Committee of Supply – Head O (Ministry of Health)

Health and Care: A Change Agenda

Dr Tan Wu Meng (Jurong): Mr Chairman, I beg to move, "That the total sum to be allocated for Head O of the Estimates be reduced by $100." I declare that I am a medical doctor in a public hospital.

In the Budget debate, I spoke on "stress tests" for Singapore. COVID-19 is testing us today. But we also need to prepare our healthcare system for tomorrow, test our plans for the future before the future tests us.

I will speak on three areas today: better care for an ageing population, amidst better care coordination, better access to treatments and better support for our healthcare workers and frontliners.

Sir, today Singapore is ageing – more chronic diseases; patients with multiple medical conditions.

I asked a Written Question in Parliament early this year: how many Specialist Outpatient Clinic (SOC) visits a patient might have in a single year in our public hospitals? Here are MOH's figures from 2019, before COVID-19.

Over 7,000 patients each had 24 or more clinic visits a year. That is 7,000 patients averaging two or more clinic visits a month. Over 2,000 patients each with 36 or more clinic visits a year. That is 2,000 patients, each averaging three or more clinic visits a month.

Each visit means travelling to and fro. If you are less mobile, it might mean having to take a taxi. If you are still working, it might mean time away from work. For caregivers, time commitment, too, and not every employer is supportive. And for some low-income, daily-rated workers, each clinic visit means loss of income.

I have met Clementi residents, worried about this. But they also see how busy our healthcare workers are across Singapore. And yet, without enough time, space, opportunity to fully coordinate the care, it is hard to reduce and simplify the number of visits and appointments and journeys across multiple medical teams when a patient has multiple medical conditions.

Let me speak on the value of care coordination. I raised this back in 2009 in the Singapore Medical Association Newsletter – the SMA News.

Sir, in Cabinet, there are Coordinating Ministers. It recognises that coordination is important, adds value in and of itself beyond a single specialisation, beyond a single Ministry. Likewise, there is a role for the coordinating physician, someone who has walked with you for years, knows the ins and outs of your medical journey throughout your journey as well. And when the situation is complex, someone that can be a bridge between different specialists, different medical teams, not taking the place of individual experts, but bringing that holistic view, working with you, for you, for your health and your care.

Sir, in some cases the coordinating physician might be a doctor who has known the patient for years – a specialist, a family physician or general practitioner (GP).

But ultimately, it is a role that requires deep knowledge of the patient, deep understanding of the patient, a certain breadth of medical experience and, most importantly, depth of wisdom. It is high-value work, it takes time, it takes effort and it should be appropriately recognised and supported throughout the healthcare system.

Sir, COVID-19 has been very, very hard on our hospitals. And it would have been even harder without the help and support of our family physicians and our GPs in the community, on the community frontlines, supporting patients, helping patients recover in the community, to help reduce the brunt of the COVID-19 wave at our acute hospitals. I know some family physicians, including in Clementi, some are themselves not young and faced significant personal risk in looking patients in the early days the pandemic especially, before there were vaccinations against COVID-19.

Some have also asked about support, closer collaboration with our hospitals, in peacetime and in crisis. Can it be easier for family doctors to link up with the hospital team, to keep updated on the mutual patient's condition, or even to mobilise the resources of a hospital cluster, working with family doctors to help support patients in the community?

We need to keep our healthcare system fit for purpose, amidst Singapore's ageing population. And this means we need to find ways to support and empower our family physicians and GPs better, help healthcare clusters and family doctors connect to work together more closely, make it easier for information to flow and be shared to build that understanding of how best to care for a patient – so that care can be better coordinated even amidst an ageing population and patients with more complex medical conditions.

Sir, let me speak on the healing power of therapeutic time because empowering healthcare workers also means understanding the work, how much time it takes to deliver quality care.

Sir, imagine sitting down with a friend, encouraging them to stop smoking; listening to their story – how they started, the challenges they face; persuading that person to change their lifestyle. It takes time.

Quitting smoking, lifestyle changes, challenging conversations in a health crisis. These are not just KPIs or targets or policy. It takes time.

Each healthcare worker has but 24 hours a day. Yet, our time is one of the most precious gifts we can give to a patient. And decision makers and planners need to get even better at understanding how much time it takes to deliver quality care – whether face-to-face in clinic; on the telephone or through video-conference, including after hours; connecting with different patient care stakeholders, different medical teams; coordinating, improving a patient's journey.

Because it is only when decision-makers deeply understand what is needed, that planning and policy can be implemented in a way that does the most good. It is like flying an airplane. Even the best pilot needs to know what is the air speed, what is the altitude, how much fuel in the tank.

Sir, let me speak about technology and IT. In 2019, the last year before COVID-19, from public available figures, there were 14 million consultations across the public healthcare sector.

Today, there are computers everywhere in healthcare but we know that the computer systems can be improved, made easier to use.

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Imagine: if healthcare workers spent just one minute less waiting in front of a computer, waiting for a computer app to load, working with a mouse, data entry, or grappling with technology. That alone, Mr Speaker, would mean 14 million minutes saved in the healthcare system; a quarter-million hours, 10,000 work days, or 27 years of someone working 24 hours a day – that is how much time could be saved.

Those 14 million minutes could have helped our healthcare workers connect better with patients. Building a care relationship to help someone stop smoking, or forging that trust through a healthcare journey, that trust which is needed in a mental health situation or when there is a life-changing diagnosis, a health crisis.

It matters in a pandemic too. Every minute matters when there are many, many people sick, needing urgent care. So, work spaces, IT user interface – not a small matter. We must give it the same attention and focus on policy and implementation that the big firms, like Apple and Google do.

We have seen that GovTech can develop best-in-class user interface: simple, elegant, gets the job done. Parking.sg – a small app but it shows we do have these capabilities. Should we also have a higher ambition, designing and building our own homegrown national IT healthcare platform, best-in-class, competitive or better than what is available internationally? As easy to use as an Apple or Google app, built by Singaporeans, for Singaporeans? And if we build something that good, we know that we can sell it to the world as well.

Sir, on access to treatments, we know that by improving access to subsidies and MediSave, we help patients and doctors manage chronic illnesses upstream before they grow into a bigger healthcare crisis. Can CHAS and Outpatient MediSave be streamlined further, access improved?

On Integrated Shield Plans (IP Plans). In September 2020, I had spoken about this, how individual patients, individual consumers do not have the bargaining power to take on an insurer, even when there are asymmetric terms and conditions. How the invisible hand of the market can become unbalanced and sometimes, you need the visible hand of the regulator to put things right on an even playing field.

Some Clementi residents have asked: "Why are IP insurers’ panels of doctors so different from one company to another?" In May last year, the Singapore Medical Association (SMA) News reported that one IP insurer for their panel of breast surgeons only had male surgeons, which meant a female patient, if needing a female breast surgeon in the private sector would have to co-pay more. But surely if a doctor is fit and proper for Company A, presumably they are fit and proper as well for Company B? Unless the different insurers have made these decisions due to business considerations, rather than clinical performance – in which case, the insurers should be upfront and transparent with patients.

I call upon MOH to continue looking at this to see how we can make the journey better for patients who have invested many years of their CPF, MediSave savings or personal funds in IP Plans.

On better medication prices, I also asked how we can ensure affordable access to new treatments, like cell-based therapies? Whether we can have cheaper, equally effective medications competing in the Singapore market amidst our Free Trade Agreements and intellectual property regulations. Can MOH provide an update?

Sir, I want to speak on supporting our healthcare workers who have held the healthcare system together amidst the pandemic. More than two years, working guts out – day in, day out.

On our nurses and our allied health sisters and brothers, I previously called upon MOH to look at paying our nurses more. Last year, then Finance Minister Heng Swee Keat announced improvements, but there is still room to look further at raising the remuneration of our nurses and our allied health workers because what our nurses and allied health sisters and brothers do is essential work, deep skills, physical, mental, emotional labour, reducing the burden of suffering for patients and patients' families.

It is important work. And so, I call upon this Government to do a deep review – see what more can be done, because how we budget, how we formulate manpower policy, it is not just a question of market forces. It speaks to the values we have, what we hold dear and to the direction and message we want to send for our society.

Sir, I want to speak for our outsourced healthcare workers. In Parliamentary Questions and in last year's Budget debate, I asked about outsourced healthcare workers serving on COVID-19 frontlines, in our COVID-19 wards, same patient care area, same risk, facing the same virus.

Can MOH provide an update on what is being done to better support our outsourced sisters and brothers in healthcare? Because every worker matters, including outsourced workers, because in a pandemic, the virus does not ask to read your contract terms and conditions before deciding whether to infect you. We need to continue looking at this and continue improving.

I also want to speak up for our young doctors who do long hours, long shifts on call. This can mean working a full day, sometimes starting at 6.00 am, sometimes earlier, working the whole night and working for a significant part of the next day.

Today's patients are more sick, more complex than when I was a houseman many years ago. There is also a much heavier load of electronic records, electronic messages, administrative loads as well for our young junior doctors.

So, we need again, Mr Speaker, to seek truth from facts. We know in America, their house officers, their interns are more likely to have a motor vehicle accident at the end of a long shift.

In 2007, 15 years ago, in SMA News, I asked whether we should do more research into how the performance of healthcare workers is shaped by long shifts and sleep deprivation. Are hospital near-misses more likely to happen towards the end of the shift? Does a night shift system change the pattern of near-misses? The aviation industry, militaries around the world have studied the impact of sleep deprivation for many years. We can learn from this and see how we can improve safety and patient care in Singapore.

I also want to speak up for healthcare workers who are caregivers at home, nurses who, after a long shift looking after very ill patients, return home and have to care for a parent who is ill with dementia, a parent who is herself or himself needing care. Young doctors who worry if becoming a mother will have implications for their traineeship journey.

We must keep on looking at how to make our healthcare workplaces more family-friendly, because that is how we build more inclusive workplace for healthcare workers across a diversity of backgrounds, a diversity of personal journeys.

Sir, as I said during the debate on the President's Address, healthcare is about our people's lives – your life and mine. The lives of our loved ones, the life of every Singaporean. We owe it to our fellow Singaporeans to keep our healthcare system fit for purpose, not just for today, but for tomorrow.

Question proposed.

Ageing and Chronic Disease Management

Ms Ng Ling Ling (Ang Mo Kio): Mr Chairman, first I would like to declare my role as a consultant in healthcare transformation. Sir, when a person falls ill and needs to see a doctor, primary care is often the first line of care in the community that they think of. It is an important line of defence and primary care family physicians play a very critical role in caring for patients for non-emergency needs, preventing acute hospital episodes where possible, especially seen during this COVID-19 pandemic period.

Many developed countries around the world attempt to provide proactive primary health services instead of reactive care where a person will only visit a doctor when they are sick. This can improve population health in general. In the United Kingdom, more than 99% of residents are enrolled with their General Practitioners (GPs) who will provide health screening and follow-up care within six months of their enrolment. This practice shifts the focus from treatment of acute and chronic diseases to disease prevention and early management.

With our chronic disease prevalence continuing to rise with our rapidly ageing population, this form of comprehensive primary care delivery may be beneficial for our population for several reasons. Firstly, when a person is enrolled to a GP, it allows both the doctor and patient to establish a long-term care relationship together. Furthermore, early screening and diagnosis can also help in better management of chronic diseases, rendering it more cost-effective in the long term by avoiding complications and reducing needs for hospitalised care.

A point to note is that to anchor health delivery in the primary care and activating more GPs to engage in preventive and chronic disease management, GPs will have to assume more responsibility for the long-term health and well-being of their patients that they are serving. This is likely to have additional workload for GPs as they would now have to monitor and provide follow-up care for more.

This is especially important to note, as we know that many GPs have already stretched themselves to support the fight against the COVID-19 pandemic. As such, I would like to ask if MOH will consider providing more resources and incentives to encourage GPs to step up in preventive and chronic disease management to enhance healthcare for our ageing population?

Primary Care

Mr Yip Hon Weng (Yio Chu Kang): Mr Chairman, primary care is the first line of defence in the healthcare system. General Practitioners (GPs) are critical to the care landscape. Not only can they help to alleviate pressure on the public healthcare system, as they have demonstrated during the pandemic, they are also important for chronic disease management, especially for our seniors.

One of the main roles of GPs is to identify the need for specialist care and to refer patients accordingly. But holistic healthcare for seniors goes beyond physical health. I wish to ask on the progress of the enrolment of GPs in the primary care network.

For holistic care, GPs should also connect patients to social service agencies for social interventions. For instance, if they need to exercise or to take part in interest groups. How does the Ministry intend to activate the GPs in these areas? How can we better connect the GPs to the various social services in the community?

In countries like Sweden and Norway, each family is assigned to a GP of their choice. This is ideal for health management, because a good doctor-patient relationship plays a significant role in fostering trust in patients to accept healthcare advice and to adopt good healthcare practices. In Singapore, some patients have the tendency to doctor-hop. A possible reason could be that different GPs have different rest days and opening hours. Do we intend to introduce a similar model of gatekeeping to specialist care as in the Nordic countries, or do we intend for this relationship to be primarily for chronic disease management?

Lastly, I would like to take this opportunity to express my appreciation to our GPs for stepping up during the pandemic.

Preventive Healthcare

Mr Ang Wei Neng (West Coast): Chairman, it was Benjamin Franklin who said: "An ounce of prevention is worth a pound of cure". He said it nearly 300 years ago, but it still holds true today. Mr Ong Ye Kung during his recent event has already predicted that healthcare expenditure in Singapore will triple in the coming decade to almost $60 billion by 2030.

Chairman, I fully agree with the Minister that preventive healthcare is critical. In the last two years, about 5% of the MOH non-COVID-19-related budget was spent on preventive healthcare efforts, including the $330 million to fund the work of the Health Promotion Board (HPB). Spending 5% of the healthcare budget on preventive healthcare is quite respectable, as compared to 2.9% in US and 5.9% in Canada.

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Currently, one of the main incentive of encouraging Singaporeans to maintain a healthy lifestyle is to give vouchers. For example, the scheme to give up to $380 worth of e-vouchers when one uses the LumiHealth app for the Apple Watch to achieve healthy lifestyle goals. In the private sector, at least one insurance company allows healthy members to enjoy insurance benefits, like additional coverage or premium discounts.

We should up our game. If you want to prevent the steep escalation of healthcare costs by three times over the next 10 years, we need to go upstream to persuade Singaporeans to live a healthy lifestyle so as to maximise their chances of having more years of healthy living and quality living in their twilight years.

Beyond e-vouchers, I suggest we could incentivise Singaporeans to exercise regularly, eat healthily and take the appropriate vaccines by giving discounts on the CareShield Life Insurance premium, that means, giving a discount to the premium that we all have to pay. And give a discount to the medical cost during visits to polyclinics and public hospitals for treatment as well as for medical check-ups. The discount given can be tiered according to the level of achievement based on clear KPIs. This may mean that we have to increase the budget for preventive healthcare because of all these discounts and incentives given. But such investments are worthy, especially if we can significantly reduce the pace of increase of medical cost over the next decade.

Next, we need to limit the intake of sugar and salt. In 2016, MOH declared a war against sugar and set up a new task force, chaired by then Minister Gan Kim Yong. Could MOH provide an update on the result of the war against sugar? Does MOH have a similar plan to wage a war against salt as well?

