Committee of Supply – Head O (Ministry of Health)

Strengthening our Healthcare System

Dr Chia Shi-Lu (Tanjong Pagar): Mr Chairman, Sir, I beg to move, "That the total sum to be allocated for Head O of the Estimates be reduced by $100."

Sir, I would like to declare my interests, both as a medical doctor practising in a restructured hospital, as well as the Advisor to a facility providing day care for seniors and people with disabilities.

It is a well-known aphorism that a chain is only as strong as its weakest link and, by the same token, a healthcare system is only as strong as its least amenable portions.

The past few years have been marked by a remarkable remaking of the foundations of our medical system: the Pioneer Generation Package, MediShield Life, a rejuvenated and expanded CHAS programme, increased flexibility of Medisave usage and increased subsidies across the board for all manner of medical services.

In fact, many of the concerns that were raised in a White Paper drafted by the Government Parliamentary Committee for Health some years ago and, indeed, raised by many Members of this House, both past and present, have been addressed, to varying degrees, by these bold initiatives.

But it may surprise many that most of these measures benefit the outliers rather than the majority, as those who are manifestly sick represent the tip of the disease iceberg, the apex of the healthcare pyramid. A truly comprehensive and robust healthcare system must look beyond treating the sick and look beyond medical treatment alone.

First, we have to focus on preventing disease and reducing the disease burden. I have previously remarked that the key to a healthy society is that, in the long run, it depends less on how well you treat sick people, but more on how you keep people from falling sick.

Managing the healthy is probably one of the biggest challenges facing healthcare workers. How does one go about convincing people to continue making the right lifestyle choices, day after day, over one's lifetime? The lure of just that one more cigarette, that extra helping of char kway teow, that one extra can of soda, that extra piece of cake, is often just too difficult to resist. Similarly, making the decision to eat more fruits and vegetables, to exercise more, always seems just that one day away.

Two worrying reports have recently surfaced: the first is that obesity rates in Singapore are rising and, in particular, amongst our children; the second, unsurprisingly given the first report, is that Singapore has the second highest prevalence of diabetes amongst developed nations. This is certainly not something which Singapore would like to be on the leader board! The WHO has also reported that, globally, there is a frightening rise in the incidence of diabetes.

Last year, during the Budget Debate, I remarked that much can be done to nudge Singaporeans to take greater ownership of their health. Anti-tobacco measures should be stepped up even further and, while some may argue that unhealthy behaviours should be penalised, by the same token, healthy choices can be incentivised. I will speak later on how we can encourage healthy eating through fiscal levers. Foods that are available in schools, for instance, could be more closely regulated to help stem the menace of childhood obesity.

Singaporeans who participate regularly in approved wellness programmes or can demonstrate that they adhere to a healthy lifestyle with regular exercise, for instance, could receive tax rebates or pay discounted rates at public healthcare institutions.

Similarly, patients with chronic diseases who adhere to their treatment programmes and clinical pathways could receive extra credit for their medical expenses.

I would like to ask what else the Ministry can do to promote good health and prevent disease in our society. Can the Ministry provide an update on the Healthy Living Masterplan? What is being done for young Singaporeans to cultivate healthy living habits? For the elderly, I am heartened by the announcement of the setting up of Community Health Networks for Seniors and I hope the Ministry can shed more light on this initiative.

I am a strong believer in the one-patient-one-family doctor concept, as the formation of a strong patient-doctor bond provides a singularly effective and efficient way to good health for life. The Ministry has enunciated this principle in years past and I would like to hear from the Ministry what progress has been made on this front.

I also appreciate the various health screening programmes that have been implemented over the years, with many at little or no cost to the individual. For instance, community health screening activities are held regularly in my constituency of Queenstown, as they are all over Singapore, but concerns have been raised on how we can ensure that screen-positive patients do follow up on their follow-ups. Has the Ministry been looking at ways in which the transition from community health screening to follow-up in clinics can be made more seamless and accessible?

Second, a strong healthcare system also needs to look after those who have undergone treatment but continue to have residual incapacity. In a rapidly ageing society like ours, we need to bolster measures to ensure that our seniors remain healthy and active and are able to age gracefully and to do so in the community where they have lived most of their lives.

Medical care in Singapore is among the best in the world but, often, even with the best and most dedicated treatments, patients are left with residual disabilities. What is broken can sometimes not be made whole and the sick cannot always be made well again. For seniors, the ravages of age alone can lead to increasing dependence.

