promise for a healthier nation overall.

In moving the Motion yesterday, the Health Minister assessed that the returns of better health outcomes from Healthier SG would take maybe eight to 10 years before tangible results might be seen. However, on returns based on dollars and cents terms, there are encouraging experiences from overseas. Prevention strategies have been shown to make economic sense as they are substantially cost-saving. It is well-known that it is preferable for healthcare systems to aim to prevent ill health rather than to subsequently treat it from a financial standpoint.

Five years ago, a systematic review was published, assessing the returns from investing in public health interventions such as promoting well-being and preventing ill health in society. From 52 studies of healthcare systems in high-income countries, it was found that the return on investment (ROI) of public health interventions was at the median of 14 to one, that, is, for every one dollar invested in public health, $14 will be subsequently returned to the wider health and social care economy. Although we do not yet know what returns Healthier SG might bring in dollars and cents, there is reason to be optimistic.

From the healthcare system standpoint, it is vital that the focus of prevention ease the pressure on our acute facilities. Even as we debate today, residents experienced very busy A&E departments in public hospitals in the past months, with patients sometimes waiting more than a day at A&E before being allocated a ward bed.

On this front, I note that in the White Paper, the Ministry has listed 22 indicators to assess Healthier SG by, including indicators of easing the load on acute facilities, such as reducing the avoidable Emergency Department attendance rate and reducing the admissions of the elderly for fall injuries. If achieved, these reductions will bring relief to patients and staff at acute facilities and contribute to better care for those most in need.

That said, I have two further observations; first, to seek clarifications on the move to capitation funding and how healthcare outcomes will be safeguarded; and second, to conclude with the importance of a whole-of-society buy-in to the plan.

First, on capitation funding. At Chapter 5 of the White Paper, it is stated that to fund Healthier SG, the Government intends to roll out capitation funding first to family doctors and then to the geographical healthcare clusters. There are scant details in the White Paper about how this will be implemented and the Minister yesterday did give a few more details. I would like to ask how the Government intends to ensure that the move to capitation funding does not undermine access to healthcare and the quality of healthcare.

As stated in the White Paper, capitation funding will be a shift away from the current funding model based on services provided, commonly called fee for service or FFS models. The Ministry has pointed out that capitation funding is in place in healthcare systems in other countries, such as in Europe, New Zealand and the United States. Yesterday, the Minister pointed out that general practitioners (GPs) here are also not new to the concept.

For Healthier SG, the Minister stated that besides the annual servicing fee paid to healthcare providers, there would still be separate subsidies for patients' medicines and screening. The Ministry's stated objective for adopting capitation funding is to, and I quote, "Create an inherent incentive for healthcare providers to focus on preventive care and right siting of patients." Put another way, healthcare providers who keep patients healthy and do not over service their patients will benefit under a system of capitation funding.

Sir, if capitation funding means that patients can go to the doctor for consultations at minimal cost, this potentially will encourage poorer Singaporeans to consult doctors to work out health plans. If successfully implemented, it will go some way towards reducing healthcare inequality.

At the same time, capitation funding has been the subject of research in many countries, particularly on whether such funding has led to healthcare providers to function as economic agents, that is, instead of focusing on the patient's best interest, healthcare providers look at the financial bottom-line and behave in certain ways which may not be in the patient's best interest. I am not saying this will happen for Healthier SG but we should be alive to the risk.

There is evidence from several studies overseas that capitation funding models tended to result in patients receiving less treatment, that is, they went to the doctor less frequently and their treatments tended to cost less than compared with the FFS models. It is often not clear whether this was a result of capitation working well by cutting down unnecessary treatments and waste, or whether, on the other hand, patients were, in fact, underserved, that is, not getting adequate treatment. It also goes without saying that the level of funding is key. If capitation funding is pegged more generously, the quality of care would generally be better.

Some studies focus on doctors' own assessments of whether the way they treated patients was different and under capitation funding compared to FFS models. There were indications that some physicians believed that funding had affected their choices of treatment.

There has also been concern whether capitation funding would lead to healthcare providers cherry-picking their patients. In other words, with a fixed annual servicing fee, it might make economic sense to choose healthier patients rather than, for instance, older patients with health problems.

Coming back to Healthier SG, I am pleased to note that the White Paper states that the capitation funding formula "will be tiered based on the health risk profile of each enrolled resident, scope of required care and the progress made in terms of preventive care for chronic disease management." Could the Ministry clarify what level of granularity will be used to tier the funding, for instance, will the funding be tiered based on the disease diagnosis and the stage of the disease progression?

Yesterday, the Minister also touched on the overall finance and budget implications of Healthier SG. He said that the set-up cost over three to four years would be about $1 billion, while there would be recurrent cost of about $400 million a year, including the annual servicing fee for patients. Does this mean that the Ministry has already worked out the detailed capitation sums for each health risk profile, and when will this information be published?

Sir, my final observation is that for Healthier SG to succeed, there needs to be a whole-of-society buy-in. Each of us needs to make adjustments to our daily lives. To illustrate the possible difficulties and inertia, please let me share a personal anecdote.

Over the weekend. I met some friends for a meal. As they continued to order local favourites, such as char kway teow, fried Hokkien mee and others, I asked them whether they had heard about the Healthier SG plan which would be debated in Parliament this week. They gave me a quizzical look and, without blinking an eye, continued to order more of the same.

Sir, this amplifies the monumental task ahead to get population buy-in for changes to deep-seated lifestyle habits. Besides having incentives to consult family doctor regularly, there will also be a need for a supportive infrastructure and to change mindsets. On infrastructure, the Government has built sporting facilities and beautiful park connectors for Singaporeans to exercise in. Besides that, healthier food needs to be affordably priced so that less privileged Singaporeans can afford to make healthy choices daily. Whatever the case, in the final analysis, changing people's deep-seated habits might be the most difficult of all.

Sir, let me conclude. This Motion to focus on preventive care as a key thrust in healthcare should be supported. It holds the promise of meaningful and fulfilling lives for Singaporeans into old age. And, if implemented well, can help reduce healthcare inequality. It is likely to be money well-spent.

At the same time, based on studies overseas, there may be risks associated with capitation funding. I hope the Ministry will clarify in due course how the funding model will be implemented so as to minimise any compromise on health outcomes.

Finally, for Healthier SG to succeed, a whole-of-society effort towards healthier living, including changing some deep-seated mindsets and habits will be needed.

Mr Deputy Speaker: Mr Gan Thiam Poh.

1.12 pm

Mr Gan Thiam Poh (Ang Mo Kio): Mr Deputy Speaker, in Mandarin.

(In Mandarin): [Please refer to Vernacular Speech.] I thank MOH for further expanding the role that our clinics and family physicians can play in universal healthcare.

Years ago, some of my Parliamentary colleagues and I proposed to the Government to allow residents to visit neighbourhood clinics instead of polyclinics, while benefiting from the lower outpatient service fees charged by polyclinics. The Government then launched the CHAS scheme, allowing residents to visit their own GP clinics at the price of polyclinic fees. Since its implementation, the plan has been welcomed by residents. I also shared feedback from residents at that time. In many cases, residents often perceive that their family doctors were more cordial, reliable and trustworthy. So, recoveries were quick after the visits.

Sir, the recommendations of the White Paper are commendable.

Residents do not need to go to the polyclinics to queue for outpatient services. They can easily go to the family doctors in their neighbourhoods for treatment and follow-up consultations, hence prevent the deterioration of chronic illnesses. At the same time, they can obtain early and proper treatment.

In the last session of Parliament, I talked about "the best doctor", that is, prevention is still the best medicine. Therefore, this White Paper is the best form of medical practice. It is farsighted and looks to the future so that Singaporeans can age in place. I hope that under this scheme, residents will have more flexibility to change clinics or GP, if the GP has transferred to another clinic or has left.

(In English): Deputy Speaker, Sir, I fully support the excellent proposals in the White Paper on Healthier SG. This preventive care model is yet another step in our journey to help Singaporeans achieve and maintain their best health and live more good years.

The proposals in this White Paper will further strengthen the role of GPs in the national healthcare framework. It is a superior strategy and deserves our full support.

I have always believed that our family doctors play an essential role in this endeavour. Residents find it comfortable to have family doctors with whom they are familiar with to look after their healthcare issues.

I believe it can be technically done to have all GPs to have online access to patients' records. However, we must recognise that there is a need to balance patients' confidentiality and operational efficiency.

In addition, I would like to ask the Ministry how will the balance be maintained between need and demand for certain medications. Some patients may ask for more than necessary, as generic medications are generally more economical. Will patients be given a choice between new and generic medications? Patients may still find it a burden regarding the choices of new medicines.

I hope this plan can be expanded soon to allow residents to visit more than one GP at similarly subsidised rates for the management of diseases. Some GPs may be more experienced and skilled at managing certain diseases. This is because certain GPs may have individual competitive strengths or specialties. Thus, each patient may like to have a principal GP doctor in attendance and be assisted by such specialists upon referrals.

Next, may I ask what would happen to the doctors or clinics in the case of uncooperative patients with problems adhering to their healthcare plans? I am concerned because the White Paper has stated that this new model will be outcome-based. I hope that the Ministry will not penalise the doctors in charge as these patients should be the ones responsible for their own health.

Many GPs clinics, especially those in mature estates, are already overwhelmed with patients. For some popular clinics, the wait for the face-to-face onboarding health consultation may take days to weeks. If the enrolment for particular clinics is always too many for the doctors to cope, how will this be resolved?

Another concern is regarding the use of Healthhub to choose preferred clinics and enroll in Healthier SG. Will assisted support on-site and via helplines be available at the clinic itself or at CCs? As many seniors are non-IT savvy and some may be illiterate, they will not be able to use the apps after enrolment to monitor their health progress. They may require simple printed materials to do manual recording. This means that the GPs will have to manually key in the progress reports into the available system to enable monitoring. This is additional work for GPs if they have many of such senior patients.

For this group of seniors, they will not know how to use apps like Healthy 365, ActiveSG and OnePA to book and pay for activities. They may have to ask the doctors to teach them during their first consultations or even subsequent consultations and this will take up the doctors' time, which could be better used in treating patients.

Another concern is about patients who are not enrolled into Healthier SG at GP clinics. The clinic assistant will have to remember to charge correct prices for patients under the Healthier SG and non-Healthier SG schemes. For the popular clinics, the clinic assistants may be overwhelmed, resulting in longer waits for all patients.

For residents who do not have chronic diseases to follow up at the GPs, the face-to-face consultation after enrolment via Healthhub will probably be the first and only visit to the GPs under Healthier SG.

I doubt anyone with no sickness would want to see a doctor regularly. If a healthy person sees the GP for their first health consultation under Healthier SG or subsequent follow up, will they be given a medical certificate (MC) or memo to excuse them from their work? Will all employers recognise such "excuse sheet", the same as during COVID-19, when employers must recognise ART-positive results as proof?

For such residents, the doctor will advise them on appropriate preventive measures as part of their health plans, such as health screenings and vaccinations. The doctor may also make referrals to community programmes. I would like to ask if it is necessary for doctors to do social prescriptions for such patients? Will health coaches not be more suitable? With that, I support the Motion.

Mr Deputy Speaker: Assoc Prof Jamus Jerome Lim.

1.20 pm

Assoc Prof Jamus Jerome Lim (Sengkang): Not long after I landed on US shores for my doctoral studies – a week after 11 September 2001, as it turned out – I had to confront the behemoth that was the US healthcare system.

One of my earliest tasks on arrival was securing medical insurance. Because I was a graduate student, I was enrolled in a plan managed by the university. The amount was non-trivial, especially for a student confronting US dollar exchange rates. But in exchange, I was able to see the doctor at any time without paying any fee, including for routine illnesses, such as cough or fever, while also enjoying fully-paid dental and access to world-class hospital facilities and surgical procedures.

I was only 25 then, of course, and like most pre-chronic-condition 25-year-olds, I thought I was physiologically invincible and I would never need a doctor. Still, the insurance plan was mandatory and so I reluctantly signed on.

After spending a dozen years embedded in the US medical system, I have come to understand just how painfully convoluted the system was. The University of California healthcare plan, which I had previously been under, was, as it turns out, a relatively good one. In contrast, many plans are far less generous in their terms and costlier to boot.

If one were to lose one's job, one would automatically lose one's health insurance – a painful double-whammy of being both unemployed and uninsured.

In contrast to my free-of-charge visits to the university health centre, most insurance plans charge a co-pay per visit, which could amount to $30 or $40 – the amount that I would pay out-of-pocket for any doctor in Singapore, even without insurance.

Why am I sharing this story? Because I used to think that the Singapore system – where we were assured of world-class medical care at a fraction of the cost – was an amazing healthcare policy success. Singapore managed to contain costs, all while generating impressive and still-improving health outcomes. We appeared to have cracked the code of healthcare financing.

At the global level, our healthcare costs do remain admirable, prompting the New York Times to question in a fawning article as recently as 2017, "What Makes Singapore's Health Care So Cheap?"

I had often attributed this miracle to a combination of Asian veneration of doctors as a calling, our scholarship-bond system that kept junior doctor salaries compressed for a half-decade out of medical school and the dominance of a largely single-payer, publicly-run, broadly universal healthcare system.

But over the years hence, our model has begun to edge ever closer toward the mixed system that characterises the United States and I am not entirely certain that this has been a positive development.

Mr Deputy Speaker, I contend that focusing solely on preventative care is an incomplete solution to limiting the demand for healthcare whose persistence has, indeed, been driving prices up. The solution our people face today must go beyond the Healthier SG initiatives, as laudable as they are. Healthcare costs are escalating, are doing so rapidly, and look to continue to do so in the future.

Even without greater attention paid to prevention, we must not limit ourselves to outsourcing yet another initiative to the end user without simultaneously tackling issues inherent to the system.

Singapore's healthcare financing is often described as resting on three key elements, MediSave, MediShield Life and MediFund, which, together with subsidies, characterise the idiosyncratic Singaporean model. But it is also worth noting that these three vaunted pillars of the system finance only a little more than 8% of total national healthcare expenditure. Including subsidies, this increases, but not by all that much.

The upshot is that, beyond the 3Ms plus subsidies, we cover a significant amount of expenditures directly out of our own pockets and savings. But even though out-of-pocket expenditures, as a share of total health expenditures, have fallen, the absolute amount we have had to pay has steadily risen. Dollar spending on out-of-pocket expenditures, even after accounting for inflation, has almost doubled over the past two decades from $448 in 2000 to $821 in 2018.

This eats into our real income gains. Over the period, increases in healthcare costs outstripped inflation at the rate of 2.3% per annum to 1.5%. Perhaps more worryingly, other independent sources peg much faster price increases in the future, between 7% and 10% per annum in more recent years.

Every month, Singaporean families spend an average of $323, or 5.5% of their incomes, on health expenses, an increase from 4.9% just a decade ago. Such spending was as much as families set aside for education and more than communication, clothing, footwear and recreation.

Moreover, this share has been growing for the least fortunate among us. While the highest quintile of income earners devotes 4.8% to healthcare expenditures, the burden on the lowest is more than one-and-a-half times greater at 7.8%.

While dedicating a little bit more than 5% of each pay cheque to health is surely a wise investment, the concern is that this could continue rising. Spending a few hundred dollars monthly may still be manageable, but this becomes much harder to bear when the amount begins to approach $1,000 every month or more than $11,400 a year.

Is this an impossible fantasy? I hope so, but it is worth noting that American households currently fork out an amount comparable annually and they used to pay our current share as recently as 15 years ago.

The issues of how informational asymmetries are endemic in markets for healthcare and health financing are well understood by members of this House and I shall not regurgitate them here. The main takeaway is simply that we cannot expect healthcare markets to function in a similar manner to other markets, which necessitates some degree of Government intervention.

One important corollary of this result is that while we may very much wish to harness market forces to contain price increases, we need to be very judicious in our application of such mechanisms because introductory economic principles may give rise to counterintuitive and perhaps even counterproductive outcomes. I will document several examples of such outcomes when I deal with potential solutions later in my speech.

Another important corollary is that any policy that increases the distance between the patient and the payee may also lead to perverse outcomes because this distance separates agents – patients, in this case – from the cost implications of their choices. This could be on the part of healthcare providers – if doctors are primarily making treatment decisions, with little input from the patient – or from healthcare financiers, if health insurers are defining available options or covering all costs involved, with little feedback from the insured.

While some gap is inevitable – I would have no idea how to choose between one treatment regimen versus another – but the more information we put in the hands of patients, the better. The suggestions I will detail also account for the importance of keeping this distance, as far as possible, to the minimum.

Moreover, public healthcare often coexists with a vibrant private sector. As the pandemic has reminded us, public health is, in and of itself, a valuable public good. But the private market for healthcare often plays an important complementary role in the overall national healthcare system.

In developing countries, the emergence of a parallel private system is what often prevents an outright collapse of overstretched public systems altogether. In advanced economies, the private system can plug gaps in care that the public system is unable to meet.

Managing the COVID-19 pandemic would have been much more challenging in the absence of private healthcare. Nevertheless, while there is seldom an "optimal" division of the proportion of healthcare provided by the public versus the private sector, resource limitations in the former usually means that it tends to ration by time, either a longer wait before an operation in a public hospital is scheduled, or a shorter time spent with the doctor at the polyclinic. While the latter, the private system, controls demand by price, which is why one tends to pay for the privilege of speed and attention when seeing a private doctor.

These differences are not problematic, per se, as long as we recognise that there are the essential trade-offs. However, we should never allow these trade-offs to become a synonym for quality.

Indeed, many of my doctor friends, including those in private practice, suggest that complicated procedures could well be best performed at a public hospital in Singapore, because they are endowed with the latest technologies and tend to see a greater volume of complex cases and, hence, acquire familiarity and expertise in dealing with them.

Sir, before I touch on some suggested refinements to the current system, I will stress this at the outset. Promoting competitive forces are often a positive and a means of containing costs. However, we want to exercise care when we apply regulation in service of promoting greater competition.

For instance, price fixing or collusion is typically frowned upon, because this allows suppliers to coordinate on a price target, which would otherwise be unsustainable in the presence of genuine competition. But such prohibitions may only make sense when the competitive landscape itself is characterised by few players in possession of substantial market power.

When there are many suppliers, coupled with free entry, firms are much more likely to compete on product differentiation rather than price. In this case, even when doctors can freely set prices, excess profits are no longer assured, at least in the long run.

Prohibitions on price guidelines, in this case, may merely induce market participants to pursue greater differentiation through the inclusion of bells and whistles, which could paradoxically elevate their costs and in turn, prices charged.

Hence, the decision by the Competition Commission of Singapore to prohibit price guidelines issued by Singapore Medical Association (SMA) may make sense insofar as we are looking at a market comprised of a small number of providers.

But this hardly describes, in general, the physician market. It would seem to me that regulating the price schedule, per se, with the inclusion of a wide range of representatives, including academics and MOH-appointed doctors and medical professionals, as has been implemented by the MOH fee benchmark, would be better than allowing prices to be completely unmoored from any guidance whatsoever.

What remains is to have all prices cross-referenced to these benchmarks, so that incentives to adopt them will remain compelling. One approach is to require all physicians post the multiplier of their charges, relative to the benchmark's median. Benchmark ranges should also not be to drift too wide.

To prevent a proliferation of procedures, fee ranges should be posted just for the most common ailments, not surgical procedures, since the latter are often less relevant to the typical patient. These should be prominently displayed at all registration counters, not just in hospitals, but in clinics and medical centres as well.

The upshot of such a move, as the Life Insurance Association (LIA) itself has allowed, is the possibility of removing healthcare provider panels. Such restrictions are inherently anti-competitive, since panel membership is restricted by definition.

With prices no longer the main criteria for panel membership, non-panel doctors will face more pressures to rein in their charges. And as SMA has stressed, panels short-circuit the patient-doctor relationship. To contain cost escalation, insurers can simply agree to pay out amounts between the 40th and 60th percentile, leaving patients a choice. Those who wish to do so may top up any of the excess charges at their own expense.

We should also be sensitive to how more players in an industry, especially in health insurance, need not automatically give rise to the most competitive prices. For instance, allowing the exclusion of pre-existing conditions effectively consigns most patients to their current insurer, once such conditions are developed and identified.

But if we value the inherent natural justice in taking care of the chronically ill and believe that competition among insurance would work to contain the inevitable increases in premiums, then the Government can resolve the coordination problem by mandating the carrying over of pre-existing conditions, because any insurer would never want to be the first mover.

Moreover, competition may also be the most effective at containing costs when there is simultaneously a dominant player, in this case, the Government, operating through MediShield Life, who takes on the role of the price setter. This requires MediShield Life to be even more proactive in negotiating and bargaining for lower prices for procedures and medications that it covers.

After all, since the 3Ms account for less than a tenth of total healthcare spending, the value of these publicly mandated components of the healthcare system must rest in the ability of the public sector to either coordinate players, or signal the direction that the system should follow. Such negotiated pricing is common in single payer systems worldwide, including Canada, France, Germany, Norway, Sweden and the United Kingdom.

Relatedly, MOH should also scrutinise the face value of public charges. There have been anecdotal reports that pre-subsidy prices of some public health providers are now significantly higher than their private sector equivalents. While I believe that the public sector still bills less than the private sector overall, it is important that the regulator keep an eye out for unwarranted public sector charges.

After all, when the typical patient will only be concerned with his or her actual, unsubsidised fees, it falls. therefore, on MOH to police price escalation "on paper" since these are benchmarks for the private sector. The Fee Benchmarks Advisory Committee should expand its scope to not just examining the overall fee schedule, but also interrogate any persistent or accelerating divergence in public-private fees.