In summary, I concur with the need to encourage healthy living. In particular, we need to allocate more resources to preventive healthcare and the efforts to keep our Singaporeans healthy very significantly, at least in the next few years. Thereafter, we can adjust the investment into preventive healthcare. This will slow the overall healthcare cost.

Dr Lim Wee Kiak (Sembawang): Sir, I will take both cuts together?

The Chairman: Yes, please.

Preventive Health

Dr Lim Wee Kiak: Chairman, I declare my interest as a practising eye doctor in the private sector.

The adage "Prevention is better than cure" still holds true and is even more relevant today as we face rapidly increasing healthcare costs. Many of us take health for granted and only start to regret when we lose it. Those who own a car will know the importance of preventive maintenance for their beloved cars but how many of these drivers actually do preventive health for themselves?

Preventive healthcare is certainly a hard sell. It is especially challenging when someone feels, “Why do I need to spend the money or the time, or worry about my health when I am feeling alright?” Little do they appreciate and, often, until it is too late, that preventive healthcare means catching potential problems before they become real big problems. Many do not realise that it is more cost effective to do regular preventive health checks than to seek help when a problem arises.

What is the response to MOH’s various health screening programmes and campaigns in the past five years? In what areas of preventive health is MOH going to focus on? What is the longer-term plan for preventive health for a healthier Singaporean population? What can be done to encourage and promote preventive health in our community? Has any study been done to understand the reasons why people generally avoid preventive healthcare? Can Government put more subsidies into preventive health to make it more accessible and affordable to all Singaporeans?

Currently, there are insurance companies who incentivised their insured to practise good and safe driving habits using various apps and offering discounts to the premiums for renewal and also offer e-vouchers for the insured to adopt healthy lifestyle. Can MOH consider more similar incentives to Singaporeans to encourage them to embrace preventive health? Perhaps Government can offer a discount to our MediShield and CareShield premiums as incentives for those who adopt regular health screening and healthy lifestyle.

Healthcare Affordability and Financing

We all have heard the saying on the ground that "one can die but cannot afford to be sick". Healthcare costs and affordability is a real concern for many as our population ages rapidly. The Government has swiftly addressed some of these concerns over the years by introducing various medical subsidy schemes, including Pioneer Generation, Merdeka Generation health benefits, CHAS cards for middle and lower-income groups to cushion the impact of rising healthcare costs. But are these enough?

Healthcare expenditure has tripled to $11.3 billion in 2019, from $3.7 billion in 2010, over a 10-year period. And with the current spending in this sector, excluding COVID-19 related expenditure, it is expected to rise and hit $27 billion by 2030, which means that in another decade, it will triple again. These are very sobering figures. What is the Government doing to slow down the rise of healthcare expenses?

What are the main drivers of rapidly rising healthcare costs in Singapore? In this Budget, one of the reasons given by the Government for the GST hike is to fund the expected increase in healthcare due to the ageing population. How will the Government use the increase in revenue collected through the GST hike to improve healthcare delivery to our ageing population? What can Singaporeans expect to see in our healthcare infrastructures and services in a decade from now?

When we discuss healthcare financing, our famous 3Ms healthcare financing framework comes to mind – our current MediSave, MediSheid and MediFund. Are they working well? When was the last time we refined, or changed or augmented our current framework? Will we see an increase in our MediSave contribution rates, an increase in MediSave limit and an increase in our MediShield premiums as healthcare costs increase?

To help Singaporeans cope with healthcare costs, especially those with chronic illnesses, can the Government raise the MediSave limit we can use for both inpatient as well as outpatient for these diseases? Can the MediSave limit be relaxed for those who are older, especially for those who have significant savings in their CPF MediSave account? They always lament that "I have money in my MediSave account, why do I need to use my hard-earned cash to pay for my medical bills, as I stretch my dollar? So, with that, I hope the Government can continue to work towards a healthier Singapore.

Healthcare Workforce Transformation

Ms Mariam Jaafar (Sembawang): Chairman, our healthcare workforce needs to transform to accelerate the implementation of the "3 Beyonds" strategy.

First, putting in place the organisation enablers to support the shifts in the "3 Beyonds" – how to manage the workforce across the public and private healthcare system in the new healthcare delivery model and increase their productivity.

Doctors, GPs, nurses, pharmacists and more in the community will play new roles and need to be empowered with new skills, capabilities, evidence‐based practices and tools, as we move beyond hospital to the community.

As we move beyond quality to value, behavioural shifts are needed across the system, from the hospital CEO to frontliners.

As we shift beyond healthcare to health, new skills will be needed, such as in data analytics and behavioural economics.

Across the board, new ways of working – much more multi-disciplinary, much more agile, will be needed. This means putting in place the right organisational structures, achieving clarity of roles and responsibilities, aligning funding models, KPIs and incentives, and bringing in and building the right talent. Can the Minister share what the Government is doing to facilitate this transformation?

Second, the work of healthcare worker needs to be re-imagined digitally as we move to increasingly digital integrated care. New digital roles will be needed in data analytics and AI, in robotics and they will need to be brought in from outside. But importantly, all healthcare workers, will need to embrace digital skills and adopt a digital mindset, seeing digital as an enabler rather than a threat. What forms of digital reskilling and upskilling programmes are being developed to help our healthcare professionals pivot to the digital future of healthcare?

Third, addressing the shortage of nurses. Nurses are the bedrock of our healthcare workforce. At around 7.5 nurses to 1,000 population, our nurse to population ratio is lower than the OECD average of nine. The burden of the pandemic has without a doubt, been felt most keenly by our tired nurses. With an ageing population, increasing life expectancy and increasing incidence of chronic diseases, the demand for nurses can only continue in intensity and nursing care required will also increase. As we shift beyond hospital care to community care, nurses will be needed not only in hospitals but also in the community.

I echo the hon Member Dr Tan Wu Meng's point that more needs to be done to raise the standing of the nursing profession and further review of remuneration. Those are calls for rationality and pragmatism in addressing the foreign nurses who complement our pool. The shortage of nurses is a global one. The UK has launched the Health and Care Worker Visa that allows settlement in the UK after five years and applicants can be joined by dependent partners and children. Are we similarly considering something like this? What more is the Government doing to attract, train and retain nurses?

Fourth, increasing diversity in the healthcare system. There is a need to broaden the definition of a healthcare worker, where someone who has good interpersonal skills and motivational skills, and with technology, can play a key role in population health. There is also scope to increase diversity in leadership, including in cluster leadership, to better reflect the population we serve and the skills and backgrounds required in the new healthcare model. Can the Minister share what is being done to recruit, nurture and deploy people from different backgrounds, especially in leadership roles?

The Chairman: Can you please wrap up?

Ms Mariam Jaafar: Chairman, it has been several years since we embarked on the "3 Beyonds" strategy. But I have a lot of hope that we are now ready to make some bold calls to really unlock it and move forward. There is an urgent need to transform to keep our healthcare costs in check. Our healthcare workforce must be ready.

The Chairman: Ms Sylvia Lim. Not here. Mr Leong Mun Wai.

Vaccination-differentiated Measures

Mr Leong Mun Wai (Non-Constituency Member): Chairman, since the end of last year, many countries around the world have removed most, if not, all of the COVID-19-differentiation measures. With the infection cases and deaths from COVID-19 still at a high level, we are not against postponing the easing of the slew of COVID-19 measures announced by Minister Ong Ye Kung on 16 February. However, we hope the Minister will not forget what he said at that virtual media conference, that these rules, meaning the COVID-19 rules, accumulated over the past two years have become quite unwieldy.

Indeed, we need to review and streamline many of these rules and the most unwieldy of these must surely be the vaccination-differentiated safe management measures (VDS) introduced incrementally from July 2021, when we switched to the living with COVD-19 strategy. This has brought significant misery to a number of Singaporeans who have valid personal reasons not to vaccinate.

Unfortunately, up till today, many of these VDS are still enforced, never mind that other rules have been relaxed with the arrival of the dominant but less virulent Omicron strain.

The vaccines reduce the severity of COVID-19 infection, but they have generally fallen short in their touted efficacy. Vaccination was not the universal panacea we imagined and had little impact in reducing both infection rate and a spread of the virus, especially with the current Omicron variant.

As we move forward towards normalcy in 2022, we urge the Government to relax all its discrimination policies based on vaccination status. The relevance and justification for VDS have dwindled and I believe the general public does not view this as being favourable or fair.

Singaporeans who are unvaccinated are genuinely concerned about their health and each has valid concerns about the vaccine. Their movements continue to be restrained and some had to give up their right to employment due to such restrictions. Now, parents too, have to contend with stress over vaccinations for their children. And there is a growing number of vaccinated Singaporeans agonising over the issue of booster shots.

The latest vaccine safety update by HSA on 23 February reported 10 cases of children, aged five to 11, with serious side effects following vaccination and 280 cases of non-serious side effects. This is of particular concern and warrants closer scrutiny. One case of severe reaction compromising a child's health, going forward, is one case too many, given the fact that children are largely spared from any adverse health challenges from COVID-19 infection.

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It is time for the Government to show its magnanimity to this small group of unvaccinated people by relaxing the VDS and not continue to punish them for making rational personal choices. They are not troublemakers as the Government seems to make them out to be.

With the continuous surge in Omicron infections despite having all the VDS in place indicates that the VDS are not critical in the fight against the virus anymore. Hence, VDS should be relaxed immediately. Instead, the Government should focus its resources on approving more therapeutics for GPs to treat patients, to deal with the surge and infections.

We are especially concerned about the senior citizens. In the last two years, we have established that age is the most important determinant in risk factors leading to death. Hence, management of the senior COVID-19 patient can be more targeted. Should approved therapeutics like Molnupiravir or Paxlovid not be made available to senior patients through the GPs, even before they turn seriously ill and need hospitalisation?

We see hope in Omicron being a game changer. Let us review and refine our measures in our fight against COVID-19 and emerge as a people that is more compassionate and united than ever.

Legislation of Medical Middlemen

Dr Tan Yia Swam (Nominated Member): Mr Chairman, I declare pecuniary interest as a breast surgeon in private practice and as the elected president of Singapore Medical Association (SMA).

Last year, I spoke on the difficulties faced by patients in the fair utilisation of their Integrated Shield Plans. I am glad that the Multilateral Healthcare Insurance Committee (MHIC), of which I am a member, has made some progress in this area over the past year. Today, I would like to share my views on the limitations of Employee Benefit (EB) plans, also commonly known as corporate insurance, or company insurance; the influence of Third Party Administrators (TPAs) and concierge services. These last two arose out of an apparent need to provide a gap in services and, like any other businesses, they charge. But how do they charge, who do they charge and who regulates them?

To give the background, healthcare economics is incredibly complex, with seven Shield Plan providers, multiple types of insurance products, numerous insurance companies offering EB plans, private hospitals, day surgery centres, close to 2,000 private specialists, 3,000 GPs, multiple radiology centres and labs and all with different business models.

TPAs and concierges are, perhaps, the natural result of market needs and forces. For any company offering health benefits, the administration needed to manage employees’ healthcare claims may be deemed too tedious or not cost-effective to be done in-house by their Human Resources team. Therefore, TPAs are engaged.

In the most idealistic form, concierge groups help patients to find doctors suitable for their conditions. Some patients would go by friends' or families’ recommendations, some ask their GPs, some would check their Shield Plan panel list, some would google and do their own research – but some, some would use concierge services. This is where things get tricky. I do not have any access to contracts and only a few colleagues have told me in confidence about how these work. Such services may be marketed as free for patients, but doctors have to pay a referral fee, which may be a percentage of their usual professional fees. In addition, it is said that doctors on such contracts are asked to restrict referrals to other doctors on such concierge contracts, thereby restricting patient choice, which is against the concept of patient autonomy.

I know that the SMC Ethical Code and Ethical Guidelines (ECEG) has clearly stated that fee-splitting is wrong, but the ECEG applies only to doctors. The onus is on us to be aware of the fees and not to fall foul of our ethical code. But are the contracts transparent? Do we understand market forces? Some say that one simple solution is for doctors to refuse to sign any TPA or concierge agreements. But it may not be possible for a doctor to refuse to sign on any of these, depending on the location and model of their practice.

A robust private sector complements the restructured services. The unity of the various healthcare sectors in rising up to the unprecedented challenge of COVID-19 is a matter of public record. The private primary care sector has answered the call of MOH, in the Public Health Preparedness Clinics and Swab and Send Home clinics.

As awkward as it is to talk about money, fair reimbursement is necessary for a sustainable business model. As president of SMA, I have received feedback on what sounds like grossly unfair reimbursements by TPAs. Several have claimed consultation fees may be as low as $6, but they are bound by NDAs, so I do not have more information. Most TPAs often have limits or caps on medications and some GPs have taken the loss on themselves if they want to provide an adequate course of medications for the patient, for example, the duration of antibiotics. This may result in a compromise of good patient care when doctors are not adequately reimbursed.

Payments may be delayed for as long as six months, causing cash flow problems for a small practice. The ongoing Fullerton case reported in The Business Times in January this year left some doctors wondering if they will ever receive their fair pay. GP clinics meet 80% of the primary care demand. They are our first line of care for the community. GP clinics are not just sources of income for doctors, they are also places where nurses and administrative staff are gainfully employed.

TPAs may be the main source of income for many private clinics and I fear that the livelihoods of many will end up being held hostage to the unilateral pressures of the larger and financially stronger TPAs. We should not allow the livelihoods of private healthcare workers to be lost in the name of turning a profit.

In reply to a supplementary question I asked in August last year, Minister for Manpower Dr Tan See Leng replied favourably that there can be increased education to workers on the use of EB versus IP plans, a relook at how TPAs and EB plans are administered, with a need for multiple stakeholders to be involved. I ask for MOH and MOM to consider this in the year ahead.

Finally, even though my leadership in SMA has a limited tenure, I believe SMA, together with our sister professional bodies, will continue to help in the integration and support of healthcare workers through stronger representation for doctors. My vision is that SMA continues to be the bridge between doctors and patients, doctors and insurers, doctors and the Government, to achieve an equitable healthcare ecosystem for doctors and for patients.

COVID-19-related Manpower Recruitment

Mr Pritam Singh (Aljunied): In late June 2021, the Multi-Ministry Task Force (MTF) announced plans to transition to COVID-19 endemicity. While the Minister for Health announced that we would be ready with 1,000 ICU beds, a figure that was subsequently clarified, it remained unclear what the plan was to ramp up ICU bed capacity without the degradation in the standard of care, in preparation for an endemic COVID-19.

I asked a Parliamentary Question on ICU bed capacity last year and the response received was that we should avoid getting near or needing 1,000 beds and to focus on stabilising COVID-19 case counts. I note the points made subsequently about the trade-offs in the standard of care if a large number of ICU beds have to be stood up. But this still does not get to the meat of the matter. To this end, what specific preparations were made for the recruitment of healthcare manpower in step with preparations for endemicity, as announced by the MTF in late June 2021?

In November 2021, Senior Minister of State Janil reported to the House that about 1,500 healthcare workers had resigned in the first half of 2021, compared to about 2,000 annually pre-pandemic. Foreign healthcare workers also resigned in bigger numbers especially as they were unable to travel to see their family back home. Close to 500 doctors and nurses, healthcare workers, resigned in the first half of 2021 as compared to around 500 in the whole of 2020 and around 600 in 2019, about double the usual rate.