I welcome the moves made by the Ministry to expand the capacity and capability of our Intermediate and Long-term Care (ILTC) sector under the Healthcare Masterplan and am encouraged by the principles that have been embodied in the Action Plan for Successful Ageing.

I would also like to ask the Ministry if they are looking at new models of assisted living in the community, apart from the more traditional avenues like nursing homes and day care centres. The reason I ask this is both from personal experience and also from interactions with my residents and patients. It is, sometimes, a difficult choice to make. Some loved ones may need extra help in their daily activities, but to consign them to a nursing home may take away too much of their liberty and many scientific and medical articles have shown that such restriction of liberties may actually do more harm for the individual than good. I would also like to ask how we can better support community caregivers.

Last year, it was announced that we were working on a home and community care plan, to facilitate ageing-in-place. How does the Ministry intend to ensure that our seniors receive holistic and seamless care? Are there plans to utilise technology for care delivery? If this is not feasible, can we assist patients with disabilities, seniors and their caregivers with transport arrangements or subsidies from their homes to the various healthcare institutions?

7.45 pm

My ward of Queenstown is already what would be classified as a super-aged community, the definition of which is that over one in five residents are over 65 years of age. A significant number live alone, or with a partner or spouse who is dependent on them. A recent article in The Straits Times noted that there were 41,200 households made up of residents aged 65 or older who live alone and that this number was expected to rise to 83,000 by 2030.

In Queenstown, for example, we have several initiatives to meet this challenge. We have a home monitoring trial; we have a community guardian network; we also have things like a charitable free funeral service for those who pass on alone without kin. Can I ask if the Ministry has plans to manage this demographic challenge?

My final concern lies in a slightly sensitive topic, but one which we should discuss as a community. Despite being ranked as one of the healthiest countries in the world and one of the best places to be born in, Singapore was only ranked 12th in the Quality of Death Index released by the Economist Intelligence Unit last year. This is a wake-up call that we should pay greater attention to improving end-of-life care. What plans does the Ministry have to improve palliative services and end-of-life care for Singaporeans?

I would like to conclude on a cautionary fiscal note since this is after all a Budget debate. Just as this year's Budget has been expansionary in the service of economic transformation, our healthcare policies have likewise been inclusive and expansionary over the past decade to meet changing and increasing healthcare demands.

But even as we increase national spending on healthcare, we should be mindful that the spending should be prudent and sustainable and that the relationship between healthcare spending and health outcomes is not always linear, as many countries have found to their detriment. I am concerned about the strain on the public purse and whether future generations can sustain such spending.

I would like to renew my call that the Government continue to rigorously assess new policies and new treatments for value based on clear outcomes. What else is the Ministry doing to ensure sustainability of our healthcare system as we hit from SG51 towards SG100? I beg to move.

Question proposed.

Waiting Time in Polyclinics

Mr Leon Perera (Non-Constituency Member): Mr Chairman, in business where the target is surpassed by a wide margin, sometimes, it is due to good performance; sometimes, it is due to good fortune; and sometimes, it is due to the target being set too low.

In the 2016 Budget Book, the KPI for polyclinic waiting time was set at a maximum of 100 minutes. By this standard, over 95% of cases consistently met the KPI for the last few years. I urge MOH to review this performance indicator. One hundred minutes or 1 hour and 40 minutes is not an acceptable time for our patients to wait, especially the elderly. I suggest that we change this time to 45 minutes to provide a more meaningful KPI for good performance.

MOH publishes the median and 95th percentile waiting times for polyclinics. In February 2016, total waiting time for registration plus consultation was roughly half an hour for the median, which is not bad, but closer to a shocking two hours for the 95th percentile. It was 2 hours and 16 minutes for the 95th percentile at Bedok Polyclinic, for example.

This points to what is probably the huge difference in waiting time between those who make appointments and those who walk-in. I suggest that waiting times be published separately for those who had made appointments and those who walked-in.

I am aware that Internet phone and mobile apps are available for making polyclinic appointments. However, in SMU's recent customer satisfaction survey, satisfaction with polyclinic waiting times fell in 2015. What is the reason for this? Is there more we can do to cut waiting times for those elderly Singaporeans who tend to walk-in? I suggest we explore several options.