Finally, we should also be cognisant of how actions by the Government, beyond MOH, may contribute to cost escalation. More than one doctor we spoke to stressed that the industry-wide need to raise prices was premised on increases in rental costs at private hospitals and that this elevated benchmark was, in turn, first set by the precedent of Mount Elizabeth Novena.

The cost of the $2 billion facility was compounded by the record-setting $1.25 billion land sale on which it sits. Here, higher land sales costs have translated into higher medical charges. The need to adapt to rising costs, of course does not fall solely on the medical profession and medical facilities. Insurers often find it easy to pass along costs, which allows them to stack additional layers of paperwork to access insurance payouts.

While I am not in favour of interfering with how private firms run their businesses, additional administrative burdens undeniably lead to fee bloat, while also adding distance between the patients and the treatment they receive.

Here, the Government can leverage information technology to roll out a central insurance claims system. MediShield Life claims are already directly submitted by CPF at the moment. However, IP claims are still independently processed by the respective insurers, this adds unnecessary steps and increases administrative costs. There is currently an effort underway to develop an integrated claims platform across insurers.

Since there is already, presumably, a common claims system for MediShield Life, MOH could enfold this proposed claims platform under the same umbrella, into an expanded, public-private partnership platform.

Mr Deputy Speaker, I understand that the complexity of healthcare has made this speech more involved than usual. But my bottom line is simple, we allow the private system to grow, sans public sector leadership and strong regulatory guidelines, at our peril. My actionable takeaways are that we include greater cross-referencing of prices to benchmarks that are limited in range, that we allow insurers to pay out within this narrower range.

And if we believe in the justice of covering pre-existing conditions, the Government should play a coordinating role in mandating such coverage. Government should be more proactive in bargaining for lower prices for procedures currently covered under MediShield Life, while also auditing excessive discrepancies between public-private fees.

And as the price increases in other inputs, such as real estate, should be managed, since this can spill over into healthcare costs. I am sure we have all heard stories of how we have experienced long wait times for admission into our hospitals lately. Data released by MOH suggest that the median waiting time could have been almost 24 hours.

The Ministry takes the question of wait times seriously, yet researchers from the Saw Swee Hock School of Public Health note that despite "measures to reduce waiting times… the problem and the concern persists."

I will conclude, Mr Deputy Speaker. I see your trigger-happy finger —

Mr Deputy Speaker: My finger is not trigger happy. I was just going to remind you that you have nearly breached your 20 minutes full complement, that is your right; so, could you wrap up, please?

Assoc Prof Jamus Jerome Lim: Thank you. My fear is that such waits are but a foretaste of what an overstretched public health system, forced to operate alongside a parallel private system with only light regulation, could yield. That said, I support the Motion.

Mr Deputy Speaker: Mr Yip Hon Weng.

1.41 pm

Mr Yip Hon Weng (Yio Chu Kang): Mr Deputy Speaker, Sir, I support this bold initiative to promote preventive healthcare. This White Paper has naturally gotten a lot of attention amongst my senior residents and GPs in Yio Chu Kang, which is a mature estate. Having spoken with them, I would like to raise feedback on several areas.

First, Mr Deputy Speaker, Sir, I will discuss Healthier SG from my residents' point of view. My residents are generally happy with the Healthier SG benefits. Notwithstanding, there are a few concerns. First, can a patient, who has already enrolled with a family doctor, consult other GPs and still enjoy Healthier SG benefits? I would like to highlight. TCM treatments.

Many patients also like to get a combination of Western and TCM treatments for their ailments. Some elderly patients prefer to get regular acupuncture treatments at registered TCM clinics for their aches and pains, rather than to rely on pain medication. Will the Government take this opportunity to review how we involve TCM practitioners in community preventive healthcare, especially, since acupuncture is also offered in our restructured hospitals?

Second, how will compliance and success be measured? Measuring health is unlike exercise, where we can determine participation and progress through counting the number of steps taken, heart rate and so on. How does the GP and the wider healthcare system assess adherence and compliance? How do we measure the impact on the individual at the personal level?

For patients who refuse to follow the prescribed health plan, how can we then determine whether the overall programme is effective, or even whether the GP is proficient? Having a good number of sign-ups is a favourable start. However, this does not necessarily guarantee in-depth participation.

What is more important would be compliance to a single GP or the Primary Care Network (PCN). How do we discourage the practice of GP hopping? Will there be penalties for either the patient or GPs? Is this a key performance indicator and who is it directed to?

Third, can we speed up the implementation of Healthier SG to residents under 60 years old? I believe we should be more ambitious, especially considering that chronic illnesses can start in the 40s. One way to do this is by allowing family members to enroll in the programme together with the senior.

For example, if an individual is 60 years old and his wife is younger by a few years, can they both enrol at the same time? This ensures better compliance. They can motivate and accompany each other for consultations and screenings, and adhere with exercise plans.

Mr Deputy Speaker, Sir, I now move on to what Healthier SG means for GPs. Our GPs have been very helpful with our efforts to build a dementia-friendly community in Yio Chu Kang. They shared with me some useful insights on Healthier SG.

First, how adequately are our GPs trained in managing chronic diseases? A GP who wants to manage more complex health problems must begin their training from medical school. In big countries like Australia, there may only be one doctor serving one or even a few towns. The GPs there are trained through medical school and postgraduate courses, with the expectation that they will function as the only doctor in the town and would, therefore, be equipped as such, with skills spanning from common ailments to more complex chronic conditions. In Singapore, because of how accessible our tertiary healthcare institutions are, many of our GPs focus on common ailments and function as referrers for more complex and serious conditions.

Second, how many GPs are enrolled in our PCNs? This may give some insight on GPs' willingness to participate in Healthier SG. Do we have the majority of GPs on board the PCN initiative? What more can we do to get their buy-in to provide effective care in the neighbourhood?

Third, will the cost of ancillary services be subsidised by the Government so that it is on par with those provided by tertiary healthcare institutions?

The Government has gone to great lengths to reassure us that the drug cost parity between prescriptions from GPs and polyclinics is reduced. Will this be done through restricting the brands of drugs brought in? What happens if a patient opts for "branded medication"? As drug sales constitute a large part of GPs' incomes, how will drug cost parity affect a GP's willingness to sell generic drugs? Does this also extend to the cost of ancillary services, such as blood tests, X-rays and other related services provided by GPs?

The White Paper also mentions a team-based care approach. Will this be similar to the PCN where backend support for care coordination and other ancillary services are provided to the GP? Would GPs have to hire additional manpower or to pay for these services?

Fourth, how many more staff are required to deal with the additional administrative workload and to handle social prescription?

Under Healthier SG, we expect GPs to provide advice on lifestyle and dietary activities but such social prescriptions can involve a longer consultation session and probably over an extended duration of time. In the meantime, GPs still have other patients' ailments to tend to. Can the GP count on the care team to help out or will they have to hire additional staff if they are unable to manage? This is more so in solo practices and goes back to my previous point on getting more GPs to join PCNs.

In tertiary healthcare institutions, typically, you would have a nutritionist speak to a patient on diet and then there will be other healthcare professionals and programmes to deal with smoking cessation, weight loss and so on. With many GPs still practicing solo, would they have the time and resources to do so?

In Australia, GP visits are by appointments. This gives them adequate time to holistically review a patient's clinical and lifestyle needs, including making adjustments. In Singapore, it is, generally, a numbers game. The more patients a GP sees, the more money a GP makes. It would only be natural that the GP would want to earn more by seeing more patients.

Fifth, will the annual fee for providing care for enrolled patients be extended beyond CDMP conditions? This could include frailty and mobility issues, which are common with old age. Delaying the onset of such problems is critical in preventive care and will greatly help to improve the quality of life.

Sixth, I hope that under Healthier SG, GPs can be incentivised to start end-of-life care planning with their patients. This includes encouraging them to do Advanced Care Planning, or LPAs, at the opportune time.

These conversations are best started by people like GPs who know the patient best and ideally understand the patient's family and social context. It is these meaningful conversations that may need to take place. It is not so much to "bend the cost curve", though it might, but it helps people prepare for the inevitable and for families to be at peace with their decisions.

Lastly, Mr Deputy Speaker, Sir, I will now talk about the role of community care providers in Healthier SG.

Can the Ministry clarify whether screenings under Healthier SG are primarily done by GPs or Eldercare Centres (ECs)? The White Paper mentions leveraging on physical spaces in ECs to conduct activities like health screening, early detection of dementia risk and other healthcare initiatives for seniors. Yet, GPs are also expected to conduct screenings. What is the envisioned eventual end state? Regular opportunistic screening systems may make screenings more widely accessible. However, they could be confusing and overlapping in intent, thus resulting in excess costs.

In conclusion, Mr Deputy Speaker, Sir, Healthier SG is a paradigm shift. The Government's Population in Brief report was released last week. It shows that Singapore continues to grapple with long-term issues, such as low total fertility rate and the ageing population.

The responsibility of caregiving for older family members will rest on fewer shoulders. If all of us can take better care of ourselves and be more independent in our silver years, we can help to reduce this caregiving responsibility for our loved ones.

At the systems level, this means reduced fiscal funding on healthcare so that the money can be better used in other areas.

But what matters most is for the individual. I recently spoke with Mdm C, a senior living alone in Yio Chu Kang. I often see her around in the neighbourhood. Most of the time, I see her at the weekly exercise class in the park or at the market after her exercise for her breakfast with her exercise kakis. I asked her what she thinks is a good life. She told me that, being in her 70s, she does not ask for much. She said as long as she can eat well, sleep early, exercise and meet up with her neighbours and her friends, she would have lived a fulfilling life.

With the benefits of Healthier SG, such as having an assigned GP who knows her well and having a proper health plan to keep healthy, I am certain she will be active and can enjoy her silver years for many more years to come.

The focus should rightly be on health and not on healthcare, and to stay healthy in the community for as long as possible and not in the hospital. As such, I would like to take this opportunity to encourage all eligible residents listening in to sign up with Healthier SG as soon as the opportunity avails.

Let us all do our part to take responsibility for our own health and build a healthier Singapore. I support the Motion.

Mr Deputy Speaker: Miss Cheng Li Hui.

1.52 pm

Miss Cheng Li Hui (Tampines): Mr Deputy Speaker, I stand in support of the Healthier SG White Paper.

Sir, allowing our GPs to play a bigger role in our healthcare system is something close to my heart. In my Budget speech in 2016, I brought up coordinated care, about GPs playing a more prominent role in the overall well-being of our people. Eighty percent of our GPs are in the private sector and only 20% of them are in polyclinics and hospitals handling 80% of our population.

I was told the ratio has improved since. I hope that with the focus on primary care, we can look forward to stronger GP-patient rapport. COVID-19 has showed us the importance of reducing our load on public healthcare institutions.

Trust and rapport are implicit in healthcare. Often, this trust overlaps generations and is passed between family members. This trust transcends doctor and patient and goes into areas of digital privacy.

In my 2016 speech, I mentioned I was surprised to see the GP in Australia pull out the x-ray and surgical records of the next patient from his computer and it really made me ponder on the importance of coordinated care. The availability of our healthcare records will empower our GPs to make informed care decisions for us. We need to trust our doctors with the data and that the systems that hold our healthcare records are safe from bad actors, hackers and lapses.

In 2016, I also mentioned that isolation is one of the biggest problems for seniors. During the pandemic, due in part to the Seniors Go Digital programme, many seniors learnt to harness the power of technology and stay in touch with their loved ones. They were taught communication skills like video calls, connecting to WiFi and basic cybersecurity.

These have helped thousands of seniors remain connected and engaged through the most difficult times of the pandemic. We should continue with the momentum to enrich their lives for them to stay connected, not isolated and yet not addicted.

There is a small issue of addiction to gadgets which may aggravate isolation. Some of you know I am very close to my nephew. I am very conscious about children's gadget time. I am even more concerned about my senior residents' gadget time. Many of them have learnt to download movies and dramas and are hooked to them. My volunteers and PA staff work hard to create programmes to draw them out of their homes to have a healthy and active social life. Programmes must be targeted at pre-retirement age so that they will continue their active social life post-retirement.

For the not so socially active seniors, I was heartened to read The Straits Times article on 28 September 2022 on retired timber worker Lim Thiam Teng who warmed up to volunteers and is now an advocate of care centres.

Sir, I have spoken several times in this House on our Tampines East three-in-one centre. The auntie who started walking to the centre before she went blind so she could familiarise herself with the route. Her meals were provided for in our centre and she could listen to the news in the afternoon, amidst other activities. The auntie who no longer needed plasters after daily exercises at the centre. She also found someone there who loves singing Cantonese songs like her.

Most recently, we had our youngest dementia client in her early fifties. We could feel the increasing need for more senior care centres. I am delighted to read that MOH has plans to increase these centres. These allow our elderly to age in place, with their family and in familiar surroundings.

I remember my first referral as a new Member of Parliament. During our regular house visit, the auntie said the flat is occupied by her and her husband who had suffered a stroke. For the past seven years, she was his only and main caregiver. I asked her if she was okay and the tears just rolled. She said, "Okay. I am tired. I cannot even go to the market for too long." Her eyes brightened up when I explained the respite services at our day care centre. She was happy she could get a couple of days off to go and meet her friends and have a walk, just like she used to.

I was reminded of its importance of care centres during the pandemic when a resident approached me at a Tampines East vaccination centre. She said, "My brother-in-law is in your centre. He has dementia. It was so hard for us when the centre was closed. The day before opening, we told him. He seemed to understand and was in a good mood and went to bed readily. The centre is a great help to our family."

Often, our mild dementia patients, our clients, will call me "teacher" and say they will go back and tell their "parents" about their day. I am not sure if they would remember to but we go with the flow on good days and manage their bad days.

I want to take the opportunity to thank all day care and nursing home staff for their contributions to the many families. It is not an easy job. It is a calling.

Sir, I had mentioned senior day care centres allow our elderly to age in place. Recently, a dementia client was supposed to be discharged from our centre. Her daughter cried when she picked her up on her last day at the centre. They were supposed to check into a nursing home that weekend as her condition has deteriorated. However, she was back on Monday. It is hard for some to send their loved ones to a nursing home. They will try and manage with some help from the Government.

With more understanding of how senior day care centres work, the lower cost involved, I believe more families will be willing to have their loved ones in day care rather than nursing homes when they are still able to handle.

We need to get our GPs to come on board to be a coordinator of care for the elderly and the Primary Care Networks (PCN) under Healthier SG to play a bigger role in our elderly care centres.

We can engage our neighbourhood doctors who know their clients well to educate or refer them to day care facilities. Our Tampines GP, Dr Leong, even contacted us when he had extra flu vaccines that had some months left to expiry for us to ask our staff and clients if they would like to take the flu jab for free and many did.

So, while some families hire caregivers and have helpers to multitask with housework, children and seniors, it lacks the exercise and activity elements that senior activity centres or day care centres provide. How can we further attract, train, support and retain the staff of these centres to take on the expanded roles as envisaged by Healthier SG?

Sir, In May 2016, the PAP Women's Wing made a trip to Hong Kong. One morning, we visited their senior day care centre. I decided to spend the day there and what struck me was the heart and effort the staff put in in caring for the elderly there.

For instance, one staff tried to feed a resident using a spoon. She tried three times before she switched to tube feeding. She explained that she did that so that the resident would still retain her ability to swallow and not just rely on tube feeding, which will aggravate her decline in her physical state.

When the day ended, their families picked them up in a trolley sort of wheelchair as they could not sit up straight. Some thoughts went through my mind such as – with this condition here, they will be in a nursing home or with a dedicated caregiver at home. Was it a lack of nursing home? What kind of training or qualifications are needed for some of the staff to manage clients with such chronic conditions? Will we see our daycare progressing to handle more chronic conditions?

We will need a well-coordinated strategy that takes into account public health, sustainability, resilience, training, trust and our ageing population. Several of these topics are intertwined and the White Paper has done a good job in articulating these areas to address. Sir, I support the White Paper.

Mr Deputy Speaker: Senior Parliamentary Secretary Rahayu Mahzam.

2.00 pm

The Senior Parliamentary Secretary to the Minister for Health (Ms Rahayu Mahzam): Mr Deputy Speaker, Sir, we all want to be healthy, but with many competing demands in our hectic lives, it can be challenging for us to do so. This is why, as part of the Healthier SG strategy, it is important to build an ecosystem and rally the community as part of that ecosystem to facilitate healthy living, making it easier for us to make better, healthier choices. Today, I would like to address various Members' questions related to preventive health and encouraging healthy lifestyles in the community.

Our efforts can be summarised with the acronym "HEALTH". "H" for harnessing existing health initiatives, "E" for enhanced suite of health programmes, "A" for active collaboration with community partners, "L" for looking out for caregivers, "T" for tracking health activities via technology, and the last "H" for health-related lifestyle nudges. Let me elaborate on each of these in turn.

The first "H" is for harnessing existing health initiatives. Currently, there are a wide range of national initiatives to support us in adopting and prioritising healthy living. To promote physical activity, there are self-directed programmes such as the National Steps Challenge – where you can participate at your own pace anytime and anywhere – to virtual or on-ground MOVE IT leisure-time physical activity programmes for those who prefer guided exercise sessions.

Good nutrition is also a key component of living healthily and we actively encourage Singaporeans to adopt a healthier diet, particularly by reducing sugar and salt consumption. Ms Hazel Poa and Ms Sylvia Lim had spoken about this earlier, in particular about improving affordability of healthier food choices. Ms Hazel Poa had gone so far as to suggest taxes on unhealthy food. Mr Xie Yao Quan had sought clarification from her yesterday during his speech so the specifics of her proposals are not clear. In any case, let me share about our ongoing initiatives.

To reduce the intake of sugar, beverages sold in Singapore in prepacked form and from automatic beverage dispensers will be subject to new Nutri-Grade labelling requirements and advertising prohibitions from 30 December 2022. Similar measures for freshly prepared beverages will come into effect by end of 2023.

Some of you may also have heard that we are working with retailers to introduce lower-sodium alternatives which are healthier than regular salt. In fact, supermarket chains FairPrice and Sheng Siong will start selling lower-sodium salt products starting from this week.

In addition, HPB supports food manufacturers and suppliers to develop healthier products through the Healthier Ingredient Development Scheme (HIDS), and partners food and beverage establishments, including hawker centres and coffeeshops, to offer healthier meal options. HPB also works actively with supermarket chains to introduce more Healthier Choice Symbol (HCS) products to increase the variety of HCS house brand products which are typically more affordable than branded alternatives.

MOH also has a multi-pronged strategy to reduce the prevalence of use of tobacco products. In his speech, Mr Sharael Taha highlighted the issue of vaping. To address the use of vaporisers, we are working with various partners to strengthen enforcement measures and public education efforts. We will step up enforcement at borders, social media platforms such as Telegram and public areas.

MOH and MOE are also working together to address vaping in schools. These efforts will be complemented by the roll out of a vape-free campaign in 2023 targeted at youths and younger adults through popular digital platforms, to communicate that vaping is harmful and illegal.

These are just some of the many initiatives we have and I am happy to note that they have impacted the lives of our residents.

One such resident is 84-year-old Mr Louis Loh. Diagnosed with diabetes 10 years ago, Mr Loh remained largely sedentary. He only grew more motivated and began exercising regularly after joining National Steps Challenge Season 4 in 2018. Brisk-walking became his everyday routine and this enabled him to accumulate a daily average of 60 minutes of moderate-intensity physical activity. Keeping active has helped Mr Loh achieve a healthier body mass index (BMI) after losing about 10 kg in the last three years and his health conditions are now better managed and controlled. Mr Loh's improved health outcomes have encouraged him to keep to his walking regime even outside the Challenge. Today, he continues to track his daily physical activity for the benefit of his health.

Another example is 63-year-old Madam Rahimah. When her family members were diagnosed with diabetes and hypertension, she realised the importance of having good health and decided to take steps towards a healthier lifestyle. To encourage healthier eating habits, Madam Rahimah cooks healthy meals at home and packs them for her children to bring to work. The HPB's Healthier Choice Symbol made it easier for her to choose healthier ingredients and the information on how to cook healthier meals have also been useful. She opts for wholegrains such as brown rice and brown rice bee hoon. When making desserts like "bubur kacang" for the family, she uses low fat milk instead of coconut milk. In her cooking, she uses healthier oil and includes more vegetables, as well as using healthier cooking methods such as grilling and stir-frying instead of deep frying. Besides eating healthily, Madam Rahimah also incorporates physical activity in her daily routine to stay active. Madam Rahimah has noticed a big difference in herself ever since she started to lead a healthier lifestyle. She is more energetic and does not feel tired easily.

Mr Loh and Madam Rahimah took ownership of their health and harnessed existing health initiatives to improve their lifestyle.

Through Healthier SG, your family doctor will support you in this journey, managing your health holistically and guiding you to develop a personal Health Plan. This includes not only recommended health screening and vaccinations, but also lifestyle adjustments. Your doctor can also recommend existing health-related activities and services in your community that will be suitable for you.

Second, "E" refers to enhancing our existing suite of health programmes. Under Healthier SG, you will be able to easily identify programmes suitable for your health status and sign up for these programmes more conveniently through one app, Healthy 365. We will collate community partners' programmes and house these on the Healthy 365 app over time to cover the range from self-directed programmes to targeted weight management interventions for residents with well-controlled chronic disease and practical nutrition workshops on preparing a well-balanced healthy meal.