I asked the Senior Minister of State at the same Sitting in a supplementary question what were the recruitment rates of healthcare manpower over the same period; what efforts, if any, were taken in the middle of last year in step with the transition to COVID-19 endemicity, to recruit foreign manpower on an exceptional or an urgent basis. Even if, for example, the training of new foreign manpower to complement local healthcare workers would take some time, it would, nonetheless, have played an important part in reducing the load on our healthcare workers in time.

More generally, a labour shortfall in the public healthcare sector also appears to persist in recent weeks. The stresses on our healthcare workers have been well-publicised online with anecdotes of longer working hours and lesser staff looking after patients' needs. As a percentage today, what is the manning situation in our public hospitals? Are we at 80% or 90%? And at what percentage must manning levels not fall below to ensure an optimal level of healthcare is rendered to patients?

It would be important for the Government to lay out its short- or medium-term solution to this. I asked the Ministry to share its manpower recruitment plans and the additional doctors, nurses and allied health workers required, in view of our COVID-19 endemic strategy. The number must also accommodate the prospect of other future contingencies including any Disease X which is likely to overwhelm our medical services.

In view of Omicron, future potential variants and surges, what is the recruitment plan for medical manpower that can sustain us through COVID-19 and, more generally, for the longer term? Has MOH develop a roadmap or a plan with public healthcare institutions to make up for the attrition in healthcare workers?

Healthcare Workers' Working Conditions

Mr Leon Perera (Aljunied): Mr Chairman, I recently filed Parliamentary Questions on junior doctors' working conditions. I would like to call for a review of the current 80 working hours per week guidelines, with a view to reducing it marginally, say, to 70 hours.

Some overseas studies do show that work hour reforms are not necessarily tied to adverse patient outcomes and that 80 hours is more than what is necessary. We can study this locally before making changes.

While it is understandable that hours are frontloaded in a junior doctor's career, so they are exposed to a variety of cases and have experience of disease progression and so on, recent reports of burnout are very concerning. Burnout harming doctors' well-being can impact patient care. Sleep deprivation research shows it can impair psycho-motor abilities to a degree comparable to intoxication. Lack of work-life balance may also push well-trained healthcare workers to work in other countries or industries.

Secondly, let us move towards 100% compliance with the current 10-hour intervals between duty periods and after in-house calls, up from 90% now. We must also ensure that there is no under-reporting. I understand from my past Parliamentary Question that MOH has indicators showing that there is no systemic under-reporting, but anecdotal feedback suggests that this still happens to some extent. In cases where under-reporting or lack of compliance is found, let us move fast to study lapses and ensure manpower is sufficient.

Lastly, I would like to suggest that MOH mandates concrete steps to shorten the time spent handing over and peripheral duties. A 24-plus-hour duty is taxing and reducing administrative time will allow junior doctors to obtain sufficient rest before their next shift.

Healthcare Workers' Mental Well-being

Dr Wan Rizal (Jalan Besar): Chairman, it is clear that COVID-19 has complicated matters, especially for our healthcare workers. Due to exigencies of service, many are required to cover one another – sometimes at the last minute – work a bit longer, do a bit more and these may add up to less rest time or family time.

The number of abuse or harassment cases rose from 1,200 in 2019 to 1,400 as at the end of November last year.

In the first half of 2021, 1,500 workers resigned, compared with 2,000 annually before the pandemic. The increase in the number of patients, coupled with rising expectations from patients and their family members for high quality care and service, may be the push factors. Hospital visitation, limited by COVID-19, may also have resulted in heightened frustration from some of the patients’ families.

Sir, our healthcare workers have always been exemplary in their service. We expect them to care and smile, but do we care and smile back? The COVID-19 situation merely spotlighted the hard work that they have always, always put in. Thus, we must ensure that they come to work energised, feel protected and respected by both colleagues and stakeholders.

Sir, I would like to ask the Ministry what plans are there to continue to safeguard the well-being of their workforce and improve retention.

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Manpower Planning for Healthcare Workers

Dr Shahira Abdullah (Nominated Member): Chairman, I declare that I work in a hospital.

Chairman, we have a healthcare manpower shortage. Recently, MOH called for help to support the COVID-19 operations as healthcare facilities find themselves overwhelmed by the Omicron wave. A Ministerial Statement in November 2021 showed worrying resignation rates with foreign healthcare workers resigning in bigger numbers.

As such, can we do more to encourage young Singaporeans to take up a career in healthcare so we can become more self-sufficient in the long term? How can we better support workers who would want to have a mid-career conversion to healthcare?

We also need to retain the senior talents that we have as they are key to training the next generation of workers. To do so, employee well-being and working environment are important. A local study by NUS Medicine, National Heart Centre Singapore and Duke-NUS Medical School in 2017 found that eight out of 10 medical residents were burnt out. During the pandemic, healthcare workers are also feeling the strain of more work and longer hours.

Taking into consideration the ageing population and the threat of Pandemic X, what will change moving forward, with the master planning of manpower capacity for the healthcare sector so we can take into account the working environment and wellness of the healthcare workers? This may mean, among other things, beyond remuneration, better work-life balance, enough manpower for better working hours, the ability to take sufficient leave instead of encashing them and the improvement of the healthcare worker to patient ratio. Would these be more effective in encouraging Singaporeans to consider a career in healthcare?

Lastly, how can we leverage workplace improvement, automation and digitalisaton to improve the delivery of healthcare? How can we improve processes to ensure that more time is spent on tasks directly related to patient care instead of administrative processes while not sacrificing patient safety?

Greater Protection of Healthcare Workers

Dr Tan Yia Swam: Mr Chairman, I declare my interest as a breast surgeon in private practice and my role as the elected President of Singapore Medical Association.

In recent months, there have been articles in the news and letters to the Forum page highlighting the abuse of healthcare workers in Singapore. Twenty-five months of COVID-19 have placed immense social pressures on every single one of us. But being stressed should not be an excuse for patients to take on abusive behaviour towards healthcare workers or anyone for that matter. The number of harassment cases reported has been increasing yearly, from 1,080 to 1,300 cases.

I am glad that there is increasing awareness of this longstanding problem. Healthcare professionals place patients at the heart of all we do and service before self. But when it comes to abuse, it becomes a really difficult thing to express how one feels abused without feeling guilty of being derelict in our duty. If healthcare workers are given the training to recognise it and the organisational support to be able to call out abusive and manipulative behaviours from patients or their families, it will give us all more protection, peace of mind and the strength to keep on doing what we love best.

Before you worry that healthcare workers over-react and claim that every patient complaint is an abuse, let me share two real-life examples.

One, after a routine, uneventful surgery, on the day of discharge, a patient’s children demanded that the ward staff arrange for daily food delivery to the patient at home because they are all too busy to do so and said, I quote, "if anything should happen, it'll be your fault".

Two, as a junior doctor, I once had to call a patient’s son to explain why a surgery had to be postponed for a second time – once, due to salt imbalance and once again due to unexpected fever. The son said, "You are lucky I am not there; otherwise, I will hang you, every single one of you".

I am certain that many healthcare workers have their own stories of abuse to share. Our professionalism mostly keeps us in check and stops us from posting on social media. And this is why there is such a skewed representation of cases of lapses in healthcare because healthcare workers would do open disclosures when a medical error has happened. Yet, when the abuser is the patient, who can we talk to? Who will believe us?

Part of the problem is under-reporting. Healthcare professionals in public healthcare institutions are categorised as Public Service Workers under the Protection from Harassment Act. Yet, many healthcare workers may refrain from making an official Police report. They feel it is just a one-off event, they feel sorry that the patient is sick and not feeling well, or that the families are worried, thereby excusing such behaviour.

Another insight is that the type of emotional or verbal abuse that healthcare workers get can be just as elusive as that in an abusive relationship. We may not always recognise it, we just feel drained and guilty after meeting such patients or their families. We are afraid of speaking up, because patients hold the power here – a complaint to the senior management or their Member of Parliament may bring in undue social pressure to give in to unreasonable demands.

For a doctor, an SMC complaint may take months or years to resolve, the media may splash a doctor's name across the main page and his or her reputation is ruined, even if found to be innocent later.

So, what can be done?

The Protection from Harassment Act (POHA) covers only public healthcare workers. It does not allow for immediate remedies to be taken. There must be zero-tolerance of abuse on many different fronts.

At the healthcare workers' level, one should have the professional option to terminate the patient-carer relationship after an encounter of abuse, with transfer of care to another provider.

At the institution level, there needs to be clear protocols for reporting and management of abuse cases: such as making a Police report, making CCTV evidence available and with calling of witnesses.

As a country, we can all play a part to be courteous and kind to one another, to give basic respect and human decency. My vision for Singapore – and even the world – is for us to be kinder, sensible towards and tolerant of differences. Even as the world becomes divided over race, nationalities, vaccine status and so on, as individuals, let us be kind, embrace the Singapore Kindness Movement and practise it in our daily lives. Everyone is going through their own personal hardships, which we may never fully understand.

As Minister Lawrence Wong said, let us build a more caring and inclusive society. I applaud MOH’s written response on 10 January that states a zero-tolerance stance towards the abuse and harassment of healthcare workers. I hope that, on the ground, we will see a greater push and enforcement of measures to ensure a safe environment.

Mr Adrian Tan, current President of the Singapore Law Society, shared in a LinkedIn post in December regarding healthcare worker abuse. That post had a wide discussion and engagement from professionals across different sectors. Some, in service industries, brought up denial of service to abusive customers. This is such a foreign concept to most local healthcare workers. But a few friends who have worked overseas have shared that, yes, their hospitals have provisions in place to turn away such visitors. These rare situations are typically for drunks or known drug addicts who come into the Emergency Department, not for a medical condition, but to demand drugs and were clearly abusive, such as screaming, shouting or even spitting at staff.

Maybe COVID-19 has, indeed, made it timely for there to be stronger legislation to protect all healthcare workers against bullying and harassment. Please, help us, to help you.

Healthcare Workers and Support Staff

Mr Abdul Samad (Nominated Member): Chairman, this COVID-19 crisis has certainly tested the patience and resilience of our healthcare system and, most importantly, our healthcare workers. We are also heartened to see many individuals and organisations that have stepped forward to lend support with food, care packs and others to show our appreciation to them.

It was very heartening that on 5 November 2021, MOH boosted the public healthcare workers with an announcement of a monetary award of up to $4,000 in recognition of their efforts in the fight against COVID-19. In fact, this applies to those at community care organisations that deliver frontline services, such as nursing homes and dialysis centres.

Notwithstanding the above incentives, there were also not so nice news, whether in social media or even mainstream, on the mental challenges faced by this group of workers within the sector. We are also not sure how many of such workers that are facing similar workplace stress and challenges.

In addition, quite a high number of reported resignations was recorded from healthcare staff due to the stress at the workplace.

Notwithstanding these reported incidents, how does MOH engage the hospitals' management to identify the workers that are having mental health issues or stress during these challenging times? What kinds of support are there? What kinds of support are provided to any worker who comes forward? For those who had resigned, were they our locals or foreigners who had decided to return home to be with their beloved families?

News of these resignations from this group of healthcare workers should not be seen as an obstacle for fellow Singaporeans or even students who may want to pursue a career in healthcare – friends and cousins that I know of are still contemplating their decision in this meaningful sector.

I am appealing to the Government, specifically to the Minister for Health, to again give out one-off bonus for this group of workers, not just confining to the earlier groups that had benefited.

In fact, there are also outsourced workers, such as cleaners, housekeepers, porters, technicians and even security officers, whose lives are equally exposed in hospitals, community care organisations and also neighbourhood clinics.

Besides that, I am not sure if MOH and MHA can also announce such incentives to all paramedics who have to receive and send COVID-19 patients either from their homes or even neighbourhood clinics to hospitals. This is because every worker matters.

Chairman, our doctors and nurses serving fellow Singaporeans to provide treatment and care in this never-ending battle against COVID-19 crisis deserve the fullest moral support in the course of their work. I call on fellow Singaporeans to continue showing support for this group of workers in the battle during this pandemic. Each simple smile and word of thanks to them will certainly help to boost their morale.

Strengthening Support for Mental Health

Dr Wan Rizal: Chairman, mental health issues and well-being are a whole-of-society approach that spans across different age groups and segments of the community, from students to workers, youth to the elderly – and rightly so. In last year’s COS, MOH announced two task forces to strengthen support for mental health and well-being as a whole.

First, Senior Minister of State Dr Janil Puthucheary shared that the Taskforce for Mental Health and Well-being will work on three areas: the development of a national strategy; creation of a resources webpage; and a competency training framework.

The second task force, announced by Minister Masagos, revolved around Child and Maternal Health and Well-being, to provide comprehensive support to women and their children. Like some say, "A healthy and happy mother has a healthy and happy child". And, of course, an even happier father.

Sir, the family nucleus remains an important bedrock of our society. Investing more in our children is, inevitably, investing more in our mothers, too. Therefore, we must continue to provide the infrastructure and support: through greater access points within the community like the GP clinics and polyclinics. Support programmes and resources for mothers and families as a whole must continue to be made available and accessible.

Sir, I also believe that screening, both physical and mental, is important, especially at the antenatal and postnatal stages so that proper and early intervention is provided.

Therefore, I would like to ask the Ministry what are the updates from the Mental Health and Well-being Taskforce as well as the Child and Maternal Health and Well-being Taskforce respectively.

Support for Mental Health

Mr Xie Yao Quan (Jurong): Chairman, it is heartening to see more open conversations acknowledging the stigma around mental health and the need to break this stigma.

Our key task ahead is how to break the stigma, keep chipping away at it, keep shifting the needle, as a whole of society.

As a first step, I believe we need to raise our collective awareness, knowledge and empathy on mental health. So, for instance, understanding that signs of distress do not mean a disorder per se. A person who shows signs of anxiety, for example, may not have an anxiety disorder. A person with low mood, low energy, feeling "depressed", may, nonetheless, not be facing a depressive disorder. Symptoms and seeking help, counselling, therapy for these, do not mean there is a clinically-diagnosed condition. There is a difference.

And conversely, understanding that a person living with a clinical disorder may not actually show signs. People around him or her may not even know. It may not be obvious.

So, we need to continue working at our collective understanding and sensitivity on mental health as an essential first step in tackling stigma as a society. Because this translates into our words, the language that shapes our discourse. And words do matter.

Where our words are understanding, authentic, but sensitive and nuanced, it helps someone else to reach out to us. The right words can open up more doors for a person who may need help. The right words can also help us to reach in, to open the doors of someone else's heart. So, building a kind, compassionate environment free of stigma starts with our words and our language. And it also takes real skills, skills to truly listen and respond with empathy.

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In a dialogue I moderated, a youth in his early 20s made this important point. He suggested that older students in higher education should all have a chance to learn such skills. This would better equip students to provide peer support and, indeed, a strong tapestry of peer support is also key to tackling stigma. Peer support can be that first net to catch and embrace persons dealing with mental health challenges.

And this should not just be for youths. We should strive to build up a state of peer support that permeates through a person's life course, through youth, as a working adult and, importantly, as a senior, when challenges such as isolation become particularly salient.

But peer support cannot replace professional help, when it is needed. In this respect, for professionals working with children, the obligation to inform is a particular challenge at times. It deters some children who need help from coming forward. And the interplay with the existing stigma adds to the complexity.