Firstly, can we provide real-time data for the expected waiting time, not just on the Internet but also by on automated phone, as well as on digital signboards outside the polyclinic? I believe this is done at some polyclinics but not all. Secondly, can we deploy staff fluent in different Singaporean languages to engage walk-in patients and convince them to try to use their phones or other means to set appointments in future?

Waiting Time for Specialist Consultation

Mr Low Thia Khiang (Aljunied): Sir, normal waiting time for appointments and medical investigations at Specialist Outpatient Clinics (SOCs) for subsidised patients has been a long-standing problem.

I asked about this during the COS debate three years ago and was assured by the Minister that MOH adopts a multi-pronged approach to address the queue at our SOCs. However, three years have passed and the situation does not seem to have improved. I have received feedback from a patient who needed to wait for six months to see a lung specialist and another three months for the biopsy result.

During this long wait, a patient's condition could deteriorate and he could develop complications which will be harder and more expensive to treat. Can the Minister share, from the time an appointment is made to the consultation with the specialist, what are the average range, median and 95th percentile waiting times for consultation at SOCs for subsidised patients? After the consultation, what are the average range, median and 95th percentile waiting times for the conduct of investigations and tests like MRI or CT scans and for elective surgery? How do these numbers compare with three years ago? Has there been any improvement?

Moving forward, to help benchmark SOCs' performance, will MOH publish SOCs' appointment waiting times regularly on its website for the median and 95th percentile, like it does for waiting times for admission to wards and registration and consultation at polyclinics?

The long waiting times seem to affect subsidised patients much more than unsubsidised patients. Are these long waiting times the way SOCs regulate subsidised patients' demands for their services or are they due to insufficient resources being made available to meet subsidised patients' demands?

The Chairman: Mr Sitoh Yih Pin, not here. Mr Dennis Tan

Patient Downgrade from Private Care

Mr Dennis Tan Lip Fong (Non-Constituency Member): Thank you, Mr Chairperson. I understand that, currently, there are two ways for patients to upgrade their outpatient status from private tertiary care to being patients in public care at SOCs at the restructured hospitals. The first is by being referred to a medical social worker who will do a financial assessment for the patient. Second is for patients to get a referral letter from the doctor at the hospital which they are instructed to take to the polyclinic. This letter will provide that the polyclinic should refer the patient back to the hospital.

The first method may not be suitable for patients who do not need a financial assessment from a medical social worker to justify a downgrade. For the second method, the patient needs to see the doctor at an SOC first to get a referral letter to the polyclinic. The patient then sees another doctor at the polyclinic. At the polyclinic, such patients have to wait in the same line as other patients, who are genuinely sick, to see the doctor. The polyclinic doctor then directs patients to the referral counter for a letter referring them back to the same hospital. The polyclinic doctor may charge the consultation even though the patient did not actually require a medical examination for the referral.

What is the basis for requiring two consecutive referral letters from doctors both at the SOC and at the polyclinic? Does the polyclinic doctor really have to do any medical consultations since he will know from the specialist's referral letter the purpose for the visit?

From my description of the typical scenario, it would seem that much time is wasted on the part of the patients by way of waiting and transport and on the part of the polyclinic doctors having to attend to what seems essentially an administrative task. The whole process becomes unnecessarily inefficient and bureaucratic.

It also involves unnecessary expenses on the part of the patients. One would have thought that their request to transfer from private to public care can be dealt with adequately by an administrative staff at the hospital. At most, perhaps the patient only needs the attention of the doctor at the SOC who can even handle this outside his clinic hours as an administrative task done without requiring the presence of the patient. The doctor can always ask to see the patient if he has some questions for the patient.

I have described the details of the process to try and highlight inefficiency and the endless bureaucratic process. Will MOH consider allowing patients to downgrade from private to public tertiary care to avoid having to seek a medical social worker to recommend the downgrade, or to skip the step of obtaining a polyclinic referral if patients are willing to go to the back of the queue and having their appointments pushed back to the end of the doctor's appointment schedule?

The process could be done in a hospital itself. This would help to relieve some of the workload on the polyclinics and the medical social workers and reduce unnecessary waiting and travelling times for patients. It will also reduce queues at hospitals as well as the polyclinics. It will be a win-win situation for patients, doctors, hospitals and polyclinics.

The Chairman: Minister Gan Kim Yong, would you want to report on progress?