Mr Xie Yao Quan called for a wider variety of community programmes so that every local community is abuzz with exercise groups and health-promoting activities, catering to different needs. We do want a vibrant and robust slate of programmes but not all programmes need to be HPB- or MOH-driven programmes. To optimise resources, we will have to channel resources towards programmes that are well-received and impactful. However, we encourage community partners to play a part in this. It is heartening therefore, to hear Ms Hany Soh share about the ground-up initiatives in her constituency.

Ground partners can supplement existing health promotion efforts and programmes, and I would like to thank Ms Hany Soh for her ideas in this area. To encourage more residents to champion their interest groups and support Healthier SG, HPB provides our Healthy Singapore Fund for individuals or organisations to self-organise activities that meet their communities' needs. We hope these efforts will continue to bloom and add to the existing suite of offerings that residents can tap on to sustain healthy lifestyles.

I would like to assure Mr Edward Chia that we will continually explore ways in which private sector partners can play a role under Healthier SG. For example, we will explore how a more comprehensive range of physical activities may be made available to residents across the island through collaborations with private partners such as physical activity providers.

HPB's Healthy 365 app will be the lifestyle application that you can use to easily access lifestyle programmes offered by community partners near you. I agree with Dr Tan Wu Meng's and Ms Denise Phua's comment on the need to assist seniors or those who are not digitally savvy. For those who need help navigating the programmes, there will be support provided, such as through the Eldercare Centres and Community Centres. With these features in place, you will be able to easily access and select suitable programmes that support your health and lifestyle goals.

Next is "A" for active collaboration with community partners. Over the years, we have worked closely with the community to extend our preventive health efforts. One example is the formation of the Malay Community Outreach Workgroup (MCO), which comprises of Malay community leaders with wide ranging experience, including PA MESRA, MUIS, Mendaki under the M³@Towns committees, and Muslim Health Professionals Association (MHPA). At this point, please allow me to say a few words in Malay.

Mr Deputy Speaker: Please do.

(In Malay): [Please refer to Vernacular Speech.] We have been working closely with the mosques for several years, to encourage congregants to lead an active lifestyle through the JKJU programme (Look After Your Health, Look After Your Community). HPB will continue to expand the JKJU network by involving more organisations apart from the mosques to develop healthy lifestyle programmes and culturally-nuanced healthy lifestyle messages for the Malay community.

Recently, we have also launched the "Saham Kesihatan" (Health Investment) initiative, a collaboration between HPB and community organisations, including M3@Towns, ActiveSG and the People's Association (PA). This initiative aims to encourage more Malay/Muslims to stay healthy through community-led interest groups.

These groups can design their own local health programmes by leveraging on the various healthcare facilities and services provided by community bodies and Whole-of-Government organisations. The pilot "Saham Kesihatan" programme was launched in M3@Jurong and M3@Tampines. We hope to nurture at least one community-led interest group in every M3@Town. We will also continue to enhance existing programmes and support the Malay community with various health programmes, to encourage them to lead a healthy lifestyle.

(In English): In her speech, Ms He Ting Ru touched on the gender health gap for women. The feminisation of ageing is a well-recognised phenomenon, where women face a greater risk and duration of loneliness as those who are married tend to live longer than their husbands. They also have greater financial insecurity than men and carry a greater budget of the challenges and stresses of caregiving.

MOH is cognisant of these concerns. In fact, I chair a Women's Health Committee which comprises community partners championing for women's health issues. Together with our partners, we will continue to increase the awareness of women's health issues and promote healthier lifestyle practices amongst women. Sustained education efforts and support for women is important in addressing this long-term phenomenon. The efforts of the Committee will complement Healthier SG in supporting women in their preventive health journey so that they may live longer, healthier.

I agree with Ms Ng Ling Ling's point on the importance of adopting a community participatory approach under Healthier SG and this is in line with our plans.

Under Healthier SG, we and our healthcare clusters will continue to work closely with agencies to explore these suggestions and we look forward to the support of all our partners to achieve the vision of Healthier SG.

Moving on, we have "L" which stands for looking out for caregivers. As we seek to empower fellow Singaporeans to stay healthy, we recognise that some of our seniors are already frail, living with dementia, or approaching end of life. These seniors and their caregivers also need our support. Second Minister for Health, Mr Masagos Zulkifli, will speak more about our commitment to enabling seniors to live and age well in the community.

Over the years, we have enhanced our support for caregivers, with a range of initiatives under the Caregiver Support Action Plan and the White Paper on Women's Development. If you are a caregiver, there are a range of care options to help ease your burden, such as the Dementia Day Care and the Night Respite Care pilot to help caregivers of persons living with dementia, and home-based respite care for caregivers of those approaching the end of life. We will also provide more help to ease caregiving costs, with an enhanced Home Caregiving Grant in 2023.

Ground-up community efforts can also let caregivers know that they are not alone in this journey. For example, peer support networks under the People's Association's WIN Caregivers Network and Project 3i empower caregivers to learn skills and receive social-emotional support.

We recognise that caregivers also need even more support as their loved ones approach the end of life. Palliative care comes in here to provide not just physical, but also emotional, psychosocial, and spiritual support to patients and their families. I would like to encourage caregivers to join and benefit from these initiatives.

In their speeches, Dr Wan Rizal and Ms Hany Soh touched on enabling caregivers to better support their loved ones. Currently, nominated caregivers can already conveniently access the health records and appointments of their loved ones in HealthHub. Next year, caregivers will also be able to use HealthHub to help their loved ones enrol to Healthier SG.

I would also like to acknowledge Ms Janet Ang's point on leveraging digital technology to engage caregivers and we will continue to work with partners to engage caregivers through various channels, including digital channels.

So far, I have covered how the Government and community can play a role in supporting our healthy living journey. For my last two points, I will cover how technology can be used to empower and motivate you to take charge of your own health journey. The letter "T" is for tracking of your health activities.

In between visits to your family doctor under Heathier SG, you can access relevant, up-to-date advice via the Healthy 365 app and the HealthHub app on your personal devices. Healthy 365 enables easy tracking of different lifestyle behaviours such as physical activity, healthier food purchase and consumption. You will also be able to share your lifestyle data by showing the app to your family doctor, enabling the doctor to have a holistic view of your progress and discuss what lifestyle goals and programmes can help you.

In addition to monitoring of physical activity, sleep and healthy food purchases, the Healthy 365 app will be enhanced with new features, such as diet logging. The diet logging tool will help you easily monitor and be aware of your daily caloric intake from food and drinks consumed, so that you can work towards achieving your daily recommended caloric intake.

This tool will have a photo recognition function, that Minister described, so that we can simply take a picture of our meal, which could comprise of local food and drinks, such as chicken rice and kopi-o, for the app to estimate the caloric intake.

There will also be ways to support those who are not digitally fluent, for example, by enabling patients’ caregivers or family to assist.

Finally, the last “H” refers to health-related lifestyle nudges, personalised recommendations and rewards to sustain healthy behaviours. At the heart of Healthier SG is empowering residents to choose health for themselves while the system supports them. We know that lifestyle behavioural change is a long-term journey requiring both strong motivation and regular participation.

While we may interact with our family doctors once every six to 12 months and participate in community activities a couple of times a week, personalised recommendations and nudges delivered via digital technology can be a constant support to help us stay engaged on our healthy journeys.

We will enhance Healthy 365 to deliver more personalised nudges, such as through recommending suitable lifestyle activities, achievement of health goals and improving adoption of healthy lifestyle behaviours.

Many private companies have been developing such technologies and some have built deep expertise in nudging health behaviour change. We will continue to explore collaborations with them to harness technology and insights to help us all take better ownership of our health.

We have also made healthy living rewarding with HPB Healthpoints. You can earn Healthpoints under programmes, such as the National Steps Challenge. You will also receive Healthpoints after enrolling and completing the first consultation with your enrolled family doctor. We will continue to improve on this and encourage all of us as we choose better health.

With Healthier SG, it will be easier for everyone to start and sustain healthy living. Let me share a fictional example of how your health journey can look like.

Madam Anna, a 60-year-old resident in Jurong, meets her family doctor to discuss her health plan after getting her screening results. As Madam Anna is overweight and has high blood pressure and pre-diabetes, her family doctor recommends that she attends the “Live Well Age Well” programme to stay active and pick up nutrition tips to avert diabetes.

Madam Anna can scroll through the Healthy 365 app to find the “Live Well Age Well” programme nearest to her friend, so that they can attend together. She is also automatically registered for the “National Steps Challenge” and “Eat Drink Shop Healthy Challenge” where her daily healthy lifestyle activities help her earn Healthpoints to exchange for vouchers. The Healthy 365 app will also remind her to clock more steps, complete more moderate to vigorous physical activity (MVPA) minutes and offer other suitable activities to add variety.

During Madam Anna’s next half-yearly check in with her family doctor, she proudly shares that she has become more active and has reduced her caloric intake by using the Healthy 365 diet logging tool to monitor her meals. The family doctor notes that Madam Anna has lost two kilogrammes in the past six months. Her high blood pressure is also under control. If Madam Anna continues to sustain her healthy lifestyle and manage her chronic condition well, the family doctor may consider reducing her regular medication at her next health consult.

Although Madam Anna is a fictional character, as demonstrated by Mr Loh and Madam Rahimah in my earlier example, it is possible to start and sustain a healthy lifestyle and Healthier SG would make it easier for you to do so.

Enrolment for Healthier SG will start in the second half of 2023 for those aged 60 and above. In the meantime, you may download and explore HealthHub and Healthy 365 to access a wide range of preventive health resources and programmes.

Healthy living starts with you and me. Thus, as the Government strengthens support for preventive health under Healthier SG, I would also like to urge all of us to make a conscious decision to invest in our health. Let us strive towards living healthier and better lives.

Mr Deputy Speaker: Ms Tin Pei Ling.

Ms Tin Pei Ling (MacPherson): Mr Deputy Speaker, in Mandarin, please.

(In Mandarin): [Please refer to Vernacular Speech.] As the saying goes, "prevention is better than cure". This wise and well-known quote is apt to describe the Healthier SG White Paper. It also represents a major turning point in our public healthcare policy. Singapore's public healthcare system has always placed a greater emphasis on treatment. From the allocation of Government funds to services provided by civic organisations, there is a clear bias towards the treatment of patients. This is a passive model. Even in the eyes of the general public, to be a specialist is better than a general practitioner. This attitude inadvertently affects the choice of students when they choose their course of study, hence has an impact on our talent supply. It also affects the perception of the public with regard to public healthcare.

Of course, when people are sick, we have to treat and take care of them. Like a parent, the Government should not only provide quality medical care for Singaporeans, but also give subsidies to reduce the financial burden from medical expenses. Against the backdrop of an ageing population, it is even more important for the Government to provide quality and affordable healthcare. However, when people fall ill in their twilight years, they may find it hard to enjoy life even if they own a mountain of wealth. Hence it is often said that health is wealth. Because if you are healthy, you will have the energy to travel around, play with your grandchildren, pursue unfulfilled dreams and scale new heights in life. In this way, seniors will not be counting down to the end of their lives, but will be anticipating every new day.

Of course, from a long-term point of view, preventive public healthcare will only bring benefits. First, although we are a rapidly ageing population, the increase in public healthcare expenditure can be slowed down and the burden on future generations will also be lightened. Second, good health helps to improve our quality of life, and a good quality of life helps to improve our happiness index. Third, a healthy and strong population means a prosperous country. With good health, one need not fear about the future.

Earlier, I heard Assoc Prof Jamus Lim's speech and I have some doubts. I would like to take this opportunity to seek clarifications from him. He talked about listing out consultation fees at private clinics. I believe benchmarking fees against market standards and listing out consultation fees at private clinics are already in practice. Is he looking for greater transparency or better consistency of consultation fees? Second, he talked about MediShield Life. From what I heard he seemed to suggest that more medical services be included in MediShield Life. Can he elaborate on what additional medical services he is thinking of? Today, we are debating the White Paper, does he expect that certain preventive care services be included in MediShield Life? If so, how will that affect the premiums of MediShield Life? How do we help Singaporeans deal with the increase in premiums? Can Assoc Prof Jamus Lim clarify on these points?

My general feeling after listening to Assoc Prof Lim's speech is that he still plays a greater emphasis on treatment, but the Healthier SG White Paper is focusing on preventive care. I would like to seek his clarification. Does he also agree that the preventive medicine is better than curative medicine? In the long term, I feel that preventive care is a better option.

Now, I would like to return to my original speech. To move Singapore's health focus from treatment to prevention is necessary. However, in my view, the key to realising the vision of the White Paper lies in getting the people's genuine buy in. Bai Juyi once said, "feel how other people would feel with your own body and heart". When we rollout Healthier SG, we must pay attention to both the body and mind. Policies play a facilitating role. At present, if we ask Singaporeans whether they should live healthy lives and take preventive care, the answer must be "yes". Ask if they support it, the answer will surely be "yes" as well. But how important is it to them? And whether they will translate it into action, the answers are not so clear. In fact, unless we are sick, we tend to have the mindset that "it will not be me". Health checks or healthy dietary habits are often not on the agenda. Hence, in the White Paper, it is right to emphasise the role of GPs in inculcating good habits among Singaporeans. Building on the existing CHAS network, I hope that all GPs will heed the call and join the Healthier SG initiative to benefit more Singaporeans.

For these reasons, I support the Healthier SG White Paper. The White Paper's analysis is meticulous and the measures put forward are suitable. But I have two questions. First, as the existing recreational facilities, community partners and health activities in each estate are not uniform, how does the Government intend to work with various Government agencies and social organisations to ensure that each estate has a basic package with sufficient space and budget, customised according to the needs of the estate? For example, in some mature estates, there may be more elderly people living alone who are old, frail and financially disadvantaged. What they need is not just recreational activities, but also social and financial support. How can the Government ensure that every community, whether it is old or new, rich or poor, provides equal services? After all, one can get chronic illnesses regardless of one's status. But one's financial ability affects one's choice in life.

Second, I am happy to see that the Government agrees with the importance of mental health. In the White Paper, care protocols are mentioned to enhance the consistency of GPs in the care of chronic illnesses. I hope that the Government will also step up its efforts in the mental health area. Singapore is a high stress environment and mental health cannot be ignored. During the pandemic, many older Singaporeans have become accustomed to staying at home or avoiding the crowds because they have lived at home for a long time. This inevitably aggravates the psychological challenges that they face. So, I think mental health is an issue that we have to deal with sooner rather than later. Can the Government introduce mental health care with the "three highs" care protocols?

Overall, the intention of the Healthier SG White Paper is clear and should be supported.

Mr Deputy Speaker: Assoc Prof Jamus Lim. I understand that it is a reply to the clarification asked of you. Yes. Please proceed.

Assoc Prof Jamus Jerome Lim: Thank you, Mr Deputy Speaker. And thank you that I got a little more air time today. I will just quickly point out in response to the two specific questions that were raised by Ms Tin Pei Ling.

The first was Ms Tin suggested that I was saying that more fees should be published, right? This is not, in fact, what I said. I appreciate that I spoke quickly. What I said was that we should publish more of a multiplier of existing charges. If anything, I think that we do not need to publish all the fees in doctors offices, per se. We should publish it as a matter of course in literature, but rather, we should allow the multiplier of fees to be published so that the consumer is aware of how much more or less expensive their doctor may be relative to the benchmark.

The second point, Ms Tin mentioned about what I was suggesting be included into MediShield Life in terms of procedures that were not covered. Again, I think she may have misheard what I said. What I said instead was that MediShield Life should be a lot more proactive in negotiating for price setting. And that is important because MediShield Life is, in fact, one of the more prominent insurers in the existing market.

Finally, I should clarify that while I did focus my speech indeed on elements of cost pricing from the supply side, I also explained why I did so. The reason is preventative care – which is, of course, the focus of this Motion – is insufficient if we wish to contain costs. We have to address the demand side, in terms of how much people are demanding medical care but also address concerns from the supply side, those insurers as well as medical providers that are providing said care.

Mr Deputy Speaker: Ms Tin Pei Ling, is there a response? No. Mr Mark Chay.

2.31 pm

Mr Mark Chay (Nominated Member): Mr Deputy Speaker, on the onset, I would like to declare that I am the President of Singapore Swimming Association and a director of two private education institutions in the business of certifying and accrediting sports coaches and fitness professionals.

Please allow me to congratulate the Health Minister as well as the team at MOH for this progressive strategy. The shift from being a reactive to a strategy that promotes preventive healthcare makes perfect sense. Quite frankly, it is high time that we make this move.

I would like to address three matters related to the White Paper: on engaging with the sports, fitness and wellness community on education and certification and on leveraging digital technology.

On engaging with the sports, fitness and wellness community, I am happy to see that the White Paper asserts that improving health goes beyond the doctor's visit and encourages residents to adopt a healthier lifestyle. This reinforces what sports and fitness practitioners have long believed. International Olympic Committee President Thomas Bach said that "sport and physical activity are the low-cost, high-impact tools for healthy bodies, healthy minds and resilient communities."

The World Health Organization statistics show that one in four adults, and four out of five adolescents do not get enough physical activity. Globally, the estimated to cost US$54 billion in direct healthcare and another US$14 billion in lost productivity. This has a significant impact on populations, more so on economies like Singapore which depend heavily on its people.

It is good to see that there are plans to activate community partners, such as SportSG and the People's Association (PA). It would be better to see more engagement with private sector entities that provide relevant and structured programmes. Some of these programmes are customised to the requirements of our seniors and persons with chronic diseases. Partnering such private sector entities would give SportSG and PA greater options and relevant programmes to communities that require specialised programming. What are MOH's plans to engage the sports, fitness and wellness community in its Healthier SG strategy?

Sports has a large part to play in getting Singaporeans active. In the last National Sports Participation Survey (NSPS), swimming, walking and jogging are the only activities that consistently rank amongst the top five most participated activities across all age groups ranging 13 to over 60 years. Physical health and mental health ranked amongst the top motivations for participants in these activities.

From my own experience, I can tell you ploughing up and down a swimming pool by yourself is not the most exciting nor the most social activity. But when you come together as a group, complete sets, set goals and throw in a little competitiveness, sports can be a fun and it can be sustainable. Which is why I believe National Sports Associations, private sports clubs and academies have a part to play in in the Healthier SG White Paper. Structured, competitive sports and games should not be limited to just a person's school years, but for life.

I would like to quote a former Nominated Member of Parliament Dr Benedict Tan who delivered a speech here in Parliament in 2015 on 10 worrying trends in Singapore's sports culture. He said, "Our sports events can be more veteran-friendly. One is never too old to participate in sport and there is ample medical evidence to show that one can benefit from exercise, even if one starts late."

I agree with Dr Tan and we can do more to design programmes which are "veteran-friendly", modifying games, adjust training intensity, make it fun, such that physical activity is a way of life. Physical activity promotes optimal health and is integral in the prevention and treatment of many medical conditions. Sport, activity, exercise is medicine. Which brings me to my second point on education and certification.

In the Healthier SG White Paper, a doctor will be able to keep track of an individual's health conditions, detect health problems early, work with the individual on a care plan and refer the individual to suitable activities or programmes in the community. Knowledge of disease care is as important as knowledge of disease prevention.

I would like to ask the Minister what are MOH's plans to provide opportunities for doctors as well as healthcare professionals, sports and fitness professionals, to attain relevant training with respect to prescribing exercise to special populations. One such course is Exercise is Medicine, which is a global health initiative managed by the American College of Sports Medicine. Exercise is Medicine strives to make physical activity assessment and promotion a standard in clinical care, connecting healthcare with evidence-based physical activity resources for people everywhere, for all abilities.

Physicians and other healthcare providers should be encouraged to include physical activity when designing treatment plans and to refer patients to evidence-based exercise programmes and qualified exercise professionals.

Training a young athlete for peak performance is different from training an adult in his or her 30s and 40s, and is different from training a senior with chronic disease. It may seem intuitive. However, many coaching and fitness certification courses do not address the physiological differences in depth. I would like to ask the Minister what strategies have been considered to roll out continuing education for professionals in this sector. Perhaps, such courses can be delivered through CoachSG and PA.

Mr Deputy Speaker, I believe education does not stop when we leave school. In Primary school, we all went through health education. In Secondary school, we went through physical education. But what happens when we become adults? Should knowledge come from the family doctor? I would like to ask if educational programmes are planned to be rolled out to inform Singaporeans of health risks, prevention methods and physical maintenance in relation to an individual's age and condition. Such information can be bespoke based on data and information collected on wearable technology and pushed through an app. This brings me to my next point which is leveraging digital technology.

As our population ages, a concern is mental and cognitive health. Dementia is a concern of mine. Perhaps, with wearable and mobile technology being more accessible, we can explore how gaming and virtual reality can help diseases such as dementia and Alzheimer's.

Researchers at UC San Francisco described that an immersive game called Labryinth-VR, where players wear a head-mounted virtual reality display and navigate through "neighbourhoods" of increasing size and complexity and run errands. Players walk through a place and move their bodies as they navigate the game, gaining physical exercise that can increase cerebral blood flow associated with improvement in general cognitive performance.

We live in an amazing time, where technology can bridge the physical and virtual worlds. During the pandemic when physical activity in groups was limited, we made do exercising from home. Technology played an important role in connecting our physical activity done at home to an online community. Many of us took part in virtual races and activities and where we logged distances walked, swum and cycled. I remember even doing a push-up challenge with Speaker to raise funds for the Community Chest. Platforms like Zwift enable us to compete in real-time in virtual reality, connecting with people from all over the world. I would like to ask if MOH has considered the applications of simulated and virtual sport to increase and track activity.