It is hard work for mental health professionals who are working with parents and children to see how best they can support each child and every case is different. But where there are successes, we should get these stories out, so that we can encourage more children and more parents who need help to come forward.

Stigma and other crucial issues relating to better mental health and care are a long journey that takes all of us. And the formation of the Interagency Taskforce on Mental Health and Well‐being is a strong signal of the Government's commitment to this very important journey. I look forward to an update by the task force about its work later.

Permanent Mental Well-being Office

Dr Shahira Abdullah: Chairman, I initially filed this cut under the Prime Minister's Office because I am raising the recommendation for a permanent Mental Health Office under PMO.

Multiple studies and public polls, such as those by the Institute of Mental Health, SG Mental Health Matters and other community groups have shown that factors impacting mental health are complex and cut across many domains of our lives. On 23 August 2021, an Interagency Taskforce on Mental Health and Well-being was set up to address the multifactorial nature of mental health and well-being. Could the Minister update on the progress of works since the announcement?

Mental well-being is something of national concern, which straddles many Ministries. Adult mental health and well-being will require a different approach as compared to that of youth and seniors. In addition to age differences, there is also a need to address the mental well-being of people of different backgrounds, such as teachers, social workers, ex-offenders and victims of scams, just to name a few. To touch all bases requires close coordination between Ministries, as well as adequate authority and resources to be able to roll out the initiatives.

Mental health issues are something that will not go away. We should not invest in mental health only as a COVID-19 response and recovery but as something permanent to create better physical health outcomes, stronger families, increased economic productivity and long-term growth and development. The mental well-being of a nation is essential for Singaporeans to reach their full potential. Therefore, would it be more effective to make it a permanent office or agency? Since it also requires close coordination among many Ministries such as SNDGO, could the Ministry share what factors it considers when determining whether to form a permanent office under PMO, to oversee an issue of national concern?

MediSave Payments for Mental Illnesses

Mr Dennis Tan Lip Fong (Hougang): Mr Chairman, COVID-19 has impacted our mental health too. An IMH study last year found that 13% of the participants reported symptoms of increased anxiety and depression. But 81.8% of participants said that they will be willing to seek professional help. I am therefore concerned that the current MediSave cap is insufficient for low-income individuals that may wish to seek help but may not be able to afford it.

Currently, only mental illnesses listed under the 20 chronic diseases under the Chronic Disease Management Programme entitle a patient to pay using his MediSave account. Patients with complex chronic mental conditions will be able to use up to $700 of Medisave per patient yearly, while other patients will be able to use up to $500 of their MediSave per patient yearly for treatments. I would like to ask MOH to review the current MediSave cap of $700 allowed for chronic mental illnesses.

To allow greater accessibility to psychiatric care in the community, the cap can be reviewed considering that on average, consultation fees in the private sector is over $100 per session, excluding the course of medication. Increasing the amount allowable under MediSave may also allow patients more flexibility to consider seeking consultation with doctors in private hospitals as the wait time may be too long in structured hospitals.

Further, as part of the new focus on mental wellness, I would like to ask that we allow MediSave payments for consultation with psychologist, which I understand it is currently not possible. We can perhaps, set a cap of a maximum number of sessions per year, for example, up to five.

Healthcare Infrastructure

Mr Leon Perera: Mr Chairman, from FY2016 to FY2018, our public and total healthcare expenditure remained constant at 2.1% and 4.1% of our GDP respectively, approximately, but has since increased.

For comparison, Japan spends 9.3%, Germany spends 10.7% and the OECD average is about 8.8%. However, these two years have shown that we need a much more anti-fragile system. Healthcare workers, including nurses, ambulance staff, junior doctors, are overworked the moment colleagues begin falling ill or are told to stay at home. This is not sustainable. I believe the Government understands that it needs to spend more. We see this in plans for upcoming infrastructure, like new polyclinics.

I would suggest that public mental health and dental care also needs to expand a lot faster than the headline rate. For mental health, I was told in a Parliamentary Question reply, that the number of psychologists here is only increasing by 4% annually. It is also not easy to qualify as a psychologist.

From conversations with my constituents in the Serangoon ward of Aljunied GRC, the waiting time to see a public sector mental health professional or dentist can be long. For such conditions, intervening early is important to limit further health or social consequences. I would like to urge greater urgency in the expansion of our public dental healthcare capacity as well as our public mental healthcare capacity, especially at the tertiary level.

A Sustainable Renal Treatment Strategy

Mr Edward Chia Bing Hui (Holland-Bukit Timah): Mr Chairman, Sir, according to NKF, dialysis centres are experiencing a growing number of applications, more than 100 a month, up from 60 a few years ago. The age profile of applicants are largely seniors. As a member of the PAP Seniors Group, I am concerned about these rising numbers and will speak on co-locating hemodialysis centres for added convenience and the promotion of alternative treatments plans to cope with the anticipated increase in caseloads.

I am heartened to know that NKF has been working with MOH to build more centres for hemodialysis at HDB void decks. In addition to building dialysis centres closer to the community, a co-location with other medical facilities such as polyclinics can enhance patients' care. For example, dialysis patients often need wound care and can seek such treatments at the polyclinic. Secondly, co-locating a dialysis centre with a nursing home can provide added convenience for nursing home clients. Lastly, co-locating a dialysis centre within transportation hubs can significantly reduce patients' travelling time. These forms of co-location provide better overall care outcomes as patients can now seek complementary treatments and greater convenience.

At large, there is an increasing demand for Renal Replacement Therapy (RRT) on a national and global level. Hence, current hemodialysis treatments are unlikely to meet demand due to inherent constraints and there is a need to look for alternatives beyond community satellite hemodialysis. Alternatives include promoting peritoneal dialysis, which is a home-based treatment where patients can carry out treatment themselves in the comfort of their own homes. Peritoneal dialysis also allows for more flexibility, enabling patients to better fit dialysis into their lifestyles. Peritoneal dialysis can also help tackle a manpower crunch faced as the number of nurses required are halved, compared to the nurses needed for hemodialysis with the same number of patients.

Despite peritoneal dialysis being a viable alternative to hemodialysis, most patients are still choosing HD as a dialysis treatment. Therefore, it is of paramount importance that we strengthen our public education on peritoneal dialysis treatments and empower healthcare providers to promote these alternative treatments.

As close to 70% of kidney failure is a result of diabetes, we need to strengthen the link between diabetes and kidney failure in public education messages. Lifestyle modifications are the best way to prevent deterioration of one’s kidney function. Upstream intervention and prevention are key to dealing with the anticipated increase of numbers of patients requiring dialysis.

The Chairman: Mr Yip Hon Weng. You can take your two cuts together.

Digital Transformation

Mr Yip Hon Weng: Mr Chairman, in Singapore, many healthcare providers leveraged on telehealth to remotely monitor at-risk patients’ conditions during COVID-19, when they were discouraged from visiting the hospitals.

With the current healthcare crunch, telemedicine is a solution to do more with less. This is especially so considering that many healthcare professionals find their time taken up by administrative work, which could be better used on clinical work and delivering better bedside care. How does the Ministry plan to use smart technology to relieve the healthcare crunch? Within the community, how can we accelerate the adoption of telehealth? The polyclinics continue to be crowded with patients, especially seniors, many of whom who are not familiar with telehealth, despite being the group that would benefit most from it.

Yet, with the convenience brought about by digitalisation, security always seems to be the trade-off. But this must not be the case, given the highly sensitive nature of healthcare data. The World Economic Forum warned that more needs to be done to strengthen healthcare cybersecurity. Serious ransomware attacks could jeopardise the timely delivery of quality healthcare. What is the Ministry doing to ensure security of our data and IT systems in the healthcare sector? How are we applying the lessons learnt from the 2018 SingHealth hack and subsequent cybersecurity breaches in other healthcare systems?

Supporting Singapore's Ageing Population

The increase in our Budget expenditure was largely attributed to the costs associated with caring for an ageing population.

The instructor-led fitness and exercise group workouts around the island by the Health Promotion Board is part of the Action Plan for Successful Ageing. It gave an outlet for seniors to stay physically and socially active. During the pandemic, these exercises took a step back. For two years, we encouraged our seniors to stay home for their health and safety. Not everyone was able to switch to electronic means of socialising and exercising.

As we emerge from the pandemic, we urgently need an update on the Ageing Plan Refresh. What are the new priorities? What are the tangible methods to measure the success of the programme? What are the significant timelines and milestones?

Even though the Ministry has committed more resources to improve the healthcare infrastructure, there are other areas of opportunity that require resources to grow. We need to improve our home-based care, caregiving and ageing in the community to free up resources from the public hospitals and clinics. By leveraging on digitalisation, we can use telecare to reduce crowds in our healthcare institutions and provide more accessible healthcare in the community and convenience to patients. A better relationship between seniors and GPs, and allowing seniors to choose their GPs, can help seniors manage their chronic health conditions better.

And, as I have spoken in my Budget speech, the palliative care sector is in need of more resources for development. As Singaporeans live longer, there is a higher likelihood of suffering from more chronic health complications and severe illness. These can bring about rather immense suffering, physically and emotionally. Palliative care plays a significant role in helping a patient maintain their dignity and peace at the end-of-life. I urge the Government to commit more resources to this.

Employment has generally been recognised as being good for health, as it provides for a sense of purpose, a social life and financial independence, which are crucial in old age. A senior-friendly workplace will contribute many more productive years to a senior's health. I hope the Ministry can have more cross-collaboration with MOM to introduce more targets and programmes to get companies in Singapore to hire senior workers and make their workplace more senior-friendly.

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Successful ageing in Singapore should be a multi-pronged approach that involves self-reliance of seniors, partnerships with stakeholders, such as employers, and empowerment of family to care for their seniors.

Careline

Mr Pritam Singh: In 2016, MOH rolled out the senior support call centre service, Careline. It was targeted at seniors living alone who could enrol in the service and receive support, medication reminders and tele-befriending, if needed.

The Minister for Health last year noted that Careline has supported around 10,000 seniors. I would like to ask how many Singaporeans have signed up and of which, what has been the proportion of seniors who have had their needs met through Careline. Has the number of sign-ups remained promising after four years?

We also know that language barriers tend to be a challenge in bringing care to our seniors. Has there been feedback on whether this was also an obstacle in Careline and what steps have been taken to bridge that?

I gather that how Careline works is not necessarily by sending someone down to the senior who calls but also by linking them up with relevant agencies and community partners to provide more well-rounded support.

It is hard to quantify the success of holistic support though. Perhaps, one way to measure efficacy would be to think of how Careline has helped expedite seniors' access to emergency responses. How many Careline calls in 2019, 2020 and 2021 have been referred to emergency services?

Which brings me to Careline's specific role. It is but one among a buffet of tele-medical services that seniors and other vulnerable citizens can choose from when they are in distress. Other 24-hour hotlines like the IMH's Mental Health Helpline. Eldercare centres also conduct check-in calls to seniors in need of support, as does the Silver Generation Office, albeit with a more targeted approach. There are also support hotlines operated by independent counselling centres and the National Care Hotline offering pandemic-related psychological support.

With so many different options, are seniors made sufficiently aware of the range of support that they can access, or is there some scope for a rationalisation exercise without drop in the quality of care? Does the Government envisage expanding Careline and rolling it out to more seniors?

Our Seniors' Health and Well-being

Mr Kwek Hian Chuan Henry (Kebun Baru): Chairman, I noted that MOH has stared on the Ageing Plan Refresh, which gives the Government an opportunity to review the whole-of-Government efforts to empower and support our seniors, which is much needed given how much change has happened with COVID-19.

We at the PAP Senior Group are watching this review closely and with much anticipation. While MOH continues with the review, I hope MOH can consider the following.

One, once Omicron subsides, decisively change the SMMs to encourage the revival of wellness activities conducted by the grassroots and by senior activity centres. This is a point that my colleague, Mr Yip Hon Weng, mentioned before.

Two, put a renewed focus on preventive health campaigns against diabetes, cancer, stroke and mental health.

Three, accelerate the efforts of Queenstown Health District and quickly scale up beyond Queenstown and hopefully, the whole of Singapore.

Four, introduce fresh ideas to encourage more seniors to come forth for health screenings.

And five, enhance the scope of healthcare screening to detect and resolve more types of preventable and degenerative diseases and conditions.

Given that we have transited to living with COVID-19 and most of our seniors are vaccinated and more anti-COVID-19 treatments are available, can MOH also share and elaborate on the current thinking on how to best care for our seniors' health and well-being moving forward?

Active Ageing

Ms Tin Pei Ling (MacPherson): Sir, pandemic has reset all active ageing efforts. While some seniors are raring to resume activities, some have retreated and gotten used to staying home. This leads to significant deterioration in mental acuity, emotional and physical well-being.

For instance, I always remember Uncle Lee to be a jovial and active senior who loved to organise day trips for residents and tell me stories. And I would see him with a big smile on his face at our community events. Since the pandemic, I saw little of him as he stayed home. Each time I saw him, he was less engaging and slower to react. In January this year, I visited him again and he just sat in his chair, unable to recognise me. It is heart-breaking.

I have also met other seniors who have aged so much faster in these two years. Some of them were pleased when I visited them and as we chatted, they broke down in tears as they articulated how lonely they felt. We must not let our seniors retreat into isolation and wither alone.

What is the Government doing to resume seniors' engagements in the community in a safe manner? How can this be expedited? What more can be done to compensate for this "vacuum"?

The Chairman: Ms Ng Ling Ling, you can take your two cuts together.

Housing and Care Needs of Our Aged

Ms Ng Ling Ling: Mr Chairman, the Population in Brief 2021 continues to report an increasing trend of our citizen population aged 65 and above, with the proportion growing at a faster pace compared to the last decade. From Census 2020 data, we note that 22.8% of this group of seniors are living alone or with their spouse only. As our population ages and family sizes decline, more seniors are likely to have only themselves or their spouses to support them in their old age and many may require community care at some point in time.

I would like to continue to call attention to integrate housing and care needs for our seniors. During the Budget debate last year, I strongly supported the Community Care Apartment model piloted at the Harmony Village at Bukit Batok. I am glad to hear from the MND's COS session yesterday that more of such Community Care Apartments (CCAs) will be launched and I hope MND will spread them island-wide to benefit more seniors.

A related issue that I hope to raise is incorporating senior care services in new BTO projects with flexi 2-room flats. During my walkabouts to newly completed BTO projects in the Buangkok Crescent estate of Jalan Kayu, which consist of mixed room types of between 2- to 5-room flats, I noticed that the flexi 2-room flats are mostly occupied by seniors living alone or with their spouse only, many of whom have chosen to downgrade to a smaller flat in their advanced years, mostly in their 70s and 80s.

BTO projects in newer estates consist predominantly of younger families and the social and community services around then tend to cater to their needs. I would like to thus suggest for coordination amongst the Ministries, between MOH, MND and MSF, to profile the BTO blocks with a larger number of seniors in 2-room Flexi Flats, to provide integrated senior care support in addition to services for young families. In fact, if more inter-generational community services that cater to both social and health well-being of our younger and older residents together, it will be beneficial to the community as a hope.

Child-maternal Health and Well-being

Mr Chairman, in my COS cut last year, I raised the concern of maternal health of mothers and its impact on their children. With our birth rate continuing to slide, every child born is precious to us. Ensuring the health of mothers and their children is hence a priority that needs our continued efforts.