Gamification creates a stickiness and technology connects and gathers data for us to make educated decisions on our health and physical performance. The potential to connect and activate is boundless. However, the strength of our strategy is only as strong as its weakest link.

The White Paper must be able to connect with Singaporeans from different socio-economic backgrounds, or different physical and cognitive abilities. This includes persons with disabilities as well as those who are not technologically savvy. It would be reassuring to hear details on how the Minister has considered these vulnerable groups in MOH's plans.

In conclusion, I would like to say that I am extremely proud of Singapore's healthcare system and our healthcare workers. I firmly believe that Healthier SG is a strategy which will support our healthcare workers, by placing a greater responsibility of an individual's health on the individual and also provide access to a wide network of support and expertise bolstered by a robust technology platform.

Healthier SG is an ambitious strategy and by no means a simple matter. It requires an immense level of coordination from various organisations to make it a success. Together, we can look forward to greater quality of life in our senior years. I support this Motion.

Mr Deputy Speaker: Ms Hazel Poa, I understand you have a clarification or want to respond to one.

2.42 pm

Ms Hazel Poa (Non-Constituency Member): Thank you, Deputy Speaker. Yesterday, I understand that the hon Member Xie Yao Quan sought a couple of clarifications from me.

First, with regards to my suggestion of tax on unhealthy food, he asked for specifics. And also, the second part is whether imposing such a tax adheres to the spirit of the White Paper.

As to the specifics of the tax, one specific example would be the sugar tax that exists in many countries and cities, including places like UK, France, India, Thailand, Malaysia and in certain cities in USA, it is is quite common. And a few months ago, a research that was funded by the World Health Organization came up with a report that examined the effect of this tax on the countries or regions that have in place this sugar tax. And it was found that it decreased demand for sugared drinks by 15%. So, it has been proven to be effective.

As to whether imposing this text adheres to the spirit of the White Paper, I do believe so. In fact, I do not see any contradiction. So, if the Member disagrees, perhaps, he can share why he feels that it does not. And, in same spirit, I would also like to ask the Member whether he thinks that our current tax on tobacco and liquor adheres to the spirit of the White Paper and does he think that they ought to be removed.

Mr Deputy Speaker: I see Mr Xie Yao Quan and Minister Ong Ye Kung's hand. Minister Ong and then perhaps, Mr Xie can decide whether he wants to respond thereafter.

The Minister for Health (Mr Ong Ye Kung): I thank Ms Hazel Poa for her suggestion on the sugar tax. We have been very reluctant to look into a tax like that.

The principle is not wrong – having a "sin" tax is the policy of this Government. When it is cigarettes, it is something that is harmful, we do tax it. Carbon, we tax it. We do tax sins. The question is sugar causes diabetes, should we tax sugar? The Member, Ms Hazel Poa, has suggested a sugar tax. I assume if you extend it further, you can also tax salt or oil, for example. We are reluctant to do this.

First, it affects a lot of people. Sugar is commonly consumed by so many people and so, you will add cost. And also, we consider the equity of the tax. There is equity involved. Because sugar is found in fruit juices, sugarcane, the pearls in bubble tea. So, you start to make such comparison, it is not going to be so easy. Therefore, the implementation will be complicated. Which is why for MOH, we decided against it – notwithstanding other countries having imposed sugar tax. We use labelling and regulation.

Senior Parliamentary Secretary Rahayu Mahzam talked about the Nutri-Grade labelling. Once we announced Nutri-Grade A to D, if you have high sugar content for canned beverages, you will be graded D, immediately, the beverage companies reformulated. As a result, today – I do not have the data with me – but we are achieving a reduction in sugar consumption as effectively as the UK with labelling and without a sugar tax. But thank you for that suggestion.

Mr Deputy Speaker: Mr Melvin Yong.

Mr Melvin Yong Yik Chye (Radin Mas): Thank you, Mr Deputy Speaker. I stand in support of the Motion, which seeks to empower individuals to take charge of our own health and wellness and help Singaporeans live longer and healthier lives.

The strategies proposed within the White Paper on Building a Healthier SG provide significant steps in the right direction to provide better quality healthcare in a more affordable and convenient manner.

In my speech, I will talk about how Healthier SG will benefit our workers who work hard, work long hours and more often than not, also work in stressful environments and offer suggestions on areas where we can and should do more.

Let me start by talking about the healthcare challenges that our workers face and how employers can play their part to help foster a healthier workplace.

During the NTUC's recent #EveryWorkerMatters Conversation, many workers raised concerns about the steady creep in healthcare costs. Concerns were understandably more pronounced among our mature workers, who are deeply worried about being able to afford treatments for their chronic illnesses such as diabetes, high blood pressure and high cholesterol.

Employers too are affected by the rise in healthcare costs for their ageing workforce as they have to spend more for their employees' medical benefits. An unhealthy workforce also reduces workplace productivity.

According to the United States' Centre for Disease Control and Prevention, some job roles can result in workers becoming more susceptible to chronic illnesses. For example, four out of the 10 most costly health conditions for US employers, which include chest pains, high blood pressure, diabetes and heart attack, could be attributed to work stress and physical inactivity caused by prolonged hours of sitting at the work desk. This relationship between certain job roles and chronic health conditions is unlikely to be unique to the United States.

The Labour Movement is therefore heartened that Healthier SG will help to make healthcare more affordable through: one, subsidies on health screenings and vaccinations; two, waiver of the co-payment requirement when using MediSave for chronic care management; and three, introduction of the new Community Health Assist Scheme (CHAS) drug subsidy tier for a whitelist of chronic disease management drugs to ensure that medications for chronic illnesses are made affordable.

Beyond general chronic illnesses that Singaporeans are susceptible to, we should also consider whether certain types of work predispose us to certain chronic illnesses.

As I have alluded to earlier, spending long hours sitting in front of the computer or in a driver's seat, among many other repetitive job tasks, can result in various forms of chronic illnesses. Examples include arthritis, carpal tunnel syndrome and hypertension. What can we do about this?

Mr Deputy Speaker, we spend most of our adult lives at work and research has shown a strong correlation between our work and overall well-being. Employers therefore must do their part to mitigate job-specific chronic illnesses faced by their workers.

They can do so in three ways: one, design the work environment to prevent chronic illnesses from forming; two, provide structured health screenings at the workplace, targeting job-specific chronic illnesses; and three, provide healthier eating options within the workplace. Let me elaborate.

First, employers must put in place a work environment that prevents job-specific chronic illnesses from forming and to adapt the workplace and work processes to help workers who are suffering from chronic illnesses, in particular, our mature workers.

According to a 2017 Swedish study, which examined the challenges involved in encouraging an ageing workforce to continue working productively, the researchers found that workers with chronic conditions can continue to work meaningfully by changing tasks and having proper physical aids to assist them. However, the study also observed that these changes often come at the workers' initiative, rather than the employer proactively doing so.

As our population and workforce ages, employers must be cognisant on how to adapt the work environment to help their workers remain productive.

Sir, as we shift away from transactional and episodic care, employers should also shift away from requiring medical certificates and provide workers some sick leave without MC. This will reduce the need to visit the doctor just to get an MC and reduce medical bills too. While some employers are already doing this – for example, workers in our healthcare clusters are given up to three days of non-MC sick leave – I urge all employers to do the same.

Second, all employers should work with their insurers and third-party administrators to include more Healthier SG clinics on their panels and offer structured health screenings and vaccinations for their workers. This benefit should also be provided to all workers, including those in the gig economy.

The Labour Movement has been pushing for this as early detection and intervention can help prevent chronic illnesses and infection of diseases.

For example, the National Taxi Association, the National Private Hire Vehicles Association and the NTUC's Freelancers and Self-Employed Unit have been working with the Health Promotion Board (HPB) to encourage gig economy workers to go for quarterly health screening and health coaching sessions, to get active and to stay in shape.

Third, companies with staff canteens can promote healthier eating options. The canteens operated by the National Transport Workers' Union have been offering brown rice at subsidised rates, to encourage our public transport workers to take up this healthier option. Since the campaign started, more than 100,000 plates have been taken up by our public transport workers.

Instead of a sugar tax, the canteens rolled out promotional discounted prices for our kopi o kosong and teh o kosong to encourage workers to cut down on their sugar intake. We are working with HPB next on a low salt campaign for our public transport workers. I hope that all companies with staff canteens can follow suit and nudge their workers towards a healthier diet.

Mr Deputy Speaker, in addition to better physical health outcomes, today's debate would not be complete if we do not consider the need for better mental health outcomes too. According to a 2021 study by the Institute of Mental Health, the COVID-19 pandemic has led to a rise in mental health issues in Singapore. Our workers are feeling the stress acutely.

A 2021 survey by software company Oracle found that nearly seven in 10 residents in Singapore said that 2021 was the most stressful year at work. More than half of respondents said that they were struggling with their workplace mental health.

I therefore fully agree with the White Paper that taking a preventative approach in mental health is aligned with the objectives of Healthier SG and I note that the scope of Healthier SG will eventually widen and include other complex chronic conditions such as mental health conditions. I would just like to ask the Minister when that will be.

Could we consider improving access to mental healthcare support to all Singaporeans by increasing the current psychiatrist-to-population ratio to 10 per 100,000 residents, similar to other countries such as the United States and Australia?

We should also encourage Singaporeans to have a dedicated counsellor or psychologist, similar to how we are encouraging everyone to have a regular family doctor, to serve as their first point of contact for their mental health.

The bottom line is that mental health conditions should be given the same priority as all other chronic illnesses and it is in everyone's interest – employers, workers and the Government – to ensure that we have a mentally healthy workforce.

I hope that MOH and the Inter-agency Taskforce on Mental Health and Well-being can prioritise the roll-out of preventative mental healthcare for the next review of Healthier SG.

Sir, to conclude, it is no secret that our health affects the way we work and our work affects our health. While the strategies outlined in the White Paper on Building a Healthier SG will help us achieve a higher quality, affordable and convenient healthcare ecosystem, we can all lean in and do more.

I encourage employers to play their part in tackling job-specific chronic illnesses at the workplace and putting in place a structured healthy workplace programme for their workers. Workers too should also do their part to go for regular health screenings, partake in regular exercise and eat healthily so as to remain healthy, productive and employable. Lastly, I hope that the next review of Healthier SG will include a strong focus on preventative mental healthcare. With that, I support the Motion.

Mr Deputy Speaker: Order. I propose to take a break now. I suspend the Sitting and will take the Chair at 3.25 pm.

Sitting accordingly suspended

at 2.57 pm until 3.25 pm.

Sitting resumed at 3.25 pm.

[Deputy Speaker (Mr Christopher de Souza) in the Chair]

Building a Healthier SG

Debate resumed.

Mr Deputy Speaker: Minister Masagos Zulkifli.

3.25 pm

The Second Minister for Health (Mr Masagos Zulkifli B M M): Mr Deputy Speaker, we have reached a critical point in Singapore's demographic history. One in four citizens are expected to be aged 65 and above by 2030, up from one in six today. While our life expectancy is one of the highest in the world at 85 years, our health-adjusted life expectancy is 75 years. This means that on average, we spend about 10 years in ill health. Our chronic disease prevalence rate has also risen. The proportion of population with high blood pressure has increased, from 20% in 2010 to 32% in 2020, and 26% to 37% for high blood cholesterol.

We want to reverse these trends and empower residents to lead active and healthy lives, surrounded by people whom they love and can support them in their journey towards better health. We must not let our health be determined by medical care alone, even if there are plentiful experts who can provide it. In fact, the way we live, work and play, and the environment we put ourselves in are as important, if not, more so.

We are already familiar with keeping healthy. From young, Singaporeans participate in activities in schools, such as physical education (PE), and go on to participate in programmes and activities in their workplaces and in the community. During our engagements, residents have told us that they are better able to sustain healthy behaviours if it is social. Much like in school – among friends.

For example, some find joy in going brisk walking with their friends. Others are motivated to stay healthy so that they do not burden their family members. One resident said "Exercise and sports, I do a lot of that. I play pickleball. If I am not playing games, I am going for walks with my friends." Another resident said "If a doctor recommends for me to do something, I would convince him that I rather do it with my friends." Like both residents, we are more motivated to exercise if our friends and family encourages us to do so or better yet, to do it with us.

Healthier SG acknowledges the importance that we place on participating in activities we enjoy, with our loved ones and friends. In support of this, community partners will provide a range of lifestyle programmes and activities to attract different profiles, and bring them closer to residents' homes, especially for our seniors. Senior Parliamentary Secretary Rahayu Mahzam has touched on HPB's support for this.

People's Association also has a wide array of health and wellness lifestyle activities, interest groups and courses catering to a broad range of preferences and interests. Those who prefer more structured support can start with Sport Singapore's network of Active Health Labs and Coaches. Active Health Labs will help residents get started and stay on their health regime. Residents will receive regular health and wellness coaching and advice on exercise customised to them, in order to meet health goals. This includes residents who are at risk of developing chronic conditions.

Even before Healthier SG, we are and will continue to be inclusive in promoting health to all. Ms Denise Phua and Mr Mark Chay asked about MOH's plan for persons with disabilities. The Enabling Masterplan 2030, which was just published in August, sets out our approach to enable persons with disabilities to live healthier lives, supported by quality healthcare.

Mr Gerald Giam asked about MOH's upstream efforts on child and maternal health. Child and maternal health is critical. We have already started on this, in parallel with planning for Healthier SG. The inter-agency Child and Maternal Health and Well-being Taskforce that I chair focuses on improving health outcomes for our women and children, starting from as early as the pre-conception stage and during pregnancy, to give every child a good start. Expecting and postpartum women can access educational information and resources on Parent Hub, which can be found on HealthHub.

Ms Denise Phua also asked about upstream interventions. We will continue to inculcate healthy habits from young by making health more prominent in schools and preschools and have started a review with MOE and MSF on this so that we can better support the health and development of our children. I have heard your concern for care and outreach to seniors participating, including males.

Ms Ng Ling Ling suggested to partner family doctor with community partners. These suggestions are important as we shape Healthier SG. We will need to ensure family doctors are plugged into relevant community level information so that they are familiar and can refer residents to these programmes. But more importantly, we hope their doctors can help them follow through on their health plans and show how these can achieve good health outcomes. Therefore, we will strengthen coordination and support across partners.

First, Healthy 365 as the entry way for all residents to easily access lifestyle programmes offered by community partners. Ms Ng Ling Ling suggested making it easy for more seniors to use Healthy 365 and HealthHub. I would like to assure her and other Members that seniors who need help navigating the app and enrolment need not worry. Help is available at our community centres, eldercare centres or through our Silver Generation Ambassadors. Already, out of those 50 years old and above, 280,000 participate in National Steps Challenge on Healthy 365. There are also about 230,000 seniors above 55 who are using HealthHub. We will reach out to more seniors and ensure they will be able to easily navigate the apps and locate the information they want.

Second, our healthcare clusters, as regional health managers, will step up. Ms Denise Phua and Mr Sharael Taha asked about the role of regional health managers. They will build relationships, coordinate activities and support across community partners and tailor programmes specific to the needs of the population in their regions. Over time, healthcare clusters will gain in-depth understanding of their residents’ needs. They will work with partners to strengthen the environmental and social support for our residents. The Agency for Integrated Care, a trusted partner of many community partners, will support this effort, integrating care across partners to better support residents.

Mr Yip Hon Weng expressed concern that there may be duplicative efforts in screening by community partners and primary care. We understand the concern. Senior Minister of State Janil Puthucheary will be sharing the care protocols that will guide screening done by family doctors and their care team. In addition, our healthcare clusters will guide supporting initiatives in the community. Over time, we hope to minimise duplication and target population segments that need more help. These partnerships will make it easy for residents to live healthily in their day-to-day lives and help connect residents to relevant programmes and services.

Mr Deputy Speaker, Sir, let me now elaborate on how we are supporting our seniors. We are committed to enabling seniors to age and live to their fullest potential in the community.

The Ministerial Committee on Ageing (MCA) adopts a whole-of-society approach towards making Singapore a better community to age in. This is one instance of a whole-of-society approach in health which Member Sylvia Lim said we should have. In 2015, MCA launched the Action Plan for Successful Ageing, covering 70 initiatives across 12 areas. I am glad to share some key achievements from the Action Plan and the latest initiatives on how we have built communities of care around our seniors.

Today, active ageing programmes exist in every neighbourhood. Our seniors have opportunities to learn new things and meet new people close to their homes. We provide targeted outreach to those who need it through the Silver Generation Office (SGO) and with intermediate and long-term care (ILTC) partners. Since April 2022, in their door-to-door preventive health visits to seniors, SGO looks out for seniors’ frailty status and level of social support. They will intensify outreach to seniors identified to have higher health and social risks so that they can be referred to the right services.

Dr Wan Rizal will be glad to know that we have been enhancing our care infrastructure and capacity to support the growing needs of our population, helping seniors to age in community, including those that are less mobile or immobile. Between 2012 and 2020, we added around 6,000 day care places and 5,500 home care places to cater to seniors with a range of care needs. Transport is provided to seniors who need it.

Healthier SG will extend to all seniors, including those who are lower-income earners. I appreciate Mr Xie Yao Quan for raising concerns about the lower-income in Healthier SG. Preventive care is not only for those who can afford personal trainers and coaches. With Healthier SG, we are making preventive care accessible to everyone. We are collaborating with GPs and polyclinics to help residents stay healthier. We are activating community partners to support them to live healthier lifestyles. Healthcare clusters have been working with SSAs and MSF’s social services offices (SSOs) in their regions to jointly address the health and social needs of the residents, particularly those from the lower-income households. For example, there are community nursing posts co-located with many SSAs and SSOs to make health services more accessible at these community touchpoints.

With Healthier SG, we will facilitate partnership and shared care of individuals across health and social agencies. We will also work through PCNs to strengthen the collaborations with Healthier SG GPs.

All hands must be on deck to enable our seniors to remain physically, cognitively and socially engaged, as well as maintain and improve their health. The MCA is refreshing the Action Plan for Successful Ageing. MCA ran a series of engagements with more than 5,000 residents. We found that many seniors continue to have aspirations even as they age, whether it is to volunteer in the community, care for their grandchildren or even start a business.

We have concluded our recommendations and are finalising the report which will be launched early next year. The Action Plan Refresh will be anchored on Care, Contribution and Connectedness, or what we call the 3Cs.

For the Care thrust, seniors will be supported through preventive health, active ageing programmes and care services.

On Contribution, seniors will have opportunities to contribute their knowledge and expertise to the community by volunteering, continuous learning and employment. Through our Citizens’ Panel on Contribution, many seniors have told us that they also wish to contribute to society by mentoring our youths. I am heartened to see such enthusiasm.

Finally, for Connectedness, seniors will age-in-community within an inclusive built environment while staying connected to their loved ones and society through digital platforms and support networks.

As suggested by Ms Hany Soh and Mr Sharael Taha, we will increase opportunities for families to provide the support system to help our seniors live healthier lives, strengthening intergenerational relationships within the family.

The Action Plan Refresh will focus on interventions in the community. The Infocomm Media Development Authority (IMDA) and SGO help seniors to be more confident in using technology to stay healthy. For example, our eldercare centres have been collaborating with IMDA to hold digital literacy workshops for seniors. The Seniors Go Digital programme also helps introduce use of Healthy 365 and HealthHub.

MOH has been working closely with MND to develop new housing-cum-care options to support seniors to age in community. We launched our first Community Care Apartments –which are senior-friendly housing integrated with care services – in Bukit Batok last year. And we will be launching our second in Queenstown in the November 2022 BTO exercise. Housing monetisation options like the Lease Buyback Scheme are also available to support seniors to age in community while boosting their retirement savings.

Eldercare Centres will be further strengthened as the key node for seniors. ECs will be the go-to points for all seniors’ health-social needs, including connecting them to social and lifestyle activities and monitoring simple vitals.

I would like to thank Ms Ng Ling Ling for her suggestion of reaching out to seniors living in private estates. Today, ECs provide support for seniors from different ethnicities and backgrounds and many of them participate regularly in activities and programmes at ECs. When we double our ECs by 2025, we expect eight in 10 seniors to be able to access these activities near their homes.

We welcome more stakeholders and community partners to come together in this endeavour to build a society that empowers seniors to contribute, be socially engaged and achieve their aspirations. All these efforts, together with Healthier SG’s emphasis on preventive care, lay a strong foundation for seniors to age in community, a major reform of our aged care ecosystem. Before I conclude, let me summarise my speech in Malay.

(In Malay): [Please refer to Vernacular Speech.] Healthier SG aims to empower all of us to take care of our own health. Family doctors will work with residents to improve our health. But beyond healthcare, we acknowledge that social and environmental factors are also important.

Under Healthier SG, community organisations will also be involved to provide various programmes close to homes to facilitate participation in programmes and activities to stay healthy. We will help seniors age in place and live to their fullest potential within the community. Ultimately, every individual must be responsible for their own health and therefore take active steps to stay healthy. Let us all make use of the resources available to live a healthier life and support one another to do the same.

(In English): In closing, the shift to leveraging community support for better health is a significant move. Everyone – families, individuals, community partners and the Government – must and will do their part, I hope.

Together, we can help one another sustain healthier lifestyles, live and age well and be a Healthier Singapore. [Applause.]

3.45 pm

Ms Carrie Tan (Nee Soon): I would like to thank the Minister for Health for the wonderful efforts to tackle our people's health challenges and also our nation's healthcare cost challenges using this upstream approach and also to thank Senior Parliamentary Secretary Rahayu Mahzam earlier for going into detail and describing the various technologies and apps – I think it is very creative to tap on Singapore's national love for food and taking pictures of food – and also considering support for caregivers, which is really important.

Minister Masagos also spoke about many hands on deck. I believe that is the correct direction to go. I am very supportive of these initiatives in Healthier SG.

I would like to expand on all these efforts a little bit more by highlighting some nuancing that I believe are quite important in the way we approach the community efforts for greater ownership of individuals.

One, I am hearted to note that these efforts to reduce cost of healthcare amidst the ageing challenges is to mitigate institutional healthcare costs, which is by de-institutionalising care. I believe the Government is already embarking on this with various "Ageing in Place" efforts, like Minister Masagos has said. I personally think that the pilot for Queenstown's Health District pilot is very commendable. It is really good to see the concerted efforts by both MOH and MND to do so.

To supplement the infrastructure design and development of care within the vicinity of people's homes, we also need to build up what we call the "soft infrastructure". As my hon colleague Denise Phua brought up yesterday, what is there in between GP visits to ensure that people follow their health plan that is recommended to them? What is there in our everyday?

To that, I would like to propose that we harness and strengthen the community's capacity to be the peer influencers and peer enablers for each other.

I would like to make two points in my speech – to involve other agencies in tandem with MOH and to expand our collective efforts towards greater health together. First of all, we need to harness our people, our citizens for mutual support to be influencers as well as facilitators.

For the past two years since being a Member of Parliament at Nee Soon, I have worked closely with Yishun Health and gotten to know and see the very good efforts they created in neighbourhoods as part of their community health outreach efforts. I am very inspired by their approach and model towards health, which is to decouple it from sickness and to emphasise instead empowering the agency within the individual for wellness.

They started initiatives like Share A Pot, which Nominated Member of Parliament Janet Ang mentioned yesterday. It is a programme that taps on seniors to gather together with other seniors. They are cooking and sharing bone broth together to strengthen their bones, to decrease their risk of frailty and risk of falls.

The other notable project is called Repair Kakis, where a group of elderly uncles come together and they provide handyman services to their neighborhood. It was actually started by a gentleman who suffers from Parkinson's disease. The Yishun Health team discovered that he was an aircon serviceman before and he possesses the technical knowledge and mechanical knowledge to repair appliances. They encouraged him and he started this group. Before long, more uncles joined him. And now, weekly, they create a session where they welcome neighbours to bring their faulty home appliances for them to repair.

I think what is really beautiful about this initiative was that it harnessed the strength of an individual, created a ripple effect and it built up this man's sense of dignity in being able to contribute to his community despite his medical condition. I think the self-esteem that he got and the wellness that he got from such an initiative and being a contributor really, really showed him to be a positive role model amongst his peers.

I also heard from the Yishun Health team that amongst these groups, there were successful cases where elderly gentlemen saw a friend of theirs pass away due to lung cancer from having been a chronic smoker. That prompted them to decide that they would also want to quit smoking.

In these examples, we see that it is actually the power of social relationships that worked wonders. Often, people do not need an expert to come and tell them what to do. People can make good choices for themselves when they are inspired by the stories and people amongst them.

As much as I am very glad for the current plans by Healthier SG that focus on physical health, I would like to encourage MOH to work closely with other Ministries such as MSF because the social determinants of health are equally, if not even more important in upstream efforts. Our efforts may go to waste if we neglect this critical piece.

As Woodlands Health Campus' Chief Operating Officer (COO) once shared with me a few years back in my then capacity as the executive director of Daughters of Tomorrow, many of the hospital's "frequent-flyer users" come from the lower-income segment. In fact, Woodlands Health Campus' utilisation trends show that 20% of patients use up to 80% of healthcare cost. Often, these are the people who will shun visiting the GP when they are sick because they cannot afford to pay the cash even after subsidies. They end up getting into A&E when their conditions get too severe. They also avoid seeing the doctor because they are in jobs that are daily paid. They work long hours or are mentally overloaded with too many chronic stresses to make healthy lifestyle choices.

Under these circumstances, the mindset that they are often beset with is, "I cannot" or "It is too difficult". Yet, in the example of the Yishun Health community outreach teams' Wellness Kampung efforts, we see how peers can influence peers to see that, "If you can, maybe I can too."

Such share and care activities harness the power of the community and the assets and strengths from amongst residents themselves to initiate activities that provide positive influence and share their own knowledge with one another. Such asset-based community development initiatives help to uplift wellbeing from lifting the self-esteem and social connection of people and contribute to their socio-emotional health – a key dimension as well as determinant of physical health.

We can scale up such efforts by involving and enhancing the capabilities of PA to do similar. People may ask, "What is the difference? We already have so many grassroots activities, interest group activities, brisk walking" and so on.

I would like to highlight that there is a distinct nuance here because to date, PA has developed itself and it is very strong as an organiser and often seen as a service provider of these activities, both recreational and social. But we are looking at in the A-B-C-D model is to enable residents to initiate and own the programmes themselves, thereby increasing their sense of ownership and their personal sense of agency.

Minister Ong mentioned that the community plays a big part in this plan. Specifically, I call for MOH to lead and to help fund a dedicated community health team within PA to train specifically personnel in asset-based community development in collaboration with Yishun Health's community outreach team as well as other community partners who are well-versed and familiar with the A-B-C-D model. I think this would help effect a very important transformational mindset shift from our people being at the receiving end of services to them being the enablers for change in the community and within themselves.

My next point: how can we better distribute care in the system so that it is not concentrated in formal settings, which are costly to provide? The good news is I believe we leverage the very good momentum that the COVID-19 pandemic has provided, where we see that in many parts of Singapore, neighbours are already helping neighbours, whether it is buying food, helping to fetch groceries when their neighbours are in quarantine and so on.

These acts of kindness and helping and care are already happening sporadically in a rather organic manner. The question is – how can we be more intentional about it and grow such mutual support and care within the community more systematically?

In Nee Soon, I am now piloting an experiment with Yishun Health to explore tapping on neighbours to help so that the hospital can readily discharge patients who are ready to be discharged but may not have people at home to care for them.

With the team there, they have created a list of care tasks and micro-errands that do not require medical expertise for people to help with. We are enrolling volunteers from the community to step up so that discharged elderly from the hospital can be adequately cared for and caregivers can have more support and more respite.

As we worked on this pilot, along the way, I met other initiatives in the form of social enterprises and ground-up groups that are doing the same or attempting to do the same. Initiatives like SG Assist by amazing Singaporeans like Adrian Tan and Greg Tan as well as Denise Tay and Michelle Lau, who founded KampungKakis. They are doing great work to excavate and pull together the human power for mutual support and caregiving in the community.

We need to grow the efforts of these leaders and champions for community care. These are social entrepreneurs with hearts that care and a commitment to pledge their careers to creating solutions for society. We should support, harness their strengths and invest in them. I would like to ask the Government to enable their growth by incentivising impact investors and philanthropists to invest in such initiatives to help scale up their work and impact to reach more of Singapore.

I have some specific suggestions to support social enterprises to provide capability building in community care so that we can help to accelerate the de-institutionalisation of health and healthcare.

One, it is possible to look into expanding the Community Capability Trust with specific funding injections from MOH to invest in social enterprises that provide such capability building services for the community. We can do this for as long as before they show any positive monetary returns or profits. This is really to help them during their startup stage.

We can also consider providing Government tax deduction benefits to impact investors who invest in early stage social enterprises that provide similar services in the same way that it incentivises donations to Institutions of Public Character (IPCs) because after all, if more people can be harnessed and built in their capability to care in the neighbourhoods, then we all can hopefully pay less taxes because of institutional healthcare costs.

Ground-up initiatives have closer experience on the ground. Often, their interventions and services are designed with personal experience of founders or beneficiaries. They can plug the last mile service gap much better than Government agencies can.

In summary, I would like to wrap up my speech to emphasis this point that aligns with the Ministry's intention for Healthier SG, which is that as individuals, we can do more to own and to take charge of our health. To do this, we need to harness the capacities, strengths and assets of individuals amongst residents. We need to invest in and grow the capacity of leaders amongst our citizens.

In so doing, we can truly bring the power of the community together and build up our citizens' agency and health by facilitating their initiative and their pioneering spirit through mutual sharing and caring activities that they start.

There is a Chinese saying, "百花齐放" – a hundred flowers bloom. I hope the Government can seriously consider these proposals to nurture and fertilise the flowers to bloom in this community health and community care space.

And so, I urge MOH to set up a dedicated work group that includes MSF and MCCY to help drive Healthier SG because the social determinants of health are key if we wish to see the outcomes we want. Hopefully, we can create, through these collective efforts, a virtuous cycle driven by the will and initiatives of our people. The more we care and share, the healthier we get. I support the White Paper.

Mr Deputy Speaker: Mr Ang Wei Neng.

3.58 pm

Mr Ang Wei Neng (West Coast): Mr Deputy Speaker, it is timely that Singapore is going to shift away from illness-based hospital care to a more sustainable way of patient-centred preventive care. This a good move but there will be challenges during the implementation stage.

The general practitioners or GPs are critical to the success of Healthier SG. After the release of the Healthier SG White Paper, I managed to communicate with a few GPs, including GPs who are practising in the Nanyang division. In general, the GPs are very supportive of Healthier SG.

While some GPs operate in residential areas and in clearly family clinics, others practise at the workplace. Those GPS who practise at the workplace are concerned that some residents or many residents would not appoint them as the primary family doctor, especially those residents above 60 years old, who are not working. How would MOH address this perceived inequality?

On the other hand, some popular GPs may be overwhelmed if too many patients want them to be their primary family doctor and they have to turn people away. Minister Ong alluded to this in his opening speech. For Singaporeans, securing a family doctor should not be a competition.

As such, I would like to ask what is maximum number of patients each family doctor can accept? What is the set of criteria which doctors can use to decide whether to accept or reject existing and new patients under Healthier SG? For instance, would they take into account factors like whether the patient had visited the clinic before, or how far away the patient lives from the clinic, or on a first-come-first-served basis? What exactly are the factors they would have to take into account and is that a priority?

Meanwhile, one GP, who is an owner-doctor running his own clinic has requested me to ask if it is compulsory for all family doctors to join the Primary Care Network (PCN). Such GPs also have questions on the need to be qualified as a family physician. Referring to page 42 of the Healthier SG White Paper, it states that each GP clinic must have at least one family doctor to be registered as a family physician within seven years of the launch of Healthier SG. Thus, I would like to ask, does it mean that the family clinic with only doctor, the sole doctor would have to be qualified as a family physician? If so, this may have profound implications for family clinics run by solo doctors.

If GPs are to oversee the end-to-end journey of caring for a patient, it would be helpful if they can work with partners to deliver this care.

According to an article from the Harvard Medical School, such GPs, who are also called primary care physicians, work in teams to keep patients at the centre of all diagnostic and treatment activities. These teams often comprise medical assistants, nurses, pharmacists and social workers.

Likewise, in the Netherlands where the GP is the central figure in Dutch primary care, GPs employ salaried nurses and primary care psychologists, who can even provide mental health services. The typical practice size is approximately 2,200 patients per full-time working GP and over 95% of the citizens are registered with one GP that they have chosen. Chronic care management is coordinated through care groups, which are mostly GP networks. These care groups coordinate care from multiple service providers for certain chronic diseases, such as diabetes and cardiovascular conditions.

Would MOH envisage the formation of such GP networks in Singapore? If so, would such networks be coordinated by the respective three health clusters?

Outside of the clinic, there are many touch points and community engagement opportunities with members of the public. I heard from Minister Masagos that the healthcare cluster will coordinate with community partners and GPs to provide healthy activities for the residents. And to this end, as a Member of Parliament taking care of the Nanyang Division of West Coast GRC, I would be happy to leverage on my community partners to work with the healthcare clusters and the GPs in Nanyang to provide healthy lifestyle activities for the residents.

As with any change, it would take time for residents to embrace Healthier SG. Preventive care requires more commitment from people to live more healthily, commit to advice from their doctors and spend time on regular health screenings. Many Nanyang residents I met and have spoken to after the release of the Healthier SG White Paper are very supportive of Healthier SG but they have also raised some concerns. Let me continue in Mandarin.

(In Mandarin): [Please refer to Vernacular Speech.] Many residents in Nanyang support Healthyier SG, but they also have some questions. Let me share an example. Mdm Tan, who is in her sixties, has been seeing a doctor at the Teo clinic near her home since young. She has just changed her job, and the clinic is not on the company's list of designated clinics. Hence, Mdm Tan cannot claim medical fees from the company for the cost of seeing the doctor at the Teo Clinic. Mdm Tan was glad to hear about Healthier SG, and wanted to appoint Dr Teo from the Teo clinic as her designated doctor, so that she could receive free vaccinations and highly subsidised pills for the "three highs". For a common cold, Mdm Tan still needs to go to company-designated clinics. This situation is just like what the White Paper has described on page 24. If Mdm Tan has a choice, she would prefer to go to the Teo Clinic which she is familiar with whenever she falls ill, just like what the White Paper has recommended. I hope MOH can solve this dilemma.

Another important aspect of Healthier SG is to encourage Singaporeans to take part in more activities that are good for their health, such as Zumba, brisk walking in parks and gardening. To date, most of these activities are only attractive to women. Many men prefer to drink in coffee shops, eat and chitchat for a long time. It seems that we need to mobilise our men and entice them to move from drinking tables to table tennis and from eating to growing vegetables. While this is not MOH's strength, it is an important factor in Healthier SG. I hope the Minister will think about it and invest more in this area.

(In English): Next, I would like to touch on another very important topic, which is the funding. Minister Ong had indicated that it would cost about $1 billion over the next three to four years for IT support and other one-off costs to bring the GPs on board Healthier SG. At the same time, the recurring cost of running Healthier SG will amount to $400 million a year, including the service fee for the GPs.

As mentioned earlier, healthy activities for the residents as coordinated by the respective health clusters are a very important component of Healthier SG. I would like to ask Minister Ong, how much of the $400 million budget will be allocated for organising healthy activities and nudging residents to engage in such activities?

Earlier, I heard from Senior Parliamentary Secretary Rahayu Mahzam that they will make Healthy 365 as a very key component of the entire Healthier SG. But we know that there are many other apps that are very popular with the residents. For example, there is LumiHealth. So, how would Healthy 365 interface with those apps that are very popular right now, like LumiHealth, so that they can be more coordinated and benefit more residents?

Ultimately, we can take inspiration from what is being done in other countries for preventive healthcare.

A research study of primary care physicians in 10 countries including Australia, Norway, United Kingdom and Switzerland showed how patients that are managed by one primary care physician are able to view information from their medical records, and can even e-mail their doctors. While this could prove quite onerous for our GPs, it would certainly go a long way in building trust between patients and their doctors.

In conclusion, I would like to quote an advice by Dr Chuang Wei Ping, an elected member of the Singapore Medical Council and a popular GP in the Nanyang division. Dr Chuang said, “People want to live a fuller live, rather than a longer life.” “People want to live a fuller live, rather than a longer life.”

Currently, Singaporeans' life expectancy is close to 85 years but they spend more than 10 years in ill health. With Healthier SG, we hope to reduce the number of years spent in ill health. This is possible if all Singaporeans, all GPs, all Government officials and all community partners are ready to make Healthier SG as a priority for a better Singapore. I support the Motion. [Applause.]

Mr Deputy Speaker: Mr Pritam Singh.

4.08 pm

Mr Pritam Singh (Aljunied): Sir, the Workers' Party Members of Parliament have raised points which cover the main prongs of the Healthier SG White Paper. These include concerns on capitation funding, manpower issues across the healthcare landscape and the future evolution of the family medicine ecosystem as envisaged, amongst other points.

The upcoming changes to the healthcare system underwritten by the White Paper are significant, and in the main, the Workers' Party supports the Government's strategic shift towards preventive healthcare, important aspects of which were pre-emptively raised by Workers' Party Member of Parliament Leon Pereira in his Adjournment Motion on reviewing strategies towards preventive healthcare in February this year.

My contribution to this Motion will be short and it covers an important but sometimes understated stakeholder in the public health care ecosystem, and that stakeholder are the Traditional Chinese Medicine (TCM) practitioners and others who are practitioners of alternative or complementary medicine. In the course of the debate, I have heard hon Members Ms Joan Pereira, Ms Hany Soh and Mr Yip Hon Weng also speak on TCM and how it interfaces with the Healthier SG White Paper. In my speech today, I will make three suggestions to bridge TCM and complementary or alternative medicine as important community partners of a healthier SG.

In July this year, I asked the Minister for Health in a written Parliamentary Question how TCM practitioners would be integrated into the Ministry's Healthier SG plans. Minister Ong replied and I quote: "Traditional Chinese Medicine practitioners are important stakeholders, especially given their emphasis on holistic and long-term care. However, unlike Western doctors, Traditional Chinese Medicine practitioners are not tightly regulated by MOH. The standard of care delivery varies widely and we will therefore not be able to take the same approach as we have taken for Western doctors."

This reply is nonetheless not inconsistent with the Minister's public comments in December 2021 where Minister was quoted as recognising the benefits of TCM in fighting chronic diseases. In fact, successive health Ministers have raised hopes of alternative approaches to healthcare like TCM, which complement and integrate Western medicine.

Some almost 30 years ago, in 1995, the Health Ministry accepted the recommendations of the Committee on Traditional Chinese Medicine and moved to begin regulating TCM. Globally, under the Beijing Declaration adopted by the World Health Organization (WHO) in November 2008, Traditional Chinese Medicine was recognised as having an important role in the improvement of public health. Acupuncture has in fact, been scientifically proven through trials recognised by WHO to be an effective treatment for more than 20 diseases and disorders.

Today, TCM practitioners in Singapore are governed by the Traditional Chinese Medicine Practitioners Act and physicians are expected to abide by the ethical code and ethical guidelines for TCM practitioners issued by the TCM Practitioners Board which also comes under MOH.

In 2019, legislative changes were made to further professionalise the TCM industry. These included the introduction of continuing professional education and raising the maximum fines on errant practitioners from $10,000 to $50,000. This hike in fines brought the TCM Practitioners Board's disciplinary powers in line with those in the dental, pharmaceutical and allied healthcare boards.

Sir, TCM and other alternative treatments such as ayurveda and other alternative therapies have a long tradition of acceptance in various Asian cultures. Singapore is no different with non-Chinese Singaporeans resorting to TCM and alternative medicine as well. To this end, some TCM products have even been halal certified.

In fact, as early as 2005, MOH allowed licensed hospitals and nursing homes to have full service TCM clinics, including acupuncture, tuina and herbal medicine services to be co-located on their premises on the condition that the TCM clinic was clearly distinct from conventional medical services.

In 2018, an acupuncturist at Khoo Teck Phuat Hospital was quoted in the newspapers as saying that around 40% of her patients who sought acupuncture were non-Chinese and under the age of 25.

The Government, for its part, has previously allocated $3 million for the TCM Clinical Research Grant from fiscal years 2013 to 2018 to support research into chronic diseases.

A further $10 million in research and development grants was also announced in 2017 as part of efforts to modernise the industry. Then Senior Minister for Health, Mr Chee Hong Tat, was quoted as saying: "After you come out of hospital, how do you help a person to get back as quickly as possible to good health? I think things like therapeutic massage actually play a very useful role."

On 29 December 2020, in a significant move, MOH announced that it was extending means-tested subsidies and MediSave coverage under a pilot arrangement to support acupuncture for lower back pain and neck pain at specialist outpatient clinics in public healthcare institutions. The pilot did not cover acupuncture used to treat other pain indications and other forms of traditional complementary and alternative medicine offered at public healthcare institutions. However, the Ministry stated that it would review the expansion of the pilot to other settings in the longer term, taking into account learnings and data from this pilot. Healthier SG may well provide the opportune platform and impetus to expand this pilot.

Suggestion one – extending use of MediSave to more procedures and allow TCM practitioners who offer them.

To this end, Sir, my first suggestion is for the Government to consider extending the use of MediSave for more TCM procedures and alternative therapies that have a proven role in the management of one's general health and, more pertinently, in the prevention of chronic diseases. This expansion should also see the inclusion of certified TCM practitioners who can be allowed to offer such approved procedures in their TCM clinics outside public healthcare institutions. In order to prevent abuse, a fixed and audited list of procedures and caps to limit the fees that can be charged for such procedures ought to be considered. Additional subsidies can also be extended to Pioneer and Merdeka card holders for these procedures, many of whom resort to TCM as an important source of primary care.

Suggestion two – consider alternative and complementary medicine to lower costs.

Second, MOH should look into the cost of alternative medicine that substantively produces the same clinical outcomes as medicines and drugs disbursed by our public healthcare institutions. For example, Fybogel, which is commonly dispensed for constipation, can cost around $20 on the shelf without subsidies, whereas psyllium husk, which confers similar, if not identical, benefits, can be purchased from Little India and even NTUC supermarkets at under $3.

In 2015, the then Head of the Traditional and Complementary Medicine Branch of the Primary and Community Care Division at MOH confirmed and I quote, "MOH constantly reviews the regulations and policies on TCM, taking into consideration the scientific advancements and rising standards of TCM." In similar vein and with a view to better manage costs, a review of commonly prescribed medicine which substantially produces the same clinical outcomes as complementary medicine should be undertaken on a longer-term basis. It would be useful to understand if the Ministry or a relevant body like the Health Sciences Authority currently carries out such comparisons of clinical outcomes between Western and alternative medicine with the view to lower overall healthcare costs.