I am glad to hear that MOH has developed a Child and Maternal Health and Well-being Strategy to provide comprehensive support to women and their children, spanning from pre-conception to youths aged 18. These are formative years with many critical milestones. I hope to have more updates on what the new initiatives are and how the strategy will address health needs and mitigate risk factors of mothers and children in Singapore.

One emerging risk that I would like to highlight is on children's screen time usage and addictions.

According to data from IMDA, Internet usage among children aged 15 and below increased from 69% in 2016 to 92% in 2020. COVID-19 has intensified the usage of technological devices for communication and entertainment. A study done in 12 countries on those aged eight- to 36-month-old showed that children's screen time increased during COVID-19 lockdown relative to before. The study found that many caregivers would have to juggle both caring for children working from home had limited access to other activities to occupy their children's time and this resulted in screen time being the only way to occupy their children. An informal study done by The Straits Times in February this year with several counselling agencies showed that the number of cases they received for intervention regarding screen time addiction rose by up to 60% during the circuit breaker period.

I also note another Straits Times' article published just last Sunday, introducing a set of guidelines by a workgroup led by KK Women's and Children's Hospital (KKH), aimed at supporting parents to instil better daily habits from birth, helping young children get enough sleep and reducing screen time exposure to improve their health and well-being in the long term.

I would like to raise two suggestions for MOH's considerations.

Firstly, can we support the good work of the workgroup led by KKH, which I mentioned earlier, by supplementing their guidelines with tool kits, play resources and other practical help to support young parents and educators in the early childhood sector to be trained and equipped with strategies to manage screen time for children from early childhood?

Secondly, can we research and implement evidence-based programmes to support educators, community health practitioners, parents and caregivers of children and youth who are at risk of developing Internet addiction or who already have total mean screen time above a certain threshold?

As we move to an endemic Singapore, I hope that more outdoor activity options will become the preferred choices of our children and youth to participate in so that screen time will not dominate their days.

Assisted Reproductive Technology

Miss Cheng Li Hui (Tampines): Chairman, last year. I spoke extensively on the need to lift the restrictions on egg freezing for singles.

More Singaporeans are getting married later and having children later, which may have some impact on fertility. For the singles who had wanted to go overseas for egg freezing in the past two years, they could not and their eggs' quality and quantity would have declined.

Singapore has been experiencing low Total Fertility Rate (TFR). While immigration helps to moderate the impact of ageing and the low birth rates in our citizen population, it is by no means a silver bullet to tackle our longer-term demographic challenges.

Couples who have wanted to seek cheaper IVF procedure or Pre-implantation Genetic Screening (PGS) procedure overseas would also have difficulties doing so with the COVID-19 situation. How is MOH helping Singaporeans with the total fertility health as part of their parenthood journey?

Individual Ownership of Health

Ms Ng Ling Ling: Mr Chairman, during the Budget debate, I spoke about the increased prevalence of patients with chronic diseases and sought clarifications from MOH on the ways that can better address this trend. Given that our resident population will continue to age, it is inevitable for our healthcare needs and costs to rise.

To mitigate the costs of healthcare on individuals, especially long-term burden of chronic diseases, I believe that we need to empower individuals to understand our own health, both in the prevention and prompt management at the onset of common chronic diseases like high blood pressure, diabetes and high cholesterol as well as long-term management and disease control.

A study on a cluster of polyclinics in Singapore has shown that the median annual healthcare costs per capita increase with the number of chronic diseases. To reduce such cost burden especially on our seniors, it is important to increase education to at-risk groups with customised and relatable content, enable screening for early diagnosis and support long-term management to prevent complications from chronic diseases.

I acknowledge that the efforts to reach out and enable more individuals to manage their own health, if solely placed on our healthcare professionals, will increase their already stretched workloads without more supportive tools provided.

In this regard, I hope that MOH will consider more use of technology, including telehealth and artificial intelligence amidst our nation's digitalisation efforts to help individuals monitor and manage our health in partnership with our healthcare providers.

I hope to ask MOH how it will leverage on technology amongst our healthcare professionals and patients, especially in the space of prevention and management of chronic diseases and how it will help to make care treatment augmented by technologies, such as telehealth affordable through, for example, the use of MediSave or CHAS.

Minority Community Outreach

Dr Wan Rizal: (In Malay): [Please refer to Vernacular Speech.] Last year, MOH set up the Minority Community Outreach (MCO) working group to improve health for minority communities. These health issues need to be addressed with care and strategically, taking into account factors, such as cultural differences.

Since then, we have seen several innovative campaigns and programmes, such as Yok Jalan Amal organised by M³@Jurong in Jurong, which received encouraging response. Besides physical health and diet, other issues such as mental health have also captured the interest of the community, especially among the youth and elderly.

I would like to ask the Ministry if it can provide an update on MCO's efforts.

2.45 pm

Adult Immunisations Programme

Dr Lim Wee Kiak: Chairman, I spoke on adult immunisation last year and, this year, I will again broach this topic.

Getting vaccinated has been a buzzword since the outbreak of the COVID-19 pandemic and we have seen so much effort put in by governments and health authorities globally. In Singapore, we have been very lucky and very successful in our vaccination exercise during this pandemic and we are pushing harder for the younger Singaporeans now to get themselves vaccinated.

Vaccination is important, not just for this pandemic, but for many other diseases. Most adult Singaporeans would have been more familiar with Influenza vaccine and perhaps also hepatitis B, measles, mumps and rubella. The National Adult Immunisation Schedule (NAIS) was set up in 2017 to provide guidance on vaccinations that anyone aged 18 and above should adopt to protect themselves against vaccine-preventable diseases. Eleven diseases were identified, namely, Influenza, pneumococcal diseases, human papillomavirus, tetanus, diphtheria, pertussis, mumps, measles, hepatitis B and varicella, which is the chickenpox virus.

The question is how many adult Singaporeans have kept up with their vaccinations according to this schedule? What is MOH's plan to encourage more adults to keep their vaccinations up-to-date to protect themselves? Even in this House, I am sure many Members have not heard about this particular programme, let alone be up-to-date for the vaccinations.

The COVID-19 pandemic has highlighted the importance of preventive health through vaccination. In Singapore, we have a well-developed childhood immunisation programme. Adult Singaporeans should be encouraged to get their immunisations updated periodically to protect themselves against diseases. Why is the adult vaccination schedule not given more limelight? Can the Government make it more comprehensive as well as easily accessible and affordable and promote it more?

Perhaps MOH can consider sending reminders to Singaporeans who have missed their scheduled vaccinations and also provide some incentives, such as MediSave top-ups for those who have their vaccinations updated? Then this would definitely encourage more to consider vaccination.

The Chairman: Order. I propose to take a break now.

Thereupon Mr Speaker left the Chair of the Committee and took the Chair of the House.

Mr Speaker: Order. I suspend the Sitting and will take the Chair at 3.05 pm.

Sitting accordingly suspended

at 2.48 pm until 3.05 pm.

Sitting resumed at 3.05 pm.

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

Debate in Committee of Supply resumed.

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

Head O (cont) −

The Chairman: Dr Janil Puthucheary.

The Senior Minister of State for Health (Dr Janil Puthucheary): Mr Chairman, our hospitals, healthcare workers and GP clinics continue to work under pressure as a result of the Omicron wave. Individuals who are not fully vaccinated are more likely to be hospitalised, to require oxygen supplementation, be admitted into ICU care and die.

Three percent of our adult population who are not fully vaccinated accounted for 25% of our ICU cases and deaths. As the unvaccinated are at a higher risk of infection and becoming seriously ill, Vaccination-differentiated Safe Management Measures (VDS) have been put in place to protect this group of individuals while allowing the fully vaccinated to resume more social and economic activities.

Mr Leong Mun Wai, I feel, has cherry-picked the data. He is advocating on behalf of individuals who have not been vaccinated; that is quite reasonable. I think he should have a proper understanding of the effectiveness of vaccinations as the most effective intervention that we have in our COVID-19 fight. Let me share a few points of data for him to consider and see if he may change his mind about how he would like to represent the effectiveness of vaccines in our fight.

For individuals below the age of 12, there are about 40 per million severe adverse reactions reported after vaccination and most of these will recover quite quickly with no effects, no long-term effects. When an individual under 12 is infected by COVID-19, the risk is that about 320 individuals per million will develop Multisystem Inflammatory Syndrome in Children (MIS-C) and about 450 per million will develop myocarditis. And each of these may require admission to ICU, certainly, admission to hospital and have the potential to be fatal. So, you can see that the infection-related complications are at least 10 times more frequent than any side effects from the vaccine; and most of the side effects of the vaccine are short-term, temporary and do not have any long-term consequences.

These infection-related complications are much more frequent, potentially more severe as compared to vaccine-related adverse events. And the odds are clear, every case of MIS-C and myocarditis is one too many. I think Mr Leong needs to weigh up both sides of the risk.

At the other end, if you are admitted to hospital, vaccinated individuals who have received their booster doses are 33 times less likely to die from COVID-19, as compared to individuals who are not fully vaccinated. So, to Mr Leong – it is not appropriate to lift the measures at this stage. Once the Omicron wave has subsided, we will be in a better position to ease our safe management measures further.

I understand that Ms Sylvia Lim is interested about the access to and approval for ART test kits. The key considerations when approving ART kits for public health use in Singapore are to ensure that the kits, when used as a self-test, are sufficiently sensitive in detecting COVID-19 infection, easy to use and affordable. The process for approving locally-produced ART kits to meet quality standards is quite clear. It is not more stringent than for foreign-produced kits and is made known to all interested manufacturers and importers who have enquired about ART kits.

The Health Sciences Authority (HSA) has made available the Pandemic Special Access Route (PSAR) for expedited registration of ART kits to be used for public health use as directed by MOH. Only ART kits that meet the quality standards of MOH are invited by HSA to apply for PSAR. And this PSAR route requires significantly fewer clinical samples than the full registration route as MOH will continue to monitor the performance of these kits as they are deployed. There have been instances where local manufacturers could not meet the quality standards, but this should not be misrepresented as an unclear process. They have been told what else they need to do to meet the quality standards.

Lower-income households can already apply through Social Service Offices and Family Service Centres for free kits supplied by MOH. MOH also provides free kits for individuals on mandatory Rostered Routine Testing (RRT) at the workplace. Those on Protocols 1, 2, 3 also have access to free ART kits via the ART vending machines located island-wide.

Sir, the pandemic has posed a challenge to both the physical and mental health of our people. We will be doing more to support the mental well-being of our citizens. Our local study "Growing up in Singapore Towards Healthy Outcomes" (GUSTO) found that the mental well-being of the mother during pregnancy can affect the brain development of the foetus, resulting in vulnerability to mood or anxiety disorders later in life. So, KKH and NUH will increase their antenatal and postnatal mental health screening for more mothers. This will allow pregnant women with depressive symptoms to be identified earlier and allows treatment during both pregnancy and motherhood to occur earlier.

Studies have shown that screen time during early childhood could have a negative association with later cognition. We agree with Ms Ng Ling Ling that more can be done to support parents in calibrating the exposure of their children to screen time. Practical guides and resources will be developed for parents to help them develop healthy screen time habits in their children. We need to encourage healthy lifestyle habits from as early as possible.

The Interagency Taskforce on Mental Health and Well-being comprises members from over 30 organisations and we met regularly to review the population’s mental health needs, discuss identified gaps and develop some preliminary recommendations. The focus of these efforts are challenges that cut across the responsibilities of several agencies.

Dr Wan Rizal and Mr Xie Yao Quan asked about our progress. The Taskforce has 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 fourth, to improve mental health literacy among the citizens and create an inclusive society for persons with mental health conditions.

One of the issues identified is the need for better coordination between the health and social service sectors for individuals with mental health needs. Another clear need is to increase community touchpoints for access to mental health services. We will better leverage existing health and social care settings for service delivery and also equip our frontline workers with skills to identify persons with mental health needs.

We are now refining the recommendations for each of these areas and we will be seeking the public’s views in the coming months. After that, a national strategy and an action plan on mental health will be developed. We will also study Dr Shahira’s suggestion to set up a mental well-being office.

Part of our efforts have been the Youth Mental Well-being (YMWB) Network, launched in February 2020. This aims to implement initiatives to enhance the mental well-being of youths, mobilise the enthusiasm of youth volunteers to work to improve our mental health. The Network has brought together more than 1,500 individuals and saw the formation of over 20 ground-up initiatives.

Moving forward, the Youth Mental Well-being Network will be transiting to a wider remit to expand the focus of engagement beyond youths. The new Network will be supported by MCCY and advised by the Interagency Taskforce. My colleague, Minister of State Alvin Tan will share more about this initiative.

During the pandemic, we saw an increase in the demand for mental health services. Planning has started to future-proof more hospital capacity for psychiatric services beyond the Institute of Mental Health (IMH), our main psychiatric hospital.

The National University Health System will set up psychiatric services at the redeveloped Alexandra Hospital, in addition to the general hospital services that would be located there. This includes inpatient beds for acute and sub-acute psychiatric care and rehabilitation, as well as services such as Medical Psychiatry, Child and Adolescent Psychiatry, and Psychogeriatrics. In addition, the National Addictions Management Service currently at IMH will be extended to other hospitals, including Changi General Hospital and National University Hospital, to make the service more accessible.

3.15 pm

Mental health care services need to be more accessible and delivered in many settings, other than only in IMH, as well as integrated into the community and general medical services. The new unit at Alexandra Hospital and the provision of new services in other centres will increase the outreach of mental health care and improve the care of patients and the support to their families.

We will extend this approach to social service organisations and other partners working in the community. We have piloted youth community outreach teams and youth integrated teams to provide a range of support to persons aged 12 to 25 who are at risk, or who are suspected to have mental health conditions. We have rolled out four outreach teams and two youth integrated teams in 2021.

To better support persons experiencing a mental health crisis such as self-harm, IMH has piloted a Crisis Response Team to respond to calls from the Singapore Police Force on cases of attempted suicide. This multi-disciplinary team will conduct an on-site assessment of the suicidal individual and provide appropriate intervention and follow-up management after the immediate crisis is resolved.

Some youths who are hospitalised for risk of suicide or severe self-harm may require post-discharge residential care to allow for space and time to integrate back into the community in a more gradual way. MOH will be developing a new intermediate residential facility to address this. This will add another therapeutic environment – not acute hospital care, not quite a community – for young patients and a new range of possible support services. Further details will be provided soon.

Mr Dennis Tan asked about the cost of mental healthcare services. Patients can tap on the MediSave500/700 scheme to pay for treatments for four mental health conditions under the Chronic Disease Management Programme (CDMP). This includes consultations with psychologists providing services to CDMP providers accredited in giving mental healthcare.

Sir, we have had several iterations of development plans for mental health. The work of the Interagency Taskforce on Mental Health and Well-being is the latest. I hope Members can see that our approach will be comprehensive and holistic. We will be considering a range of challenges from prevention upstream to how to deal with acute, severe illnesses, where time is of the essence. We will also take a good look at facilities, skills and processes, all the way from the community, a new residential centre and the acute services within the hospitals.

We will do this work together with the many professionals and voluntary community organisations that have stepped up an extraordinary mental healthcare response to the challenges of the pandemic, for which I thank them. We will ensure that the lessons learnt become institutionalised and sustainable to benefit our collective mental health for the future.