Separately, I suspect more than a few in this House would have encountered cervical episodes for which traction and other specific thoracic mobility stretches are commonly prescribed through physiotherapy. Similarly, TCM also advances traction and certain stretching and mobility exercises as rehabilitative procedures.

In this light, would the Ministry consider whether there is scope for such rehabilitation or physiotherapy to be undertaken at TCM clinics by TCM practitioners? Such rehabilitation is not usually just more affordable than physiotherapy sessions at many private and public healthcare facilities, but the convenience of having such options for Singaporeans within one's neighbourhood and perhaps right under one's block can ensure that patients complete their rehabilitation and live healthier and more mobile lives.

Suggestion three – leverage on TCM practitioners to achieve Healthier SG.

Mr Deputy Speaker, late last year, a Straits Times article reported that the Government's feedback channel, REACH, discovered that many seniors were reluctant to get their COVID-19 vaccines due to and I quote, "advice from their doctors, mostly traditional Chinese medicine (TCM) practitioners who are unsure of what advice to give". In response to this, MOH arranged to meet all TCM practitioners to explain why vaccination was critical.

Sir, while TCM and other alternative therapies have not been covered in any substantive detail in the White Paper, it is clear that TCM practitioners do not have a small footprint in the mindshare of Singaporeans when it comes to our health, particularly in the heartlands. Like Healthier SG, prevention of long-term diseases is a core belief of TCM and complementary medicine. And this does not start in one's senior years. Their treatment philosophy places an acute focus on prevention before a disease arises. They advance the view that one's lifestyle is intimately related to health, which can be improved through effective mental health management, rest, a good diet and interventions based on a person's specific physical conditions, amongst others. By watching such indicators, one is well on his or her way to good health, regardless which economic strata of society one belongs to.

Indeed, the White Paper lists a number of community partners, such as AIC, Sport Singapore, the People's Association (PA) and the National Parks Board (NPB), that will empower residents to chart their own journey towards healthy and active lives. In our journey to live more healthy lives, I would suggest that we should not underestimate the wide reach of the local sinsehs in our neighbourhoods. MOH should tap on them to help share healthy living tips and preventive healthcare strategies, not just to our seniors. And MOH should not rule out subsidising TCM practitioners in this endeavour, subject to their contributions towards objective criteria under Healthier SG. Such an approach would also be consistent with the aim of successive Ministers of Health who had hoped to integrate Western medicine and TCM and alternative medicine as far as practicable, even as both branches of medicine operate in different cultural and professional milieus. While progress in this regard appears to have been fitful so far, Healthier SG provides a new-found opportunity for TCM and alternative medicine to play a more active role in the primary healthcare space and in preventive healthcare.

In conclusion, Sir, just like family doctors, many Singaporeans have been going to the same TCM practitioners for decades. For some, the reasons behind this may well be behavioural, peace of mind and more comfort dealing with a TCM practitioner. The Government is on record to say that TCM practitioners are an important stakeholder in Healthier SG. The Ministry should consider concrete plans and strategies to include them in the country's strategic shift towards preventive healthcare as Healthier SG is fleshed out and operationalised in the months and years ahead.

The Ministry will not be starting from ground zero. With decades of regulatory experience and periodic reviews of the TCM landscape undertaken by the TCM Practitioners Board, a dedicated effort must be undertaken, driven by the Ministry to draw on the treasure trove of alternative and complementary medicine that has been relied on by generations of Singaporeans for their well-being. This is an opportunity that should not be missed.

Mr Deputy Speaker: I was going to call Mr Henry Kwek. But Minister Ong, you have a clarification?

Mr Ong Ye Kung: I thank the Leader of the Opposition. I am glad that he read my Parliamentary answer on TCM and also my December 2021 speech on TCM.

I just wonder, last month, I gave two more speeches about TCM and Healthier SG. I just wonder whether he is aware.

Mr Pritam Singh: Yes. On 11 September?

Mr Ong Ye Kung: You are. Thank you very much. And 18 September.

A few Members have raised this issue. I will give a fuller response later in my closing speech. Thank you.

Mr Deputy Speaker: Mr Henry Kwek.

4.23 pm

Mr Kwek Hian Chuan Henry (Kebun Baru): Mr Deputy Speaker, loneliness can wither away even the bravest souls – a spouse passes on, siblings disappear, children distancing themselves. These can be devastating to our seniors. Some never even had close family members or friends to begin with.

For them, their final years can be harsh. Many of them decide that in the absence of love, health is meaningless. They decide to fade away. Yes, loneliness can kill, sometimes, in the most undignified way.

But I have seen it with my own eyes that it need not be so. It need not be so.

A few years ago, Dementia Singapore and my volunteers set up a self-funded eldercare centre from scratch within Block 115 in Ang Mo Kio. The centre combines health and social care for the most vulnerable seniors living in that block of rental flats, most of whom are frail and without familial support.

We took over four units of HDB studio apartments and we did up the void deck. We got doctors and nurses from TTSH to review the health status of every senior under our care and to come up with a personal health plan. By health plan, it means more than just doing monitoring their vitals or ensuring medical compliance. It also includes social prescription, getting them to join in regular exercises and activities, getting them to eat healthy meals together and getting them to join in the kampung downstairs. These social prescriptions were delivered by a few staff and seniors were given micro-jobs. We also have the assistance of community partners and volunteers from all walks of life.

The results were dramatic. Let me just talk about just two seniors, although we have seen impact in almost all the seniors under our care. Both have consented for me to share their stories, but I will still mention them using pseudonyms.

One, Uncle Paul, who is in the 80s. He has a heart that is functioning less than a quarter of what it needs to be. He was frequently admitted to the hospital, taking medicine was a chore because he felt hopeless about life. But when he felt the love and support of our volunteers, he decided to fight on. With proper medications and regular reviews, his health has improved. Today, even though he continues to be frail, he is energetic and cheerful.

Two, Uncle Ong. Uncle Ong is a single, retired construction worker in his late 70s. He has always been independent, never troubling others for help and he never joined our activities. He developed chronic conditions and did not take medicine regularly. He relied extensively on alternative medicine. One day, Uncle Ong injured his toes and it turned gangrene soon after. The gangrene spread upwards towards the shank and he had an amputation just below his knees. He was depressed and in great pain. Our volunteers prepared special meals for him which we brought to him daily.

Initially, Uncle Ong was uncomfortable to be "served" and "cared" for by several volunteers. But, over time, he accepted the services supported. And now, he complies with his medication and goes for reviews. He has learnt to come to terms with his disability. He even participates at social events now. His chronic conditions are also under control.

Now, given what we have seen, my volunteers and I are, of course, thrilled when we heard that under Healthier SG, MOH will set up many more eldercare centres that integrate community programmes with health. There are many more such seniors beyond our rental blocks – in our HDB estates, in our private estates.

And more importantly, I have seen first-hand how the various aspects of Healthier SG can come together – personal healthcare plans, social prescription, healthcare workers working hand-in-glove with our community partners and local volunteers. I have also seen our frail seniors, having received support and concern, take personal responsibility of their health. Healthier SG is, indeed, the decisive shift that our healthcare system needs.

But preventive health is better than curative health or rehabilitation. I believe the future of preventive health can be found in the science of longevity medicine which Minister Ong Ye Kung mentioned at the end of his opening speech.

Over the last few decades, researchers have made tremendous progress in understanding the science of ageing. There is now ample evidence on how affordable preventive interventions can slow down ageing and increase our health span, which is the proportion of our lives that we spend in good health. It is now clear that a person can be much healthier than what his age suggests, with the right lifestyle and clinical intervention. Lifestyle intervention can include things we already know very well, such as intermittent fasting or exercises.

But what is more interesting are clinical interventions – potential new supplements, existing drugs repositioned for healthy longevity and new drugs over time.

And it is more and more possible to measure one's biological age through a series of biomarker tests, so that we can see the progress or the regression of our health span more clearly so that we can take better responsibility for our own health.

Last month, I was delighted to attend and join in a panel at Singapore's first longevity research conference where Deputy Prime Minister Heng Swee Keat launched NUHS' Centre for Healthy Longevity.

Yes, I understand the science is still developing, but it will be wonderful if MOH can sketch out what our emerging plan is because healthy longevity can have a profound impact because Singapore can be the first country to systematically translate longevity research into practical intervention for all.

Brilliant plans, bold plans require brilliant execution. I would now like to make a few brief points about the implementation of Healthier SG.

Firstly, MOH must decisively break down the silos of information that exists today. I also concur with member Dr Tan Wu Meng that we must build a world- class healthcare IT system. Our family doctors must have access to quality medical history pulled from all different healthcare institutes. They need prompt and relevant information to create meaningful health plans that Singaporeans trust.

Secondly, our Government needs to do more to encourage all Singaporeans to exercise more and eat less sugar and salt. While we have done much, much more can be done. It would be helpful to hear concrete plans from MOH.

Thirdly, I hope that our healthcare leaders boldly invest resources and imagination in preventive health, even though our natural instincts are to spend the most to care for the sick. I certainly hope it is true for the National Healthcare Group, which serves Kebun Baru and which sees many seniors, perhaps even more than other regions.

However, I can understand why MOH wants to use population size as the basis for funding our healthcare clusters. The more time we spend debating on what is the precise level of funding, the more time we lose in pivoting towards preventive care. Because being roughly correct today, is better than being precisely correct after the ship has sailed.

But I do hope that MOH can keep close tabs to ensure that all regional health systems spend enough on preventive care. And that over time, MOH can refine the funding model to factor in differing age distribution, social economic status across different healthcare clusters. And that MOH can also help clusters scale up particularly innovative efforts.

Mr Deputy Speaker, to conclude, as a member of PAP Seniors Group, Healthier SG is a necessary reform, a bold reform of our healthcare system. It deserves our full support, even though there are many challenges ahead, even though it will take a decade for us to see real dividends.

My volunteers and I are also deeply committed to making Healthier SG work for Kebun Baru. We feel this way because we understand the possibilities. In fact, we have started creating our Kebun Baru local action plan for healthy longevity, that we hope to partner with NHG on. We will grow as many exercise and wellness groups as we can and build bridges between them and NHG. We will create a single service directory on how to care for our seniors and we will share it with all our local partners including family doctors. We will join Ang Mo Kio GRC’s efforts to set up a dedicated helpline to serve the seniors. We will improve our existing local efforts on dementia, palliative care, assisted living and we will build up support groups for stroke and cancer. We will reach out to the Centre for Healthy Longevity, so that our residents can benefit from longevity interventions as soon as possible. And lastly, we will power some of these local efforts with micro-jobs for our healthy seniors. With that, Mr Deputy Speaker I stand in full support of the White Paper.

Mr Deputy Speaker: Senior Minister of State Janil Puthucheary.

4.33 pm

The Senior Minister of State for Health (Dr Janil Puthucheary): Mr Deputy Speaker, Sir, the Healthier SG strategy focuses on GPs and residents, as we encourage them to develop closer, longstanding relationships to better enable preventive care. Family doctors, General Practitioners (GPs) will play an important role. MOH is supporting GPs to help them on board to Healthier SG. We have consulted GPs extensively about this and I thank them for their time and valuable feedback.

GPs are supportive of Healthier SG and agree with the focus on health, not illness. They have raised some concerns and suggestions on how this will be implemented. Several Members of this House have also raised similar concerns and provided suggestions.

GPs require support for their enhanced role. We have worked with primary care teams to develop 12 care protocols. These will provide clarity and consistent processes for the GPs and the clusters who will support them. The protocols are on providing screening and vaccination, and managing common chronic conditions like diabetes, hypertension and lipid disorders. This will be a multi-year effort and we will continue to develop more care protocols, such as for mental and dental health.

Mr Xie Yao Quan suggested we strengthen the integration between GPs and the healthcare clusters. Our clusters will work closely with the Primary Care Networks (PCNs) to do this, developing clinical programmes for shared care.

Ms Janet Ang and Mr Ang Wei Neng asked about the enrolment process. Enrolment is tagged to the clinic, to enable service delivery even when a specific doctor is away or unavailable. After enrolment, residents can still visit other clinics if needed. Residents can also choose to change their enrolled clinic. For example, if your doctor leaves the clinic to join another group, you have the option to switch and enrol with your doctor's new clinic. Others may prefer the convenience of staying with the same clinic in the same location. Ms Ang also asked if three generations could enroll to the same doctor as well. This is ideal. But for now, we have to consider the capacity of GPs for the enrolment process, especially early in the roll out of Healthier SG. And we will consider this approach that Ms Ang described as we open up to other age groups.

Ms Denise Phua and Mr Gerald Giam also asked about enrolment to polyclinics. They will assign enrolled patients to a regular care team, so that there is one team looking after the resident for continuity of care.

Ms Joan Pereira asked if enrolled patients can use branded drugs at their own cost. They can. However, the enhanced CHAS chronic drug subsidies will not apply. The enhanced subsidy tier applies to a targeted list of clinically effective and cost-effective chronic drugs, which will be reviewed regularly. For drugs outside of this list, the current CHAS subsidies will still apply. MOH will announce more details next year, including standard safeguards and reviews to guard against excessive purchases as raised by Mr Gan Thiam Poh.

GPs have questions about their remuneration, the design of the annual service fee, will they be penalised if patients refuse to adhere to their health plan and would some GPs be incentivised to cherry-pick patients. They are also concerned about the impact on their business when drug prices are made more comparable with those at the polyclinics. These points were also raised by Dr Lim Wee Kiak and Mr Gan Thiam Poh.

Let me first explain how the annual service fee will work. There will be a base rate that will differ for enrolled patients with and without chronic conditions. This is regardless of whether the enrollees, the residents, are compliant with the health plans. On top of this base rate, additional payouts will be provided upon the completion of critical care components recommended in the GPs' care protocols and the residents' Health Plan. For example, have patients with diabetes gone for their annual eye and foot screening?

So, at the start, doctors will be paid not on the basis of whether the blood pressure or the blood sugar levels have come down, but whether the patient has engaged with the interventions that will help bring down the blood pressure and the blood sugar levels – at the start.

GPs have shared that educating and encouraging Singaporeans to turn up for screening requires dedicated time and effort, and the design of the service fee addresses this and minimises the impact of cherry-picking. This new annual service fee is on top of the existing Government subsidies and the patient revenue that GPs already receive for services rendered.

GPs can also expect more revenue from these patients with the increased uptake of recommended preventive care services which will be fully subsidised. And more comparable drug prices will help patients, who may have otherwise visited polyclinics, to see their GPs instead. Taken together, all of these means that GPs will be fairly remunerated for the care that they deliver under Healthier SG.

Ms Denise Phua highlighted the plight of busy GPs. We hope this set of changes will also help them gradually evolve from a volume-driven model to one with more opportunities to connect with and empower their residents for health.

To Ms Hazel Poa and Mr Gerald Giam's comments on MediSave, we have limits on the use of MediSave to ensure Singaporeans have sufficient savings to meet their various healthcare needs throughout their lifetime. We will continue to review the adequacy of each Medisave limit. MOH also reviews the list of conditions on the Chronic Disease Management Programme (CDMP) regularly and has recently expanded the list to include three new conditions such as gout, allergic rhinitis and chronic hepatitis B, bringing the total to 23 conditions.

To Mr Xie Yao Quan and Ms He Ting Ru's questions on personnel and overseas Singaporeans who are healthcare workers, we are actively growing our pool of family physicians to meet our target of 3,500 by 2030. The annual intake for family medicine has been increasing and we will continue to review the training numbers. MOH has been working with the Family Medicine Training Advisory Committee and the College of Family Physicians Singapore on expanding the number of training places. We are also increasing exposure to family medicine in the undergraduate curriculum and have incorporated preventive care in all clinical modules.

We conduct regular recruitment and retention efforts to reach out to overseas Singaporean medical students studying in medical schools recognised by us. We provide them with details on applying for jobs in Singapore and offer them Pre-Employment Grants to help with their school fees, in return for being bonded to work in our public sector healthcare institutions. We also offer, as appropriate, housemanship training positions or more senior jobs. Our aim is to facilitate as many of them as possible to return home. Overall, about 200 overseas trained Singaporean doctors come back every year.

Mr Edward Chia asked about telehealth providers. Telehealth will be an important enabler. In line with this, we will also consider how remote providers, without standard in-person clinic facilities, can be included. We will share more on how GPs can leverage telemedicine to offer regular check-ins for their residents under Healthier SG in future.

Let me also address Mr Ang Wei Neng and Ms Denise Phua's queries about doctors on company panels. We need to ensure that as many GPs as possible who are on employer panels join Healthier SG. The Singapore National Employers Federation (SNEF) and NTUC, employers and union leaders agree that they will need to get more of their panel GPs to join the Healthier SG programme.

What does this mean for an employee? If most panel clinics are on Healthier SG, the employee can benefit from Healthier SG benefits and employer medical benefits when they enrol with a Healthier SG provider that is on their employer's panel. If and when they change employers or retire, they can stay with the same clinic and continue to enjoy the Healthier SG benefits. These Healthier SG benefits will build on top of the employer medical benefits.

Regardless of the coverage of the employer medical benefits, employees on Healthier SG will receive a free consultation on their health plan and will be encouraged to complete the free nationally recommended screening and vaccinations.

With effective preventive health, some employers may see savings in employer medical benefits. SNEF has been urged to plough back these savings into other health and wellness programmes to enhance the health of employees and SNEF is supportive.

Mr Ang Wei Neng asked about the family physician requirements and how it will impact solo clinics. The intent is for all participating clinics to have at least one family physician per clinic. There is a seven-year runway to achieve this. PCNs support clinics in their network to achieve the requirements for Healthier SG and AIC can also provide support to clinics. We will find ways to facilitate the participation of solo GPs in Healthier SG.

Dr Tan Wu Meng and Ms Joan Pereira raised concerns about the administrative burden of data submission and whether the IT systems would adequately support the work of GPs. Many GPs we engaged also highlighted the importance of IT and that the systems need to be improved. We will work closely with GPs and their IT vendors, this work has already started with GPs and their IT vendors, to support the enhancement of IT systems, to simplify administrative processes, improve data flows and sharing – all while ensuring data security.

The indicators that will need to be submitted for outcome tracking and remuneration have been streamlined, taking reference from existing clinical indicators that doctors would routinely document and track, in their own records, to deliver good care. We want GPs to use a Clinic Management System (CMS) that supports their daily operations well and connects to all the key public health IT systems. And this then, will save them time on administration so that they can focus on the patients. We are working closely with the commercial CMS vendors to improve their products and strengthen their backend services.

Some GPs today continue to use pen and paper services, we will provide them an interim web portal, for them or their staff to enter the essential information while they adopt a CMS and we have given them some time to do so.

We know that it is not easy for GPs to upgrade to an IT system that is Healthier SG compatible, and they will have one year from the launch of Healthier SG to adjust. We will also provide a one-off IT support grant to support this transition. MOH and AIC will continue to support GPs in this process. We want them to come on board Healthier SG.

Our plans will require a close collaboration among family doctors, the healthcare clusters and a wide range of service providers. However, the use of IT and record-sharing differs widely, hindering coordination and communication across partners today. Going forward, to deliver Healthier SG, we must transform how we communicate and share data for more holistic, integrated and coordinated care. Ms Mariam Jaafar and Dr Tan Yia Swam spoke about this.

One key tool will be the National Electronic Health Record (NEHR). NEHR will capture summaries of patient medical records in one platform. Those healthcare workers who need it to support the clinical care that they are delivering, such as family doctors, will be able to draw from, and contribute to, a common platform.

We have put in place controls to restrict the access to sensitive health information to selected user groups only. There are also additional authentication processes for the sensitive health information and we audit the access to this set of information. We will continue to implement safeguards to balance patients' need for privacy and to ensure that the correct healthcare providers are able to access critical information necessary to provide care to patients.

We will introduce new legislation, the Health Information Bill, in 2023. This Bill will facilitate the proper collection, use and sharing of health data among healthcare providers in a safe and secure manner. This includes our healthcare clusters who will serve our residents as regional health managers. Only authorised personnel will be allowed to access the data, which will be limited to what is necessary for their work. MOH will be seeking feedback on the Bill later this year and we look forward to hearing your views.

Ms Mariam also highlighted the importance of data analytics. Data-driven intervention is indeed our intent. We will continue to work with clusters and partners to share data and deploy such capabilities to help our residents. It is important therefore that we set up the NEHR, with the safeguards and obligations spelled out in the proposed Health Information Bill.

We are strengthening the IT platforms, the services and the connections across all the partners: family doctors and healthcare clusters. I thank the many IT teams, public and private, who are collaborating on this. It is with their help that we will improve the flow of data, impact health outcomes and optimise the user experience for residents and our healthcare providers.

I am glad that Mr Xie Yao Quan has also highlighted the importance of having sufficient IT and cybersecurity talent. While we have built up expertise, a key challenge remains to attract and retain skilled IT professionals in a competitive market. We will continue to remunerate competitively. We also hope that healthcare IT colleagues see the contribution they make and the fulfilling career they can have in transforming our system, caring for our society.

Ms Ng Ling Ling suggested that more comprehensive health screening is needed as we move towards preventive health and Mr Abdul Samad further suggested more MediSave utilisation for this. We take guidance from the recommendations of the Screening Test Review Committee. This guidance is based on scientific evidence to ensure that screening tests are safe, effective and suitable for population level screening, means it applies to everyone across the population. We need to strike a balance, to balance the practice good preventive care, but consider what the test involves, without going overboard. In some cases, some of the tests, some of the screening tools, are better applied to targeted population. It may be better for some cases to take a calculated, risk-based approach, to offer tests that are effective and easy to administer to high-risk groups. One example is what we are doing for those aged 50 and above, such as with the 2-day Faecal Immunochemical Test (FIT) which is for colorectal cancer.

So, there are some tests which the science suggests we should apply it to the entire population and there are some tests which the science suggests we should apply to targeted population. We will continue to review emerging scientific evidence on these screening tests as well as the effectiveness of our financing models. Fundamentally, access will not be denied to those who need it.

Ms Janet Ang asked about regular eye and dental screening. These are important, we must look after our teeth and have our eyes checked, and most of us do so. The screening processes and tools are less appropriate as a mass exercise for all under the population approach for Healthier SG and again, are more suitable as targeted effort for certain groups of Singaporeans.

Healthier SG is a multi-year effort, we will continue to review and include other necessary care protocols in future. Meanwhile, to reassure Members of the House, regular oral health and eye screening programmes are already easily and readily available as a routine service in many settings, and we will continue to offer these. For example, Project Silver Screen conducts check-ups for seniors at community locations for age-related decline in vision, oral health and hearing, so that they do not have to visit a clinic or hospital, and so that timely interventions can be provided. Likewise, we would like to assure Mr Dennis Tan that there are already similar preventive dental health programmes in place.

To Mr Abdul Samad's comment, there are nationally recommended health screening tests widely available at CHAS GP clinics, polyclinics and participating community providers. In future, Singaporeans should go to their enrolled clinic to enjoy free screening.

Finally, let me address mental health and well-being, a topic important to many we engaged during our public consultation. Several members such as Ms Tin Pei Ling, Ms He Ting Ru, Dr Wan Rizal, Mr Melvin Yong and Mr Dennis Tan have also raised this. Good health is also about good mental health. The current planned interventions under the first phase of Healthier SG will support mental well-being. People have asked when will we start to look at mental well-being? Yesterday – actually, years ago! The interventions we already planned under Healthier SG, starting with our initial emphasis on eating well and regular exercise, will have a positive effect on mental health. But allow me to also highlight what we have put in place over the last few years to promote mental health and well-being, even before Healthier SG.

To raise mental health awareness, we have developed MindSG, a trusted online resource portal that provides comprehensive and current information on mental health. To improve access to community mental health services, we developed Community Outreach Teams (CREST). We have the redeveloped Alexandra Hospital coming up, which will provide psychiatric services. The National Addictions Management Service at IMH will be extended to other hospitals, including Changi General Hospital and National University Hospital, to make the services more accessible.

We have been working closely with AIC and GP partners to have more GPs provide mental health support. As of March 2022, there were over 390 GP partners trained to care for persons with mental health conditions in the community.

We have convened the Interagency Taskforce on Mental Health & Well-being with members from over 30 organisations. The task force has reviewed our mental health needs and identified four focus areas. First, to strengthen services and family support for parents and youths. Second, to provide and improve access to quality and affordable mental health care by integrating health and social services. Third, to provide employment support for persons with mental health conditions. And four, to improve mental health literacy among the citizens and create an inclusive society for persons with mental health conditions.

We have completed our public consultation on the issue of Mental Health Strategy in August. Members of the public and key stakeholders have shared their feedback, and we are now refining the recommendations. The task force will share its findings soon.

Mr Deputy Speaker, Sir, a Healthier Singapore requires a whole-of- society approach. We need the support of all healthcare professionals, the healthcare clusters, community partners and many more. We need to, and will, put in place systemic enablers for this challenging set of reform to succeed. Ultimately all of us need to also play our part in taking some responsibility for own health and change our behaviours. By working together, we can improve health for all of us. [Applause.]

Mr Deputy Speaker: Deputy Leader.

Debate resumed.

Mr Deputy Speaker: Minister Ong Ye Kung. Mr Gerald Giam, I will take clarifications at the end of the Debate, please.

4.55 pm

The Minister for Health (Mr Ong Ye Kung): Thank you, the speech is slightly long. Mr Deputy Speaker, Sir, I thank the Members for all their questions and my MOH colleagues for answering the bulk of them. In closing, I will address the few remaining issues and then, I will then take a step back and share the broader perspective of the challenge that we are facing concerning healthcare.

Let me start with TCM, as raised by several Members and Leader of the Opposition, Mr Yip Hon Weng, Ms Hany Soh, Ms Joan Pereira. Maybe I will start with – we seem to have this mood here where we talk about who made what speeches in the past. Let me give my version. [Laughter.]

I came into MOH about a year and a half ago, what struck me was the tremendous amount of groundwork that was done by my predecessor in laying a preventive health infrastructure, the IT system, the three clusters and all the medical protocols. So, I walked into a workplan seminar. As the new Health Minister, I had to speak to the senior doctors and management. At the workplan seminar, it was very daunting. I discussed with three very learned persons, our three Director of Medical Services (DMS), Prof Kenneth Mak, Prof Benjamin Ong and Prof Tan Chorh Chuan. I had in-depth discussion with them, discussed what was the next phase of healthcare and I think we zoomed in on preventive care.

The good thing is, so much groundwork has been laid. On 23 May 2021, I think, I made my first speech in MOH. We talked about two topics. One was COVID-19 – Living with COVID-19 and second was preventive care, that was when Healthier SG, was first talked about. But really, thank you to the several Ministers before me and the whole team who laid so much groundwork.

Then then we had COVID-19 closures and all that. We did not have many events until December. I thank Mr Pritam Singh for reminding me. I got invited in December to an event by the TCM community and that is why I spoke to them, with the indication that if we focus on preventive care, I think it is an impetus that we can make a breakthrough and feature TCM in preventive care. And that was how the thinking first started.

And my last two speeches about TCM, I made quite a few TCM speeches, they are all in Chinese. The coverage has been uneven, so it is good that I have this opportunity now to explain it in English. The two speeches I last made was quite recent, Mr Patrick Tay was there, in one of the events in September last month. In summary, this was what I have been telling the TCM community and what we have been doing.

One, MOH has always recognised the tremendous value of TCM and the benefits they have brought to the community. I specifically always mention, during COVID-19 – and the Leader of the Opposition mentioned this as well – I personally wrote to our TCM clinicians to say: "Please advise your patients to take the vaccines." They were a great help and really helped us moved the needle in getting heartlanders to take the vaccine.

But, I also explained, we must recognise that Western medicines and TCM, they evolve very differently throughout history. They are two separate systems, complete systems with their own disciplines and their own know-how. They may intersect at some point, they may overlap, but you cannot make one to be like the other. It is not possible. They are two complete holistic systems.

Take for example, you ask a western doctor, "how do you balance the five elements of a human body to keep him healthy?" Most western doctors would profess they would not know. We have doctors in the House, I do not think you would profess that you know. If you ask a TCM doctor, "This patient need a life-saving, urgent operation, can you replace it with herbal medication?" They would say "No, go for the operation." Most TCM practitioners I know, would say that too. I think they respect each other's space, their strengths and their disciplines.

When it comes to regulation, there is a fundamental difference as well. Western medicine is a lot about research, clinical evidence, efficacy, safety. You get the data, then, the drug, the treatment can be approved. It is tightly regulated and by law.

TCM is passed down from generations, great-great-great-great grandfather took that and passed down to great-great-great grandfather. Culturally, traditionally, they trust that herbal medicine. And you ask for clinical evidence? They do not have. You want to go for MediSave? Today's rules mean it must be a medicine, it must be certified by HSA with clinical data. For TCM, that is hard to come by.

What TCM is very strong in is preventive care. More than 2,000 years ago there was already the saying: 养生三法：“饮食有节、起居有常、不妄作劳.” Very hard to translate, but let me try. Even the literal translation does not capture the full meaning. It means there are three key aspects to health: you eat not just in moderation, but 饮食有节 means you eat what your body requires, you go according to the seasons. 起居有常 means you have a healthy daily routine that follows the rhythm of the day, the month and the year probably, and not to over-exert your body, heart and mind.

So, in the area of preventive health, that is where I think Western medicine and TCM share a common understanding. You would notice in my opening speech, I have a symmetry, where I talk about preventive care and how the other side also has been emphasising on it. Both disciplines believe that early management of risk factors and disease can stave off problems and complications later on in life. Therefore, I believe, when we focus on preventive care under Healthier SG, we hope TCM can play a role.

While we work that out, in the mean time, we encourage TCM practitioners to continue to do what you are good at, advise the patients to take care of their health, pick up good habits, live healthily and take care of their health holistically.

But like I said in my Parliamentary reply, TCM is self-regulated, with varying standards of practice. So, over the last year, MOH and the TCM community have established two workgroups. They work on issues such as enhancing TCM clinical training and improving career development. And once completed, this can be a basis to explore how to involve TCM in support of Healthier SG. But I do not think, as one Member suggested, I do not think we should impose the regulation of Western medicine on TCM. I think self-regulation for something that is traditional and cultural, would be more appropriate. But we need to strengthen that self-regulation.

We have recently also finalised the succession plan of the Chairman of the TCM Board. This is MOH's partner in the TCM community. Mrs Yu-Foo Yee Shoon has been Chairman for I think at least three terms or more, a lot of contributions. The incoming Chairman will be Dr Teo Ho Pin, another familiar colleague of ours. He has taken up the Chairmanship with gusto. I have had several discussions with him. He understands the big shoes he has to fill, MOH's position and thinking, especially in the context of Healthier SG, and I think he understands his task as the TCM Board Chairman. Once we can feature TCM in Healthier SG, then the suggestions that the Leader of the Opposition has put forth, I think will be considered. And there will be a certain natural forward movement in our policy thinking.

I just have one last thing before I move to another topic. Mr Pritam Singh mentioned psyllium and fybogel. I think it is the same thing. It is not that one is Western medicine and one is TCM, one is funded and one is not – I am not wrong. There are doctors in the House, please correct me. I think it is the same thing. Psyllium is the seed for fibre supplements, fybogel is essentially psyllium with a brand, called Fybogel. Both are not medicine, both are dietary supplements, fibre supplements. But like all things sold in the polyclinic, including the gauze used to dress your wounds, they will all be subsidised, including supplements. But there are doctors in the House; so, please correct if I am wrong.

Let me move to the next topic, crowded GPs, raised by several Members. Dr Tan Wu Meng, Mr Yip Hon Weng, Mr Ang Wei Neng, all expressed concerns that if GPs become very popular, residents can get squeezed out by the huge demand. I tried to explain some of this in my opening speech that we will try our best to manage this. We will ask GPs to set a limit on number of residents they can enrol. How many will depend on the clinic and the doctor's own judgement, how many more can he take. So, it will differ from clinic to clinic.

We are also implementing enrolment in phases; we will prompt residents to enrol with their usual GPs, the dropdown list, your most frequented GP will be first; and we will encourage residents to enrol early and not wait.

I take comfort that we are discussing this because we are worried the demand will be overwhelming. It is in a way, a good problem. It is better than if the feedback comes back as, "We think nobody will enrol". That would be a bigger problem.

But if GPs are to over time accept enrolment from the entire population and help keep them healthy, they have got to shift out of some current load. And I am glad that a couple of Members have given a good suggestion. Mr Melvin Yong suggested for employers not to insist on workers producing medical certificates (MCs) whenever they are sick. Many common ailments like cough and cold can be managed with more rest, drinking more water and perhaps some off-the-shelf, over the counter medication, including TCM medication. Ironically, the disease where this is most practised now is COVID-19.

But if we insist we want to see a GP, we queue up and see the family doctor in order to get an MC – today, a lot of people practice that – but actually it is not the best use of the doctor’s precious time and resources.

Many employers already do not insist on MCs for COVID-19. Mr Melvin Yong mentioned that our healthcare clusters today accept up to three days of sick leave without the need to produce an MC; the Civil Service grants officers up to two days for mild conditions like cough and cold. I hope this can become a prevalent practice.

Let me talk about drug prices. Mr Gerald Giam asked a series of questions about our effort to substantively remove difference in drug prices, between GP clinics and polyclinics for residents enroled in Healthier SG. As I said in my opening speech, the basis of subsidy for polyclinics and for CHAS in GP clinics are different. The former, which is polyclinic, takes into account age. But for CHAS in GP clinics, a major factor for consideration is income.

So, we cannot remove the differences up to the last cent and for the higher-income households, the difference may well remain in dollars. But parity of drug prices is an important concern, told to us by many residents when we did our consultation. And we will try our best to make sure there is drug price parity, especially for the lower income.

Let me move on to the next subject which is delivering outcomes and KPIs. A number of Members talked about KPIs and outcomes and there was an exchange between Mr Gerald Giam and Ms Mariam Jaafar yesterday. Of course, we have to measure outcomes and set targets. That is why we listed short-, medium-, long-term KPIs in the White Paper. The work has just begun. Healthier SG is a dynamic multi-year transformation exercise. There will be twists, turns and uncertainties along the way. MOH is having extensive discussions with clinicians and other stakeholders to set out the technical definitions and our approach to data sharing and measuring these outcomes. And from there, we will establish the baselines of various indicators and then, determine what targets we want to achieve and by when.

While it is important to measure outcomes and targets, those who have run organisations before will know that this is not straightforward. I used to be involved in workers' training, so I interacted a lot with HR practitioners. And HR practitioners always lament – and this is not just for Singapore, it is the whole world. They always lament employees are over-managed but under led. The unions always say that.

Because if you are manager and you are in the middle of a big change management exercise, you will likely instinctively say, what are the targets, let us measure the targets, whatever gets measured, gets done. That is what the manager always says. Ms Hazel Poa went further to say, let us measure the targets achieved by the GPs. And if they do not achieve, clawback the service fee. But as Dr Tan Yia Swam cautioned, it is important for GPs and MOH to work together, for GPs to feel that they are integral part of this change. And I agree with Dr Tan.

Ms Mariam Jaafar, my colleague from Sembawang, and an experienced management consultant, immediately raised a red flag. I think she has seen enough organisational changes to notice the danger of blindly chasing KPIs and targets. Because I talked about what the manager would do.

But what will a leader do? A leader that is driving the change will have a different starting point. He or she, the starting point is, bring everyone on board, make sure everyone understands and buys into the mission in objective. Then, we jointly set KPIs and targets and then do our best to achieve them in the right spirit.

If we do not do that, then we are not leading. We are only managing. And if in our zeal to over-manage, we penalise people for not meeting targets in the middle of a big change, that is when people become cynical and they lose heart, and then you get perverse outcomes like what Dr Lim Wee Kiak said.

Imagine if we really say to the doctors, "If you do not meet your KPI, we will claw back your service fee". Then, it is very simple for the doctors. Number one, either I do not join Healthier SG; or two, I join, but I cherry-pick the healthy residents. So, the way we look at KPIs, always, you are able to differentiate the leaders from the managers.

Since we are on the topic of outcomes, I want to respond to Ms Mariam Jaafar. She is not here today, she has to fly off for work. But she had a very thoughtful and insightful explanation of value-based care and I think it is worth responding to her. She cited several good international practices. I want to assure the House that our hospitals have already been implementing value-based healthcare through many such initiatives too. We just did not feature them in the White Paper under Healthier SG.

There are many examples. One, all the community measures taken to help resuscitate out-of-hospital cardiac arrests by making defibrillators available in the community, training members of the public to perform CPR, alerting them through apps, that there is a cardiac arrest nearby. And so far, the survival rate of out-of-hospital cardiac arrest has improved by 10 times – 2% to 22% over the years.

Changi General Hospital has set up a post-acute myocardial infarction clinic to support patients in their post-heart surgery recovery. The idea is to review the patient's condition early within two weeks. This has resulted in a reduction of the 30-day re-admission rate from 14.3% to 9.6%. There are many such examples and I hope Ms Mariam Jaafar and the House will be comforted that our clinicians are always thinking of better ways to deliver better clinical outcomes.

Let me now comment about capitation. A few Members have raised the issue of capitation. I agree with Members on the benefits of capitation funding, but we are doing it step-by-step and carefully. I explained how we are doing it at the GP level during my opening speech by extending them a standard base fee per enrolled resident. So, it is loosely a capitation payment.

At the healthcare cluster level, we have changed the basis of calculating their budgets to be capitation-based. They still get the same budget, except that the basis of calculation has moved away from based on workload to capitation – the population that they are taking care of.

So, they receive fixed capitated budgets for residents of different age bands. For the very young, they have to do a lot more work, at a higher capitation rate. Young adults will have the lowest capitation rates and as you get older, as you need to pay more attention to their healthcare, capitation rate goes up again. So, age bands are a reasonable proxy for both workload as well as health risks.

Ms Sylvia Lim asked whether we can publish the rate. For now, I think it is better we keep this as internal parameters within MOH. In any case, the annual reports and financial statements of the clusters are available, if you get them from ACRA.

Clusters, in turn, will cascade down Healthier SG key performance indicators (KPIs) to all their institutions and partners. But they will not yet capitate the budgets of hospitals, polyclinics or community hospitals.

So, below the clusters, healthcare institutions will still be funded the same way for now. But capitation funding is a direction we want to move towards. It is a big change and we will have to study and plan each move carefully, making sure every institution, every partner is ready before we do so.

When it happens, it must be accompanied by a significant granting of autonomy so that healthcare institutions can make the right-siting decisions properly.

I will give Members an example. Let us take a palliative care hospice, for example. Today, we fund them through workload – same formula – but we can capitate their budget. So, a palliative care provider can receive a standard based fee for each palliative patient they take care of and then they decide which services are in the best interest of each patient, whether they should go to inpatient hospice care, home care or day care. They do not have to worry about separate funding for separate services under separate settings. That is where we have a lot of potential.

Let me now move on to the next important topic, which is manpower.

Several Members – Dr Tan Wu Meng, Dr Tan Yia Swam, Ms Mariam Jaafar, Mr Dennis Tan and Ms He Ting Ru – raised concerns about manpower and I appreciate that. It is a major challenge.

The key challenge is to have sufficient nurses, allied health professionals and support care staff to operate hospitals, clinics and also eldercare centres. These few groups number about 58,000 now and MOH estimates that this will need to grow to 82,000 in 2030 – 58,000 to 82,000 from now to 2030.

We will broaden training for our healthcare workers – nurses, allied health professionals and pharmacists – so that they can take on the crucial roles alongside doctors in preventive care. For example, nurses in the community will be trained in lifestyle coaching to empower residents to make good choices according to their care needs. Undergraduate allied health courses comprise specific modules on population health, health promotion and chronic disease management.

Mr Mark Chay suggested some useful training for doctors on physical fitness. I think we will follow up with discussions with him on how we can improve or broaden the range of courses that doctors can go to for their continuous training.

Our community pharmacists are now able to provide smoking cessation and weight management services and there are plans to train them in influenza vaccination.

But first, there must be enough people to train. There is, again, a certain narrative going around – some Members alluded to this narrative – that hospital staff are leaving because they are overworked, attrition rate is at a record high, people are avoiding the healthcare sector and that we must do campaigns, reduce workload and raise salaries to attract more people. That is the common narrative now going around.

There are some elements of truth in this narrative, such as there is, indeed, a manpower crunch and hospital staff have been working very hard, especially during the pandemic. But the rest is less than fully factual. They propagate some negative energy and may not help us tackle the actual problems.

Take the attractiveness of the healthcare sector. Are young people really avoiding the sector? Ten years ago, ITE, Polytechnics and Universities in Singapore took in about 1,500 nursing students a year. Now, this has gone up to 2,100 and we are trying to increase it further to 2,300 in the next couple of years. Our education institutions receive many more applications than there are places.

At this number, we are attracting 4% of the student cohort into nursing. If we maintain that number while cohort sizes shrink, the percentage will drift up to maybe 5% of each cohort. That means that for every 20 local students you see in a class, one will be trained to become a nurse and they are applying. So, healthcare has a very fair share of the local talent pool, considering there are so many sectors vying for local talent.

On attrition rate – is it really at a record high? If we look at local nurses, the normal annual attrition rate every year is about 6.4%, which is not high by any industry standard. In 2020, when the pandemic struck, it went down to 5.4% because many of our nurses who were planning to retire or resign, in the face of the pandemic, decided to stay and fight. In 2021, there was a slight rebound to 7.4%. In 2022, this year, so far, the numbers have reverted to that of normal years. There was no mass exodus of local nurses. These are the numbers. Nurses have remained dedicated and steadfast and bravely stood their ground in the face of the pandemic.

What has gone up is the attrition of foreign nurses – from about 8.9% in normal years to 14.8% in 2021. This is where there is record high attrition, at least, over past few years. We know the main reason, and Dr Tan Yia Swam talked about it, which is that the pandemic has increased the demand for nurses all over the world and our foreign nurses are being poached by other countries. They go to New Zealand, Australia, the UK, UAE.

So, if we want to tackle the manpower crunch in healthcare, the starting point is to hold on to our foreign nurses in the face of heightened international competition. Only then can we reduce the workload for all nurses, which many Members have called for. But we must be clear where our starting point is.

Remember, healthcare is one sector that is directly affected by our demographic changes. An expanding aged population needs more healthcare and more healthcare manpower. A shrinking young population limits the number of new local talents that we can bring into healthcare. Therefore, if we are honest with ourselves, we know the numbers simply will not add up if we just rely on local nurses or local manpower, no matter how hard we try to expand the local pipeline.

Therefore, if we want to take care of our seniors and the sick, if we want to reduce the workload of healthcare workers or at least make it more manageable, we must expect foreign healthcare workers to play a bigger role in the coming years. This is especially so in areas where there is a more severe manpower crunch, such as aged care or palliative care.

The great majority of our nursing workforce will still be locals but the number and role of foreign nurses will need to grow. MOH is, therefore, securing various pipelines of good foreign healthcare workers from different source countries to bring them here and further train and develop them. Some may leave us after a few years but we will try to keep the majority, especially those who have become an integral part of our care teams.