If I may then, Sir, turn to a different issue – technology.

In response to Ms Mariam Jaafar, as we move to more telehealth solutions and a paper light environment with electronic medical records, clinical staff will receive training and orientation for new workflows.

We agree with Mr Yip Hon Weng that we should continue to better leverage technology in healthcare delivery and our efforts have accelerated during the pandemic. For example, telehealth, virtual ward programmes, the use of chatbots, messaging, video or phone calls to interact with patients, so that they can recover at home instead of in the hospital.

The initial success of these programmes and services has prompted us to study how we can extend it to other groups of hospitalised patients and more clinical services under a Mobile Inpatient Care at Home (MIC@Home) sandbox. We will provide updates on this in the future.

In response to Ms Ng Ling Ling and Mr Yip Hon Weng, similar technology is also being used to help patients manage chronic conditions. For example, the Primary Tech Enhanced Care (PTEC) Home Blood Pressure Monitoring programme at selected polyclinics. These patients monitor their blood pressure regularly at home and submit their readings to a care team in the polyclinic, through a Bluetooth-enabled blood pressure machine and a mobile phone application, saving them a visit to the polyclinic while still receiving timely support. We will be scaling this to all polyclinics and progressively introduce the approach to other conditions such as diabetes.

Project Pensieve is another technology driven initiative. It could enable the earlier detection of dementia among seniors who are at high risk of the disease. Many of our seniors with dementia and their caregivers are not aware of the condition until a more advanced stage of the disease, missing the opportunity for early intervention. This is in part because early symptoms can be subtle and require specialised assessments by a trained healthcare professional in a clinic or hospital, taking up to two hours sometimes.

By using local clinical and technology expertise, an interagency team has developed a digital drawing test, draw with a pen or stylus on a tablet. It takes as little as 10 minutes to estimate the risk of dementia. It uses shapes and symbols and is not affected by which language the patient prefers. Artificial Intelligence is used to analyse how these shapes and symbols are being drawn. The process is simple and can be administered by non-clinical staff and volunteers. The test, then, is accessible. More seniors who are at risk could benefit from earlier diagnosis. This project is still in the research phase, but it represents some of the ways in which we are using technology and local clinical expertise to address the health problems we will face in the future.

We share Dr Tan Wu Meng’s view that technology must enable our healthcare workforce to deliver better care to patients. Good IT user interfaces can indeed improve ease of use and productivity, if they are well-integrated with data systems and clinical workflows. The user experience as well as the manpower and time savings are important considerations when we enhance or roll out new healthcare IT systems. We currently either procure or build our platforms, depending on the availability of ready solutions in the market that meet our needs, at an appropriate price point.

Even as we digitalise, we agree with Mr Yip Hon Weng on the importance of protecting and securing systems and data. MOH has addressed all the Committee of Inquiry (COI) recommendations arising from the SingHealth incident and learnt from them to improve our cybersecurity defences.

We would like to assure Mr Leon Perera that we are actively managing healthcare capacity for future challenges. Last year, we opened three new polyclinics and five new nursing homes including the new NTUC Health (Tampines) Nursing Home which has operated as a Community Treatment Facility (CTF) since September 2021 to support our fight against COVID-19.

This year, the new National Cancer Centre Singapore (NCCS) and Sembawang Polyclinic are on track to open. Preparation works for the redevelopment of Alexandra Hospital and the new Eastern Integrated Health Campus at Bedok North have also started. In addition, the Woodlands Health Campus (WHC) and the TTSH-Integrated Care Hub (ICH) are scheduled to open progressively from 2023. As part of our plan to expand to 32 polyclinics by 2030, residents of Taman Jurong can look forward to a new polyclinic by 2028. The existing Queenstown Polyclinic will also be redeveloped by the end of the decade.

For dental health, we are expanding and upgrading our specialty centres. The new National Dental Centre will be expanded as part of the overall Outram Campus plan. The National University Hospital Dental Centre has started accepting specialty referrals and the new National University Centre for Oral Health has started operations from 7 January 2019. The number of dental specialists in our public health care clusters has risen by 9% per annum from 2017 to 2021.

Mr Edward Chia asked about a sustainable renal treatment strategy. The emphasis should be on the upstream prevention of chronic diseases, through screening for diabetes and hypertension, and promoting healthier lifestyle interventions. MOH has also taken steps to provide better access and integration of care for dialysis patients through the co-location of renal dialysis centres with polyclinics and community hospitals and will continue to do so. In addition, we are encouraging the use of peritoneal dialysis which can be administered at home by the patients themselves.

Sir, in my speech, I focused on mental health, technology, services and infrastructure, but the most important part of our healthcare system is our people, our healthcare workers. Details about our plans from MOH will be provided in the further speeches by my MOH colleagues, but I would like to record my thanks to all healthcare workers for their service to Singapore. Protecting us, keeping us healthy. On a personal note, I would also like to record my heartfelt appreciation to those healthcare workers across our institutions that I have had the privilege to work with personally. My colleagues, my students, most of all, my teachers.

In my speech, I have highlighted examples through which we will make sure that our healthcare workers will have the best possible tools, technology, services and infrastructure, so that they can focus on delivering the best possible care. Curing the sick, relieving suffering, easing our pain and fears and helping all of us to prevent disease and stay healthy. With that, Sir, I wish you and all Singaporeans good health. [Applause.]

The Chairman: Senior Minister of State Dr Koh Poh Koon.

The Senior Minister of State for Health (Dr Koh Poh Koon): Mr Chairman, today, I will address the challenges faced by our healthcare workers, especially during the pandemic and outline MOH’s longer term efforts to take care of our healthcare workers’ well-being and professional development.

Even before the pandemic, an ageing population and increased burden of chronic diseases have placed an increased demand for more healthcare manpower. We factored these needs into our manpower plans and recruitment initiatives.

But COVID-19 has stretched us further. We had to adjust our manpower deployment during the pandemic to meet evolving needs such as the migrant worker dormitory outbreak, as well as swab and vaccination operations.

To Mr Pritam Singh’s query about preparations for ICU surges, I want to reassure him that we have sufficient equipment and consumables to step up ICU beds significantly. And as of January 2022, more than 800 non-ICU nurses have been trained as a reserve to augment ICU nursing manpower by up to 57%. This would enable us to stretch our ICUs temporarily if needed. Thankfully, our ICU capacity is able to cope with the current surge and patients requiring ICU care are a fraction of what we had during the Delta wave. Nonetheless we will continue make the necessary contingency plans given how unpredictable the pandemic has been.

But the pandemic had caused a sudden surge in workload and severely stretched our healthcare workforce. We reprioritised workload and reduced non-essential elective treatments. Absenteeism rates have stayed low, below 10% so far.

Not only have we stretched the public healthcare sector, but those in the private sector stepped forward to help in so many ways, including support from nursing and other healthcare students, as well as SAF. Many have gone beyond their call of duty and we owe them a debt of gratitude.

In spite of COVID-19, we have persisted with actively recruiting for our healthcare workforce from both local and international sources. As of end 2021, the public healthcare workforce stood at about 62,500 staff, an increase of about 1,800 compared to end 2020.

To address Mr Pritam Singh and Dr Shahira Abdullah’s concerns about attrition, MOH had previously shared that the average attrition rate of doctors and nurses from public acute hospitals in 2020 and 2021 combined together was comparable with that in 2019. Specifically, the attrition in our public healthcare workforce was 9.6% in 2019 and it dipped to 6.8% in 2020 at the height of the pandemic. This then accumulated, resulting in a rise in 2021 with a 9.8% overall attrition. But this is rather similar to our 9.6% in 2019.

Specifically, for the acute public hospitals, the average attrition in the period 2020 to 2021 was about 7% to 9% for nurses and about 3% to 5% for doctors. So, the two-year average was quite similar to 2019 levels. However, the 2021 attrition among foreign nurses was 14.8%, much higher than the 7.4% among local nurses. Understandably, some left due to family and personal reasons as the COVID-19 travel restrictions had stopped them from being able to visit and be with their loved ones. But our healthcare workers have stood their post. They have not abandoned their fight against COVID-19 and we thank them for the commitment and the steadfast efforts.

Having said that, this does not mean that we dismiss the concerns of attrition. We will still need to do more to tackle our growing manpower needs. Given our low birth rate and shrinking local workforce, there are just not enough Singaporeans to meet all our healthcare manpower needs.

3.30 pm

As many Members, including Ms Mariam Jaafar, have pointed out, we will need a combination of approaches to ensure an adequate and strong healthcare workforce.

First, we must ensure adequate local training pipelines and continue to attract and enable more mid-career locals to enter the healthcare sector. Our intakes for healthcare programmes at the Institutes of Higher Learning have increased over the past five years. Between 2016 and 2021, intakes for medicine and nursing each increased by about 15%, while the combined intake for allied health programmes increased by about 65%.

The healthcare Career Conversion Programmes (CCPs) enables mid-career locals to acquire relevant training to join the healthcare sector as nurses and Allied Health Professionals (AHPs). An average of around 180 mid-career locals per year entered training between 2019 and 2021 amid COVID-19, higher than the average of 110 per year between 2016 and 2018.

We will regularly review remuneration, to ensure that we continue to attract and retain staff and maintain market competitiveness. We last enhanced the salaries of selected groups of doctors and dentists in 2019. Dr Tan Wu Meng asked that we do a deep review of salaries for nurses and allied health professionals. In fact, we enhanced the salaries of nurses, allied health professionals, pharmacists and allied admin staff in 2021. And there is a second tranche of increases for nurses this year, 2022. We will continue to monitor and review salary benchmarks in a timely manner.

But with a tightening workforce situation here in Singapore, we will have to accept that there will continue to be a need to hire foreign healthcare manpower to complement our local workforce and meet the needs of our ageing population. So, I thank the Leader of the Opposition Mr Pritam Singh for supporting the need for us to hire more foreign manpower to support our healthcare needs.

We are also looking on retaining foreign nurses, including keeping their remuneration competitive. We have also worked with other agencies on factors that are important for their retention.

We also need to look beyond manpower to ensure our resources are optimised. This includes further leveraging technology to extend the capabilities of our healthcare workers and innovating the way we deliver care and services and redesign healthcare jobs along with training and development opportunities so that each category of staff can perform at the top of their licence. This includes training for digitalisation for healthcare professionals to be prepared for the future. For example, NUS has a Nursing Informatics course to equip nurses with the knowledge on the development, analysis and evaluation of information systems augmented by technologies that support, enhance and manage patient care.

We will also continue with our job redesign efforts in introducing new role and new breeds of staff such as Care Support Associates (CSAs) that blend clinical support, administrative and operations responsibilities. We will also change our care models to ensure efficient and effective delivery of appropriate care at all care settings. This includes making sure we right-site patients to ensure that our resources are optimised.

But there will never be enough manpower if we do not empower ourselves to improve our own health. Hence, through preventive health, population health, Healthier SG, as Minister Ong will address later, we will also reduce the load on our overall healthcare system.

To Ms Mariam Jaafar's point about organisational enablers, we agree that this is important and thus, as part of population health, we will be aligning incentives and KPIs with public healthcare clusters in how we design our programme.

All these measures are in progress and will take some time to bear fruit. But there are also immediate pressures that we need to resolve and support our healthcare workers straining under the burden.

The COVID-19 restrictions on healthcare workers intermingling to bond and destress has led to a sense of isolation among healthcare workers. So, I want to assure Dr Shahira, Mr Leon Perera, Mr Abdul Samad and Dr Wan Rizal that staff well-being and morale is an important priority for us.

MOH had set up a cross-cluster Staff Well-being Committee in 2019 to improve the well-being of staff and to minimise burnout. All three public healthcare clusters also provide their staff with counselling services, helplines and peer support networks.

MOH is working with the clusters to review and improve staff feedback channels, staff well-being and mental health tracking and monitoring processes. There are also plans to appoint a Wellness Officer or its equivalent in every cluster to oversee and develop the system changes that are needed.

We are also reviewing our staffing norms in the public healthcare system to strengthen our resilience to future shocks and better cope with fluctuations in workload.

We also agree with Ms Mariam Jaafar's feedback that clusters ought to continue to induct a diverse range of talents and skillsets in their talent development and leadership pipeline.

As highlighted by Dr Tan Wu Meng, one specific group of concern are the junior doctors who had to do long shifts on night calls.

Singapore Medical Council guidelines stipulate that junior doctors may work up to 80 hours a week, including overnight duties of not more than 24 hours, with up to six hours after that for handover or training. This is benchmarked against the USA’s Accreditation Council for Graduate Medical Education’s (ACGME) guidelines.

Surveys showed that 20% of all junior doctors exceeded the stipulated 80-hour work week. This could be due to the nature of clinical work in certain departments or exigencies of service.

Some have proposed night float systems. This entails doctors taking turns to work night shifts for a few days at stretch without covering the daytime work, whilst others work the day shifts. Doctors may feel more refreshed when they start their night shifts with a full day’s rest, although there are possible trade-offs in requiring more manpower to do a shift system, more hand-off between team members, which carries some risk of omission in tasks, and possibly reduced learning experience as they may not follow-through in the entire care process to see how their patients progress over time.

It would be useful in disciplines where doctors on night duties have fewer opportunities to rest, such as Internal Medicine or General Surgery.

The system has been tried in two large departments. Plans to trial this in smaller departments, unfortunately, were curtailed due to COVID-19. When the situation allows, we intend to restart the trials.

As we look at the issue of work hours, let us not lose sight of these important considerations which are inherent in the nature of our work as doctors. With shorter working hours in a week, a junior doctor may have to undergo a longer apprenticeship to acquire the necessary competencies.

But we also recognise that the workload and the nature of clinical work today is different from yester-years, a point which Dr Tan Wu Meng has made, with an ageing population and higher chronic disease incidence, and expectations of more collaborative and consultative care from patients and their families, the nature of clinic work has changed for our junior doctors.

The stresses faced by junior doctors today are symptomatic of a wider need for transformation in the current care delivery arrangements. Whether it is 24-hour or 30-hour shifts, what is clear is that we should not stretch our junior doctors beyond what is physiologically possible and what would risk compromising patient safety, a point also highlighted by Dr Tan Wu Meng.

But I want to caution that a simplistic framing of the issue as just work hours is not diagnosing the root cause of the problem.

Recently, I met with junior doctors from the Singapore Medical Association’s (SMA) Doctors-in-Training Committee and other groups of junior doctors from all three healthcare clusters. They were proactive in sharing best practices on the ground. We had a candid discussion on the challenges they faced, particularly in this COVID-19 period, as well as the trade-offs of possible junior doctor workflow changes.

I am heartened that many of them recognised the complexity and inter-linked nature of the issues pertaining to junior doctors’ working hours.

Therefore, as a first step, MOH has formed the National Wellness Committee for Junior Doctors. Co-led by senior doctors from all three healthcare clusters and MOH, we aim to review and recommend changes to existing healthcare practices and guidelines to improve and ensure the well-being of junior doctors, in three main areas.

First, a review of junior doctor workflow models and work hour norms. Other than the considerations I shared earlier, the review will also have to be done carefully as it will have an impact on the workflow of other healthcare workers who work alongside our junior doctors.