Dr Tan Yia Swam suggested granting the good performers PR and MOH is supportive of this. ICA always assesses PR applications holistically, including taking into account the economic and social contribution of the applicants. So, when it comes to evaluating applications from foreign healthcare workers, ICA will certainly consider the important contributions of healthcare workers and MOH's support for the applicants.

At this juncture, Mr Deputy Speaker, I would like to say a few words to our healthcare workers through you.

I believe the great majority of Singaporeans respect and appreciate our healthcare workers. We have seen the outpouring of public support in the recent past for the sacrifices made by frontliners as they steadfastly battled the COVID-19 pandemic.

However, many of our healthcare workers have also experienced abuse by patients and family members who lashed out at them because hospitals and clinics are high-stress environments.

I hope that our healthcare workers will look past a small minority that show disrespect and have faith that the great majority salute you, which includes everyone in MOH. I believe I speak for every one, every Member of this House, that we, too, respect them and their work, whether they are men or women, young or old, locals or foreigners. [Applause.]

Abuse against healthcare workers cannot and should not go unaddressed. We hope to raise public awareness on abusive behaviour that should be stopped and equip healthcare workers to better handle such situations.

Mr Deputy Speaker, Sir, ultimately, we need to squarely tackle the challenge before us, which is that our society is ageing fast.

It is a worldwide trend. By 2030, the old will outnumber the young in the world – the first time in recorded human history.

East Asia, in particular, is ageing faster than any other region in the world due to declining fertility and people living longer lives. Within East Asia, the countries ageing the fastest are Japan, South Korea and Singapore. We are called the "advanced agers".

Members have heard this statistic many times. By 2030, one in four Singaporeans or thereabouts will be 65 and above, up from one in six today. But it is not just a statistic. The number translates into real impact on our lives and we have yet to feel the full brunt of it.

For companies, you will face a shortage of workers, requiring you to move into automation, adopt less manpower-intensive business models while using foreign workers judiciously.

For schools, shrinking student intakes, which is why MOE has to merge schools and some of us find our alma maters gone.

Within communities, we have to make sure estates are now barrier-free. At traffic light junctions, the green man will have to appear longer because people take longer to cross the road. If you are a driver, you will have to slow down in the HDB estates and we already have silver zones.

For families, more and more couples will find that they have to take care of two sets of aged parents, in addition to their own children.

In the healthcare sector, we see rising disease burden and escalating demand for hospitals, clinics, doctors, nurses, budget and so on.

Most importantly, the seniors themselves, as they see more of them, they will be asking, "How do I live purposefully and healthily, with dignity, in my old age?"

Mr Henry Kwek, Ms Tin Pei Ling, Miss Cheng Li Hui and Ms Carrie Tan raised these concerns and, importantly, they warned us of the danger of isolation of seniors and the importance of social contacts for seniors.

Ageing is a major topic. Its impact spans across various sectors. Today, let me just address the implications on healthcare.

Our basic premise must be this – ageing may be an inexorable trend but a rapid escalation of disease burden and suffering need not be a given. We can manage this, provided we stay healthy.

Many of us, myself included, are guilty of being caught in the old mould where life stages are determined by age – five years old, go preschool; 12 years old, take PSLE; 20-plus, graduate; by then, roughly, you should find a boyfriend or girlfriend and apply for BTO; late 20s, get married; 50s, beware of onset of chronic illness; 60-plus, retire; beyond 80, you may start to become frail.

The age markers remain relevant and can continue to guide us in understanding life stages, key events and risks throughout our lives. But we need not be strait-jacketed by them, especially when it comes to health and ageing. For example, there is no reason why 50s has to be the onset of chronic illnesses. We can stay healthy and not have chronic illnesses in our 50s.

There is no reason why once you cross 65, you go into the wrong side of the dependency ratio. There is also no reason that why being in our 80s must be associated with frailty. We can delay it as long as you can, well into your 80s or 90s.

Policy planners will continue to monitor the statistics based on age, but as individuals, we can choose to differ from these widely accepted assumptions. And the Government can make policy changes and reform our systems to help individuals achieve that. To do so, we need to recognise now that the healthcare system is not one system, but three interconnected systems, working together to deliver good outcomes.

The first system is the acute care system. This is what typically comes to mind when we think of the healthcare system. It comprises hospitals, specialist clinics, emergency departments – the places that treat us and cure us when we are very sick. We are expanding this system, building more acute and community hospitals in the coming years.

The second system, less known, is the public health system. One important part of the public health system is the control of infectious diseases. And we can see these systems springing to rigorous action during the pandemic. The other important part of the public health system is the one that improves the health of our population. This comprises the policies and processes for preventive care, including the network of family doctors, their long-lasting relationships with residents, the practice of regular health screening, the culture of good lifestyle habits, all of which keep a people healthy. This is the system that we are now building and strengthening through Healthier SG.

We have seen how the two systems complement each other during COVID-19. The public health system strengthened the surveillance of the virus, got people to adopt good hygiene habits, received vaccinations, stayed home if unwell. The acute care system took care of those who got infected and experienced more severe symptoms. But still, the two systems are not enough. In an ageing society like ours, the third system is equally critical and that is the aged care system.

This is the support system for the large segment of people who are advancing in age. And this system is not only about nursing homes. The nursing homes, they serve an important purpose, which is to care for seniors who are very frail and unable to live independently, whose families cannot support them. But nursing homes are not and cannot be the mainstream solution to ageing. We are building nursing homes very quickly, from 16,200 beds now, to 31,000 beds in 2030. I am sure we need them as our population ages, but the projected pace of expansion is worrying.

In our Asian culture, we value caring for our seniors at home. Our seniors also prefer to age in a familiar environment and we should not lose this. As a society, we must guard against the assumption that seniors will always become sick and frail, and unable to take care of themselves. This is quite a risky mindset because it will exacerbate our challenge. Because over time, society will, perhaps unintentionally, push more older people to become isolated – which many Members have warned us of.

Our instincts backfire from time to time. We would have come across such stories. Let us say, a senior went marketing in a wet market and then he fell. The family may, to protect him, tell him, "Do not go out anymore, we will hire a domestic helper to watch after you." Or a senior cooks forgot to switch off the stove, and fortunately, it was discovered early. The family may tell her, "Do not cook anymore, we order in for you, every meal." We might do all these out of concern for our loved ones, but in so doing, we deprive them of physical activity, a sense of agency, a sense of dignity.

We want to protect them, but we unintentionally expose them to an even greater risk of isolation and loneliness. That is when the spirit wears out, the body gives way. If that mindset becomes entrenched, then over time, seniors become a problem to be contained, put aside in nursing homes – out-of-sight, out-of-mind. It is like a room in your house, where you put all your problems and you do not want to see. One day, that room will burst.

We must support as many seniors as possible to continue to live in the community, independently or with some help, contributing to the best of their ability, able to choose their own activities, having a full social life with friends and family.

I visited Block 115 that Mr Henry Kwek talked about. It is not run on a big budget, a lot of passionate volunteers, we all know who got involved, but it is doing such heavy lifting and making such a huge difference to the seniors living in that block. I came across this piece of research, which estimated that the health impact of loneliness for a senior is equivalent to smoking 15 cigarettes a day.

We estimate that today, 97% of our seniors above 65 can either live independently or with some help in the community. We must maintain or improve that share and not inadvertently give them the equivalent of 15 cigarettes a day, and weaken their health and ability to live independently.

For the large majority of seniors, what they need most is social care, more than healthcare. The way to deliver that is to enable ageing in communities. We will need a range of solutions to anchor ageing in communities. These include building more Community Care Apartments that Second Minister Masagos Zulkifli talked about, on releasing land for private assisted-living facilities. But the greatest asset for managing ageing is actually right before us – and that is our HDB estates. Most estates already have ample shared spaces for interaction and activities, you got your void deck, your coffeeshop, your supermarket, your RC centre, our Eldercare Centre, your community clubs. We did not specifically build them as infrastructure to support ageing, but they are extremely valuable in our ageing society.

And that is why MOH is rapidly expanding our network of Eldercare Centres to activate these existing spaces and create more shared spaces and social networks for seniors. We are working closely with AIC to provide training opportunities for our centres to take on an expanded role under Healthier SG.

As a social worker told me, a very effective initiative is to simply bring the seniors to that shared space to cook and enjoy a meal together and once they eat together, they socialise, they start doing different kinds of activities together. There is no risk of forgetting to switch off your stove and we will definitely improve the way the Eldercare Centres work.

As suggested by Ms Janet Ang, for those who are in their last lap of their health journey, we are expanding palliative care, especially at home, to allow our loved ones to pass on as comfortably and with as much dignity as possible. This is the wish of most seniors and we should try our best to fulfil it. Ageing in communities will be the next major area of change and reform in healthcare that we need to work on.

When all three systems – acute care system, public health system, aged care system – work together synergistically, healthcare happens everywhere and not just in medical facilities.

So, I thank Dr Tan Wu Meng for sharing the story of Ah Ma, and pointing out that the healthcare subsidy should not be tied to services being delivered in brick-and-mortar facilities. This will naturally have to be reviewed as we shift our paradigm.

Mr Deputy Speaker, Sir, let me conclude. Some countries may place a stronger emphasis on just one of the three systems or organise them in a way that they end up working in silo. For example, Japan, as a super-ageing society, has a great focus on aged and institutional care. The US acute care system is state-driven, but public health is driven at the federal level.

In Singapore, we take an integrated approach. Acute care, public health, aged care, all come under MOH. The Minister for Health, is also the Minister in-charge of ageing issues and chairs a multi-Ministry task force going beyond healthcare.

And this is an important advantage for us. MOH is in a position to develop a cogent and comprehensive plan, muster resources to transform and fire up all three systems, to deliver health outcomes for our people. Healthier SG is a key effort to activate and reform the public health system, empower individuals to choose health and lay the foundation for the aged care system I spoke about.

We need all stakeholders – doctors, community partners, healthcare clusters, employers, residents – to join us in this effort, to shape a healthier Singapore. We do this for ourselves, we do this for each other.

All societies, at some point, will have to confront population ageing. It is an urgent and stern test, and some societies end up with bankrupted healthcare systems or let healthcare cripple their society and economy. We are determined to overcome this test. We have the resources, ability, organisation and determination to do this.

I seek the support of this House and of the people of Singapore to endorse this Healthier SG effort as the basis to transform our healthcare system, so as to strive towards the vision of long and healthy lives for Singaporeans. [Applause.]

Mr Deputy Speaker: We have had a healthy debate over two days. Members deserve a chance to seek clarifications. This will also allow MOH's officeholders to further explain MOH's priorities. In the interest of time, Members are invited to ask short clarifications, please. Dr Tan Wu Meng.

5.42 pm

Dr Tan Wu Meng (Jurong): Mr Deputy Speaker, I thank the Minister for Health for his support and statement, supporting our healthcare workers across Singapore, who continue keeping Singapore patients safe and looked after, even as the COVID-19 pandemic winds down and the BAU load continues apace.

I also want to thank Minister for recognising the challenge that my Clementi resident, Ah Ma, went through, the family had asked me to tell her story and I am glad that the difficulties she and her family went through, have been recognised and will be looked at by MOH.

I have a clarification to ask about how we support residents and patients who are in the frail stage of their health. These are residents who may have a number of medical conditions, who are not quite so ill that they may need to be admitted or have to go to a care home, but not quite in the pink of health. And they often have many medical conditions, with many, many follow-ups.

In a Parliamentary Question earlier this year that I asked, and which I raised in Committee of Supply, there are Singaporeans today who may have 20 or even 30 outpatient visits in a single year, each of these visits poses challenges for the caregivers, especially caregivers who may be daily rated and cannot get time-off from their employer.

As part of Healthier SG and strengthening coordination of care, can the Ministry also help look at ways to reduce the number of visits, by giving care providers, doctors and healthcare workers additional time and bandwidth, to help further coordinate and streamline the care for such patients who face frailty and many medical issues?

5.45 pm

Mr Ong Ye Kung: Thank you. We will try our best to streamline the procedures, but without belaboring what I have just said in my closing speech, frailty, we may see it as a permanent condition but they can improve.

And if you ask Mr Henry Kwek, in his Block 115, people have improved. They saw seniors who could not walk, you create that common space in that block. First step, make sure they stick to their medication; take their medication; gradually, they improve; then, give them better food, social connections with nutrition and confidence interacting with people; they actually become better, even though they are in their 80s. I think Mr Henry Kwek can tell more of that story. But we see it. It can happen.

We see in Kampung Wellness that Ms Carrie Tan spoke about. A different shape but similar effort. So, without belabouring the point, I think there is a lot of potential we can do for the current generation of aged, ageing in community's social care, including healthcare, can improve their health and push back frailty as long as possible. For the younger group, Healthier SG – postpone frailty as long as we can, make sure our healthy life is as long as our biological life.

Mr Deputy Speaker: Mr Pritam Singh.

Mr Pritam Singh: Thank you, Mr Deputy Speaker. Just a minor point to clarify the query the Minister raised about the particular product I was referring to, psyllium husk. I think Minister will understand why I had some trouble when I identify the name it is marketed under because the box says, Telephone Brand (Sat-Isabgol) Psyllium Husk. And so this product is produced in Gujarat, that means, as the Minister said, substantively the same product as Fybogel. And Fybogel, as we know, is commonly prescribed especially after invasive surgical procedures where individuals may suffer from constipation.

The point I was making really is in parallel with the point the Minister made about the intersection between Western medicine and alternative medicine. And if we can extract savings from that intersection, I think this will be consistent with watching the fiscal umbers on healthcare going forward.

Mr Deputy Speaker: Ms Ng Ling Ling.

Ms Ng Ling Ling (Ang Mo Kio): Thank you, Deputy Speaker. I want to thank all the officeholders for Health for the very, very helpful responses to all the speeches that had been made. And you will see that the members in the Government Parliamentary Committee (GPC) for Health, we have all spoken up because it is a really important initiative for the population health of Singapore.

I have one clarification for the Minister for Health. I would like to ask, of the $1 billion start-up funds that the Minister mentioned and potentially, $400 million recurrent funds, to support this whole initiative, how will it be broadly, allocated to the stakeholders in this whole ecosystem that need to make this work, especially for the GPs that we know have to do a lot of the heavy lifting, as well as the residents who have to feel the incentive to take ownership of their health?

Mr Ong Ye Kung: I do not have the numbers with me but of the $1 billion, slightly over $1 billion, there is a chunk for the central IT system, there is a chunk to upgrade the capabilities and IT capabilities of GPs, there is a chunk to upgrade or build up capabilities within the clusters in order to be regional health managers, there is a chunk to do a one-time ramp up of social activities. We are also thinking during enrolment, there could be some incentives – so, there is another chunk there. So, they all add up to over $1 billion .

But what the Member did not ask is also, in terms of recurrent, I did mention recurrent expenses of about $400 million a year. That recurrent amount, about half will go to GPs as their service fee, the capitated service fee, for looking after enrolled patients, and another half will be the additional subsidies for residents, including healthpoints, health screening and so on, which will be free. So, it is about 50-50 for recurrent.

Mr Deputy Speaker: Dr Tan Yia Swam.

Dr Tan Yia Swam (Nominated Member): Thank you for the opportunity. Mr Deputy Speaker and the House, I would like to thank Minister Ong for acknowledging the contributions of healthcare workers, especially in the past two years.

Three big points. One is that my own term here as a Nominated Member of Parliament is limited and will come to an end pretty much soon. I hope that all of you will continue to engage with healthcare workers on the ground, not just doctors to reflect our view. Doctors have always felt that we cannot be a union and sometimes, we are marginalised. As it is, there are 15,000 doctors in Singapore. There are even more nurses around and someone needs to help represent healthcare workers as we forge forward for Healthier SG.

Final point. Oh no. I am so nervous that I have lost my train of thought. I will email Minister Ong separately about my final point.

Mr Deputy Speaker: But you have the opportunity to ask it if you can think of it in the next five minutes.

Dr Tan Yia Swam: I remember now.

Mr Deputy Speaker: Okay, go ahead.

Dr Tan Yia Swam: I am so sorry. About the KPIs, one big thing is that, as MOH and various committees talk about KPIs, please remember to involve doctors in the conversation and not be chasing economics – which is more economically viable. Let doctors advise you on what we think are feasible, medical and clinical KPIs.

Mr Ong Ye Kung: On the second issue, that is natural. For MOH, we always err on the side of over-consulting especially our medical experts.

On representing healthcare workers in the Chamber, I think we have NTUC here and they will always champion workers and especially nurses and healthcare workers. We had Ms K Thanaletchimi as Nominated Member of Parliament before. But even we do not have a healthcare worker as a Nominated Member of Parliament, be rest assured NTUC is there and the Minister for Health will be here too.

Mr Deputy Speaker: Mr Gerald Giam.

Mr Gerald Giam Yean Song (Aljunied): I thank the Minister and Senior Minister of State for responding to my proposals and questions. I would like to seek clarifications from both of them.

First, for the Minister, I would like to clarify that KPIs and targets are not synonymous. The White Paper already lists many good KPIs. I am just asking MOH to take the next step to set targets for each KPI so that all stakeholders can work together towards achieving those targets. The best practice in performance management is actually to jointly set KPIs and targets with stakeholders – including doctors of course – and then review them regularly and make adjustments if the conditions change. So, they are not set in stone. But I also do not think that we should start out such a major initiative without any target set.

Secondly, for the Senior Minister of State, can I clarify with the Senior Minister of State that under the Healthier SG initiative, residents can choose to enrol with polyclinics instead of with GP clinics?

And lastly, the Healthier SG White Paper said that MOH will waive the requirement for residents to co-pay part of their bills in cash. Can I clarify that patients will be able to use MediSave to make that co-payment? And will that still be subject to the annual withdrawal limit? Because if this is so, then patients will more likely hit their annual withdrawal limit and thereafter, have to co-pay in cash. So, even if MOH cannot remove the annual withdrawal limit now, can it consider increasing it to, let us say $1,000 a year?

Mr Ong Ye Kung: I will take the first question and then Senior Minister of State Janil will take the next two. I thank the Member for the clarification about KPIs and targets. I think we are now essentially on the same page.

Dr Janil Puthucheary: I thank Mr Gerald Giam for his questions. Yes, they can enrol with polyclinics and we will continue to review the issue of the annual withdrawal limits.

Mr Deputy Speaker: I see last two hands. We will have Ms Hazel Poa and then, we will conclude with Mr Liang Eng Hwa.

Ms Hazel Poa (Non-Constituency Member): Thank you, Deputy Speaker, I just want to make sure that I understood the Minister correctly. When he said that there will be no KPIs for family doctors and no clawback, because that would mean that essentially, if I recall correctly, the amount of money that will be paying in service fee is $400 million a year. Does that mean that we will be paying this $400 million a year, with no accountability?

Mr Ong Ye Kung: Ms Hazel Poa asked a question but she is actually making a statement. She is saying that Healthier SG, $400 million to spend, as I just answered, $400 million is, first, to subsidise residents for health screening, health points and all that. The other half is a service fee to GPs to help us take care of population. And I think she just made a statement to say this is not a good spend of money and if you want it to be spent well, give KPIs and targets to the GPs, and if they do not meet, claw back the fees.

This is not what we should do.

In a major effort like this, we want to bring in the GPs to be part of this. Of course, there will be KPIs with targets and we collectively work together to achieve it. At the GP level, they will have certain targets as well. But I do not think we want to treat them like vendors and contractors where if you missed out on a certain KPI, we claw back the fee. They care about the health of the population as much as we do, maybe more than Members in the Chamber.

Treat them as part of the team, together in the right spirit, we will look at how well we are doing together by reviewing the targets and adjust along the way to achieve good health for Singaporean. A billion-dollar set-up, $400 million, if we can keep the population healthy, is money well-spent, even though the Member may think otherwise.

Mr Deputy Speaker: Mr Liang Eng Hwa.

Mr Liang Eng Hwa (Bukit Panjang): Thank you, Mr Deputy Speaker. Sir, I am really happy that the Minister mentioned about the Elderly Centres, and the plan to build more in the community. I agree fully there is a real need for that.

But the problem is, like in many of the estates, like my constituency Bukit Panjang, we are running out of void deck spaces to build such centres. And we need to reserve some of these void deck spaces for other activities like funeral wakes and so on which is also a reality of ageing.

So, can I ask the Minister whether would MOH be open to allowing standalone centres, those outside the void decks, which understandably will cost more to build? But there are some spaces that can actually allow such facility to be built. And specifically, my question is whether MOH will fund this this facility that is outside the void deck centres which may cost a bit more but, because of the space constraint, we have to do that.

Mr Ong Ye Kung: It sounds like a specific Bukit Panjang issue which we can discuss. We always do not say no right at the outset. Let us look at the circumstances. But the larger point is this. We also tend to look at the problem and then we want to solve the problem and the first thing is, we need real estate.

As I mentioned earlier, if we want to enable ageing in communities, look at what assets is already right in front of us. And visiting Block 115 in Ang Mo Kio is a bit sobering but it is so inspiring too. They are using their void deck spaces. They took back four units or HDB helped take back four units on the second floor. And in that four units, there is a medical centre, there is a therapy centre, there is a place for them to have activities. And so, you create the space. Look around our communities, HDB estates are brilliantly built with lots of shared places. We just need to activate them.

So, while we will look at the Member's proposal, let us not close our minds to also the assets that is already right in front of us.

Question put, and agreed to.

Resolved,

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.