Another area will be to look at the fundamental balance between training and service workload, and transforming our manpower model. It would not be sustainable for us to just simply increase the "flow" of trainees going through the system to meet service demands, as this will eventually lead to a large "stock" of doctors and cause an oversupply later on. Instead, we need to raise the importance and attractiveness of work roles that are core to the service workload.

The second area of focus is career development and training of our junior doctors. Traditional specialist-focused residency programmes are not the only desirable career pathways and there is a need for stronger broad-based generalist paths such as family medicine and hospital clinicians, which if successfully implemented may also address the issue of care-fragmentation across multi-specialty teams.

One such pathway is the Hospital Clinician track we launched in 2020, which we hope to expand significantly in the years to come.

A third area of focus for this Committee will be on working with key stakeholders to promote a more inclusive culture where junior doctors can feel safe in speaking out on matters related to their safety and wellness, and importantly, to co-create policies and solutions at both the institutional and national level.

The issues are complex and seeks to change years of established practice. We aim to put forth preliminary recommendations by the middle of this year so that some immediate measures can be implemented, with a view to completing their final recommendations by early 2023.

We recognise that our healthcare workers have always gone above and beyond, especially during these trying times.

Mr Abdul Samad and Dr Tan Wu Meng would also be pleased to know that MOH has extended the COVID-19 Healthcare Award not just to healthcare staff in public institutions, but also to outsourced staff. This includes cleaners and security officers, who were directly contracted by the public health institutions and publicly funded Community Care Organisations (CCOs). Paramedics under SCDF would be recognised in their own way.

But the biggest encouragement for our healthcare workers must come from the support and appreciation from Singaporeans-at-large whom they serve. We read about spontaneous ground-up actions from Singaporeans to encourage and thank our healthcare workers; examples which were cited by Mr Abdul Samad.

Unfortunately, COVID-19 has also brought out some bad behaviour. We have read about the cases of abuse and harassment towards our healthcare workers. The perpetuators have been taken to task and convicted by the Courts.

Sadly, the number of cases has been on the rise. At end 2021, there were about 1,500 such cases, up from 1,080 cases in 2018.

The actual number may be higher, as many healthcare workers exercise empathy and, therefore, do not always take a legalistic approach, and report and escalate every altercation. However, their compassion should not be misconstrued as an acceptance to abuse or harassment. We need to make sure that our healthcare workers feel safe in their work environment. I agree with Dr Tan Yia Swam that we need to recognise such abuse and institute safe reporting systems and clear penalties on offending parties.

Let me unequivocally state that verbal or physical abuse of any healthcare workers will not be tolerated and offenders will be taken to task. MOH and our public healthcare institutions adopt a zero-tolerance approach towards abuse and harassment of our healthcare workers. Under the Protection from Harassment Act (POHA), public healthcare workers are accorded enhanced protections under section 6 if abused or harassed while carrying out duties.

Aside from legislation, we should look at other ways to deter abuse and harassment and move more upstream. Healthcare workers should have the assurance that their employer and the healthcare system have their back, while providing them with the training to handle situations where compassion and empathy are tested to the limits.

MOH will, therefore, be establishing the Tripartite Workgroup for the Prevention of Abuse and Harassment of Healthcare Workers. With representatives from MOH, the Healthcare Services Employees’ Union, public healthcare clusters, community care partners and private healthcare providers, the workgroup aims to spearhead a coordinated national effort to prevent abuse and harassment of healthcare workers in the public, private and community care sectors.

Our healthcare workers should feel safe to be able and to call out abuse to allow them to focus their energies with the right frame of mind on doing their best for their patients.

3.45 pm

Sir, let me address some other issues raised by Members.

On healthcare affordability, Dr Tan Wu Meng will be happy to know that from 1 July this year, we will expand the number of chronic conditions in the Chronic Disease Management Programme from 20 to 23. The three new conditions included allergic rhinitis, gout and chronic hepatitis B. More than 134,000 individuals will benefit as they can now use their MediSave and CHAS subsidies for these conditions.

We will strengthen our private sector partnerships to meet our growing healthcare needs. Dr Tan Yia Swam raised the need to have stronger oversight over business practices and medical middlemen. Today, Third Party Administrators (TPAs) and concierge services are not regulated under the Private Hospitals and Medical Clinics Act (PHMCA) or the Healthcare Services Act (HCSA), which focuses on regulating direct service provision.

Nevertheless, the Singapore Medical Council's Ethical Code and Ethical Guidelines (SMC ECEG) guide that medical practitioners contracting with TPAs should ensure they remain objective in their clinical judgement, provide the required standard of care and reflect their fees fairly and transparently to the patients.

MOH will continue to monitor patient safety risks and study the evolving landscape of these TPA companies. We will examine how the TPA market will need to be reshaped as we make bigger shifts in preventive healthcare beyond healthcare to health.

On Dr Tan Wu Meng's concerns on Integrated Panels, we had earlier announced that Integrated Shield Plan (IP) insurers had accepted the Multilateral Healthcare Insurance Committee's (MHIC) recommendation to expand their panels.

Today, most IP insurers have at least 500 private specialists, with each insurer's panel covering 80% to 90% of their private medical institution claims. To enable even greater patient choice and better continuity of care, the MHIC is considering if doctors who are already with an IP panel can be recognised by other IP insurers to some extent, as Dr Tan Wu Meng has suggested. We will announce more details in the coming months.

Regarding access to treatments, our Free Trade Agreements and Intellectual Property obligations provide due recognition to investments that patent proprietors make in developing pharmaceutical products. This is not only fair, but also ensures that Singapore remains an attractive location for drug manufacturing, research and innovation. Having said that, we are working with relevant Government agencies to ensure that generic drugs are not unduly delayed or obstructed from entering the Singapore market.

MOH will also continue to strengthen our position as a biomedical hub and anchor our domestic capabilities in new technologies, such as cell-based therapy, and strengthen the resilience of our healthcare system.

Mr Chairman, in today's speech, I spoke extensively about our healthcare workers. To our healthcare fraternity, I know many of you may have felt exhausted and demoralised, especially in the last two years. Take heart – Singaporeans are appreciative of your steadfast commitment and dedication.

MOH is undertaking reviews to introduce structural changes in our healthcare system and manpower. We seek your patience as we work with the healthcare clusters to engage you on improving the situation on the ground.

Let us uphold the values of the healthcare profession to provide the best care we can for our patients. Indeed, patients must be at the heart of all we do. But every healthcare worker also matters. Let us all, Singaporeans, help them to take better care of us. [Applause.]

The Chairman: Minister Masagos Zulkifli.

The Second Minister for Health (Mr Masagos Zulkifli B M M): Chairman, families form the bedrock of our society. Since our Independence till today, they have been our first line of support, crisis after crisis. During the pandemic, families have been a key pillar of strength, supporting each other through the ups and downs, in many ways that we, the Government, can never replace. Over the decades, we have strengthened our policies to support the building of strong and resilient families.

At MOH, we are fully committed to this mission. One way that we are doing so is by making Singapore a great place to raise families. And we will do so by building a more integrated social-health ecosystem for our next generation – our young. This support will be anchored in the community, close to our homes and, most importantly, anchored around the family.

Our starting point is to give every child a good start in life. This also means enabling parents to raise healthy, happy and able children, who can reach their fullest potential in life.

MOH has been building an integrated ecosystem to support children and their families, across the health, social and education domains. Last year, we set up the interagency task force to develop a five-year Child and Maternal Health and Well-being Strategy.

Ms Ng Ling Ling and Dr Wan Rizal asked for an update and how we were addressing the health needs and risk factors of mother and child. Let me share briefly.

Over the past year, the task force has focused our efforts along three main thrusts.

First, we have reviewed evidence-based research findings and are translating them into policies and programmes. This will enable us to effectively address the health needs, risk factors and the wider health determinants across the developmental stages of a child, starting as early as pre-conception to adolescence.

Second, we have reviewed the current model of service delivery for children and their families, with the aim to improve accessibility to services. We engaged a wide range of stakeholders on how we could strengthen support for them. This included parents, grandparents, caregivers and professionals from the healthcare, education and social service sectors.

Third, we reviewed how we communicated and engaged these stakeholders because we wanted to know what mattered most to them and to ensure that our messages and support to them remained relevant. I am glad to share that we have completed the first phase of review and planning. We will continue further cross-domain and cross-agency discussions over the next year.

Allow me to elaborate on two cross-agency initiatives that we will be rolling out from this year.

Let me first say also that parents play a pivotal role in their child's development. To build strong and resilient families, we need to ensure that parents can get timely access to health services so that they are healthy and able to take care of their children.

We recognise the challenges that many parents face. They are often stretched for time, having to balance multiple roles, both in the family and at the workplace. This is an area where we could better integrate services so both parents and child can receive support concurrently without making multiple trips.

To this end, we started two mother-child dyad service pilots at our polyclinics – the Integrated Maternal and Child Wellness Hub programme at Punggol Polyclinic since 2019 and the EMBRACE programme at Yishun polyclinic in 2020.

Families can access integrated services, such as vaccination, childhood developmental and postnatal depression screenings and breastfeeding support services concurrently, for both mother and child. Since their launch, I am glad that more than 10,000 children and mothers have benefited from these services.

An example is Ms Joan Zhu. She had brought her nine-month-old son to Punggol polyclinic for his vaccinations. At the same time, the care team at the Integrated Maternal and Child Wellness Hub provided her with detailed guidance on what to expect at each stage of her son's development, for example, the types of food and developmental activities that may be appropriate at different stages. Through their support, she and her husband have developed better knowledge and are more confident in caring for their newborn. We are happy with the success of the pilots and the positive feedback given by the parents.

Therefore, I am pleased to announce that MOH will scale up the mother-child dyad services to 12 more polyclinics over the next three years. We want more children and their families to benefit from this service.

To strengthen support for children with higher or more complex needs, the National Healthcare Group Polyclinics has also rolled out the EMBRACE^PLUS programme, a component of EMBRACE pilot. It actively identifies and supports young children under three years old from low-income families living in rental flats, to address potential health risks.

Under this initiative, the children will be systematically screened for both health and social needs, when they visit the polyclinic for their regular check-ups, such as vaccination or childhood developmental screening, for example, whether the child's family may be facing any financial difficulties that could impact their health and well-being.

The EMBRACE^PLUS team will also work closely with social and community agencies, including practitioners from KidSTART. This ensures that their needs are holistically supported.

Next, we want to take integration a step further and will do so across the health and social domains so that we can provide for our mother-child dyad, beyond just physical well-being and those with complex care needs like the EMBRACE^PLUS.

To this end, I am glad to share that we will pilot an integrated family support programme later this year. It will be called "Family Nexus". Families can access varied services at a one-stop community node near their homes, such as polyclinic, a GP clinic or a social service agency.

For example, families can attend both parent support groups organised by Families for Life @ Community and receive vaccinations or developmental screening for their children at the same location. We will also have a "concierge service" representative onsite. They can assist families with accessing other relevant programmes by our community partners. We will also explore the use of virtual access to services to enhance convenience.

The pilot will reduce the need for families to visit multiple sites for different services and most importantly, to integrate and provide wraparound support across the social-health domains for families as their children grow. Our support for families and their children must also be holistic and comprehensive. Senior Minister of State Janil has shared on initiatives to promote mental well-being and improve lifestyle habits and Parliamentary Secretary Rahayu will elaborate on our public education efforts.

In closing, together with the support of Singaporeans, community partners and Government agencies, we will continue to strengthen support for families. We will anchor care and support for our young and their families in the community and, most importantly, around the family, because we want Singapore to be a great place for families to thrive and flourish. [Applause.]

The Chairman: Parliamentary Secretary, Ms Rahayu Mahzam.

The Parliamentary Secretary to the Minister for Health (Ms Rahayu Mahzam): Mr Chairman, preventive health is an important part of ensuring overall health and well-being. Good preventive health will lead to lower health risks, earlier detection and management of diseases, as well as longer-term sustainability of our healthcare system.

To support good preventive health, we constantly evolve and adjust our approach to build a healthy ecosystem for Singaporeans. In response to Ms Ng Ling Ling's question on how we encourage individuals to take ownership of their health, we do so by making it easier to adopt and prioritise healthy living and bring more lifestyle programmes closer to our residents.

Our efforts can only succeed with strong participation of Singaporeans. Today, I seek the continued support of Singaporeans as I share our upcoming efforts to collectively nudge the community towards healthier ways of life and strengthening support for women, seniors and their families.

Key components of a healthy lifestyle include good nutrition and diet as well as sufficient physical activity.

First, good nutrition and diet. We actively encourage Singaporeans to adopt a healthier diet, particularly for sugar and sodium consumption.

Mr Ang Wei Neng asked about the War on Diabetes, which we declared in 2016. Since then, based on the recent National Population Health Survey, age-standardised prevalence of diabetes has remained stable at 7.9% from 2017 to 2020.

4.00 pm

In 2019, MOH announced plans to introduce regulatory measures for beverages high in sugar content. From 30 December 2022, Nutri-Grade beverages sold in Singapore in prepacked form and from automatic beverage dispensers will be subject to new labelling requirements and advertising prohibitions.

The Health Promotion Board (HPB) also extended the Healthier Ingredient Development Scheme (HIDS) in 2018 to support the development and commercialisation of lower-sugar products. As of December 2021, seven beverage suppliers were on board the scheme.

Through these efforts and support from the industry, we have observed early success with the industry accelerating the reformulation of sweetened beverages.

Singaporeans can now choose from a larger variety of healthier drinks. From when engagement started with the industry in 2017 to 2019, the proportion of healthier choice beverages in the market increased from 58.6% to 71.7%. The median sugar level of sweetened beverages has also decreased from 8.5% to 6.3% over the same period.

To further reduce the intake of sugar, MOH also announced in 2020 that the labelling and advertising measures for sugar will be extended to freshly prepared beverages. HPB has conducted an implementation consultation with the industry on the proposed specification. More details of the measures will be released when ready.

Together with public education, we will continue to explore using regulation and industry support to make healthier ingredients and foods easily accessible to Singaporeans.

Mr Ang Wei Neng will also be pleased to know that we will be doing more to reduce Singaporeans’ sodium consumption. Singapore residents are on average consuming 3.6 grammes of sodium a day. This is almost double that of World Health Organization’s recommended limit, translating to more than 1.5 teaspoons of salt daily.

High sodium intake is associated with increased risk of hypertension, which is in turn associated with higher risks of stroke and heart attack. The National Population Health Survey revealed that slightly more than one in three Singapore residents aged 18 to 74 had hypertension during the period 2019 to 2020. This is a significant increase from 2017 and reminds Singaporeans of the need to adopt better dietary practices.

We will introduce a three-pronged strategy to reduce sodium consumption.

First, sodium substitution. We will increase support through HIDS to shift the food service sector towards using lower-sodium alternatives such as lower-sodium salt, which contains about 30% less sodium compared to regular salt at the same quantity.

Second, increasing the range and variety of lower-sodium salt, sauces and seasonings. HPB will work with major salt suppliers and retailers to expand the range of lower-sodium salt. We will also ramp up existing efforts using HIDS to spur reformulation of lower-sodium sauces and seasonings.

Thirdly, public education. HPB will launch a multi-year nationwide campaign to raise awareness of the effects of overconsuming salt in our diet and educate the public on available alternatives and ways to replace salt without compromising on taste.

Sufficient physical activity is also important for a healthy lifestyle. There are various efforts to support Singaporeans to exercise. For example, the National Steps Challenge^TM continued amid COVID-19 and is now in its sixth season.

Additionally, HPB’s leisure-time physical activity programmes such as mall workouts at health promoting malls, Sundays at the Park, Community Physical Activity Programme are still available where possible, in line with prevailing safe management measures. Where feasible, some on-ground programmes are taken virtually, for participants who work from home or prefer to work out remotely or individually to keep active.

Another area of concern impacting healthy living is smoking. Tobacco use is the single greatest cause of preventable death globally. About 10.1% of Singaporeans smoke daily based on results from the National Population Health Survey 2020.

In Singapore, we are committed to our long-term goal of bringing the overall smoking rate to a level that is as low as possible. We need to consider Singapore’s context and local trends of tobacco use in developing our tobacco control strategy.

Globally, there is an increasing trend of smokers using vapourisers. Together with HPB and the Health Sciences Authority, we are employing heightened multi-pronged measures against vaping. This includes increasing education on the harms of vaping, enhancing the penalty framework for vaping and better whole-of-Government coordination in preventing smuggling and illicit sale and use of vapourisers. To strengthen public education efforts and reduce demand for vaping, HPB is planning to roll out a vape-free campaign later in 2022 targeted at youths and younger adults through popular digital platforms.

To support smokers who wish to kick their smoking habits, we previously announced plans to provide subsidies under new tobacco cessation pilots at public healthcare institutions. I am pleased to share that we have received proposals from our healthcare institutions and are evaluating them closely.

Concurrently, we will continue to strengthen our existing multi-front approach to curb tobacco consumption and vaping.

With a healthy diet, active and smoke-free lifestyle, we can all live better. To help us make timely adjustments to our lifestyle behaviours and seek treatment early if needed, I encourage Singaporeans to seek appropriate, evidence-based health screening.

Chronic disease screening participation rates had hovered around 63% to 66% from 2017 to 2020. We note Dr Lim Wee Kiak’s interest in health screening. We will be doing more to increase take-up, such as working with partners to further encourage the use of Screen for Life, a national health screening programme that provides heavily subsidised chronic disease and cancer screenings.

As Dr Lim Wee Kiak pointed out, immunisations are important to protect ourselves against vaccine-preventable diseases. The National Adult Immunisation Schedule (NAIS) was introduced in November 2017 to provide national-level guidance on important vaccinations for persons aged 18 and older. Based on the National Population Health Survey 2020, the uptake for influenza vaccination in persons aged 65 to 74 has increased from 14% in 2017 to 23% in 2020.

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

To make vaccinations recommended under the NAIS more affordable and accessible, subsidies have been extended to these vaccinations since November 2020, at both CHAS GP clinics and polyclinics. MOH actively works with our primary care partners and other stakeholders such as HPB to increase uptake of these nationally recommended vaccinations, especially among seniors for influenza and pneumococcal vaccinations. We urge Singaporeans to proactively find out more and take up these vaccinations.

To support everyone to be as healthy as possible, we also cannot adopt a one-size-fits-all approach, as everyone faces different risks and challenges. Our health promotion efforts are inclusive to all and targeted efforts taking into consideration different backgrounds and cultural preferences are layered on for select groups to increase their access to healthy living resources.

HPB’s Healthy Living Passport programme was piloted with about 50 families last year to serve the needs of our lower-income families. Activities that parents and children engage in include planning for healthier and economical meals as well as games emphasising the importance of parent-child communication and a balance of physical activities with age-appropriate use of smart devices. Volunteers who befriend the families also participate in the programmes and continue to provide health tips based on the families’ needs after the programme.

Preliminary results from the pilot indicate that more than 90% were satisfied with the programme and about one-third of them have started to adopt healthier habits in the areas of nutrition, mental well-being and physical activity. HPB will be reaching out to more families this year. Mdm Chairman, please allow me to say a few words in Malay.

(In Malay): [Please refer to Vernacular Speech.] Dr Wan Rizal asked about outreach efforts to our minority communities. Last year, I shared plans to form a new workgroup aimed at strengthening health efforts for the Malay community. After identifying the key issues that should be given attention, HPB has brought together community leaders with the experience and expertise to form a Malay Community Outreach workgroup, or MCO. Under MCO, there are five new sub-committees focusing on mental well-being, reducing smoking, improving dietary habits, increasing physical activity and health screening within the Malay community.

MCO will work with various parties to expand the reach of successful HPB programmes. For example, HPB collaborated with M³, the Malay Activity Executive Committees (MAECs) and mosques to organise online wellness workshops for more than 200 Malay residents. This year, HPB will expand its reach by working with all MAECs.

To encourage healthier eating habits within the Malay community in the month of Ramadan, HPB partnered with MAECs, Mendaki, mosques and Malay-Muslim organisations, such as the Tabung Amal Aidilfitri Trust Fund and Perdaus to distribute healthier groceries to more than 24,500 Malay families. We will work with more MAECs, mosques and Malay-Muslim bodies to promote healthier eating habits during the month of Ramadan this year.

I would like to share and celebrate the success of Mr Azrin, a strong advocate for healthy living in the community. Mr Azrin has served the Marsiling MAEC for more than 10 years. As chairman of Marsiling MAEC, he works actively with HPB and other partners to organise various activities that cater to residents’ needs, such as health talks and screenings. During Ramadan last year, he helped HPB to distribute healthy grocery packs to low-income families and encouraged them to choose healthier food during the festive period. As the Vice-Chairman of An-Nur Mosque, he also onboarded the mosque on the Jaga Kesihatan, Jaga Ummah (Taking Care of Health, Taking Care of Community - JKJU) initiative. Mr Azrin also practises what he preaches daily. He and his family stay active by walking and cycling, and chooses healthier products that carry the Healthier Choice Symbol when buying groceries. May Mr Azrin's efforts inspire the community to lead a healthier lifestyle.

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

(In English): Similarly, HPB also considers cultural sensitivities and partners stakeholders to implement health promotion activities for the Indian Community.

For example, HPB has been working with key stakeholders like the Singapore Indian Development Association (SINDA) to tap on their programmes and culturally significant events such as Deepavali to reinforce healthy cooking and eating as a family. HPB also actively engages Indian food and beverage outlets to participate in the Healthier Dining Programme, which provides and rewards customers for selecting healthier options.

Individuals, such as Mdm Lalitha have also stood up to promote health within the community. Believing that mental well-being is just as important as physical health, she co-founded Club2Care in 2017, a non-profit organisation to create awareness of the importance of mental well-being and seeking help when needed within the Indian community. Club2Care is a supporter of HPB’s "It's OKAY to reach out" campaign for good mental well-being. Thank you, Mdm Lalitha, for your support and extension of our work.

HPB is partnering MCCY to establish a $1.5 million Our Healthy Singapore Fund. The fund will support more community volunteers and partners like Mr Azrin and Mdm Lalitha to develop programmes that are closely in tune with their communities’ needs, and therefore, be more targeted and effective in developing a healthier nation.

Other than keeping the general population healthy, MOH is adopting a whole-of-Government approach to provide holistic support to women as well as their partners and families for better population health outcomes.

Minister Masagos and Senior Minister of State Janil shared on the Child and Maternal Health and Well-being Strategy to give our young a head start. Please allow me to elaborate on some of our communications and engagement efforts under the Strategy.

Over the course of last year, HPB has conducted focus group discussions and in-depth interviews with parents-to-be, fathers, mothers, medical and social service professionals to gain insights to their needs and preferred type of support.

HPB also launched Parent Hub recently. It is a one-stop evidence-based resource portal providing local health information. Resources are broken down into actionable steps that parents can adopt for children and youths' health and well-being. This addresses feedback from couples and parents about being “lost” in the varied opinions that are available online and consolidates reliable information in one place.

Parents like Ms Richelle and Mr Tan have given their stamps of approval for Parent Hub. As parents of two children of different ages, Ms Richelle and Mr Tan shared that most online resources and e-books they referred to previously were age-specific and time consuming to go through, but they now can find all the information they need for their children under one portal. As relatively new parents, my husband and I are also benefiting from the nuggets of information and quizzes on Parent Hub.

In addition, we are working across various public agencies to coordinate programmes so that parents-to-be and parents are kept up to date, equipped with relevant information and skills, and can easily navigate programmes from different agencies. For example, updates on school-based health programmes are also shared via MOE’s Parent Kit, a resource kit that parents can conveniently access digitally via the MOE’s Parent Gateway mobile application.

4.15 pm

We understand Miss Cheng Li Hui had concerns about how we are supporting couples on fertility health. Firstly, as fertility declines with age and the likelihood of pregnancy complications increases with maternal age, we should continue to encourage couples to marry and start their families early. We are looking into supporting couples with ready access to evidence-based fertility health information to empower them to make fertility decisions and enable them to seek help when needed.

Secondly, Minister Indranee had earlier shared that we will be introducing new funding support for certain types of Pre-implantation Genetic Testing, which will benefit Singaporean couples who would like to conceive but are at risk of transmitting serious inheritable diseases to their offspring. We also recognise the psychosocial impact that fertility treatments may have on couples and are exploring how we may better support them.

Our partners in the community have done good work to increase awareness on women’s health issues and promote healthier lifestyle practices amongst women. Some of these partners like Breast Cancer Foundation, Singapore Cancer Society and Persatuan Pemudi Islam Singapura (PPIS) have been encouraging women to come forth for their recommended breast and cervical cancer screening tests. Other partners, such as Osteoporosis Society Singapore, have been reaching out to the wider population, from Primary school students to adults and seniors, to increase awareness about bone health, osteoporosis and fall prevention.

To amplify awareness and create sustainability to some of these initiatives, the Women’s Health Committee that I chair will run a women’s health event in the later part of the year. This would strengthen our outreach efforts by bringing together all the members’ efforts, events and activities with the aim of getting women to take charge of their own health under a common umbrella.

Finally, I would like to bring your attention to another core segment of our society: our seniors. We are committed to celebrating our seniors and enabling them to live to their fullest potential in the community.

Mr Yip Hon Weng asked about the Ageing Plan refresh. We have engaged over 5,000 Singaporeans from all walks of life to discuss the refresh of our Action Plan for Successful Ageing.

Over the past year, we also started working on our plans to support seniors in the three Cs: Care, Contribution and Connectedness.

The first C – Care. Many seniors take pride in staying active and taking charge of their own well-being. To support this, MOH actively onboard aged care facilities onto the new Eldercare Centre Service Model, where seniors can receive Active Ageing, Befriending and referral to Care services.

Ms Tin Pei Ling spoke about engagement with seniors. This model enabled seniors to remain connected to both care staff and other seniors even during the pandemic.

For example, Mdm Jarnail, who stays alone, has received continuous support and social engagement from the Blossom Seeds’ Eldercare Centre care staff. With their support, she continues to engage in both physical and virtual activities, such as the National Day Intergenerational Programme with schools. She also participates in exercise sessions, where she made friends with other seniors and became healthier and more alert. Mdm Chua from the same Eldercare Centre, also benefits from the Healthy Ageing Promotion Programme For You, HAPPY in short, which consists of dual-task exercises incorporating cognitive and social engagement elements to delay physical frailty and prevent dementia. This enables her to stay socially connected and healthy, while her son works in the day.

We are encouraged by these and many other positive stories and feedback received and are expediting the onboarding of more Eldercare Centres. By June 2022, we will set up over 115 Eldercare Centres. These will be accessible and located near both existing and new BTOs.

Ms Ng Ling Ling can be assured that we will provide care and support services for seniors, including those living in new 2-room Flexi flats. Befriending is also a key part of the Eldercare Centres, especially for seniors staying alone. This will be complemented with outreach by the Silver Generation Ambassadors.

In addition, we provide tele-befriending and emergency response services to seniors through the "CareLine" social support hotline. CareLine runs 24/7 and is supported by call agents trained in vernacular languages. I would like to share with Mr Pritam Singh that CareLine is supporting around 17,000 vulnerable seniors, as of December 2021. Each month, we also receive around 30 calls that require emergency services. To reduce the burden on emergency services, call agents are trained to triage seniors’ conditions after a distress episode and provide remote assistance or activate non-urgent in-person assistance through nearby community providers.

Over the past few years, we have taken many steps to strengthen care initiatives for seniors in a comprehensive, accessible and cost-effective manner. We will share more details during the launch of the Refreshed Action Plan later this year.

The second C – Contribution. Many of our seniors want to contribute meaningfully. This may be through learning, volunteerism and employment.

One interesting project which emerged during our engagement sessions with Singaporeans was "Stories for Our Seniors". Through this initiative, seniors can volunteer to tell stories using their Mother Tongue Language. This encourages the building of inter-generational bonds with younger Singaporeans and the imparting of life learnings and values through recounting their own experiences, history and heritage. These active interactions can help to address concerns raised by Ms Tin Pei Ling about the deterioration in mental acuity, emotional and physical well-being that seniors may face during the pandemic.

I would like to assure Ms Tin Pei Ling and Mr Henry Kwek that we have also been actively resuming active-ageing programmes and revising the guidelines to facilitate seniors’ participation in a safe manner.

Next, HPB and the People’s Association will also jointly roll out a new Health and Wellness Programme called "Live Well, Age Well" in our community nodes. Through a holistic programme, it aims to empower seniors to improve and maintain their physical, mental and social well-being. It will be gradually rolled out nationwide from May 2022.

The last C – Connectedness. We will continue to support seniors to age-in-place by increasing access to diverse home and community-based care options within an inclusive built environment. For example, as Mr Yip Hon Weng pointed out, palliative care is an important focus. We have grown our home palliative places steadily from 2,900 places in 2019 to 3,400 places in 2021 to fulfil seniors’ wishes to pass on at home. This enables seniors to access affordable care options, even at the end-of-life and as they stay close to their families and friends.

Last year, we also launched the Community Care Apartments at Bukit Batok, which was oversubscribed. We, therefore, see potential in expanding the housing-cum-care model to the private sector.

As announced by MND, we will launch a private Government Land Sale in 2022 to catalyse care innovation for seniors, where tenderers will be invited to propose innovative assisted living models. This will complement the public Community Care Apartment model. Seniors can look forward to a continuum of care that supports their physical and mental well-being.

To conclude, MOH will continue to enhance upstream efforts to sharpen our preventive health strategy. We are also committed to strengthening our support for couples before and throughout their parenthood journey and seniors to age well in their golden years.

As the Government puts in place various measures and resources, we would also like to urge Singaporeans to take greater ownership of your health today and make positive strides, so that together, we can all live better, for longer. [Applause.]

The Chairman: Minister Ong Ye Kung.

The Minister for Health (Mr Ong Ye Kung): Mr Chairman, I want to thank Members for all your questions and your cuts, and my MOH colleagues for addressing most of them and stitching up most of the cuts. There is a remaining batch mostly on preventive care, which I will address.

Mr Chairman, please allow me to start with a tribute to our healthcare workers. For over two years, they have toiled and fought against the COVID-19 virus, putting themselves in harm’s way, undergoing tremendous stress and, even as we speak, they are keeping our population safe and life in Singapore as normal as possible.

At MOH, we have been doing whatever we can to support them, ensuring sufficient PPE, prioritising them for vaccinations, decanting as many patients as possible to COVID-19 Treatment Facilities and out of the hospitals, persuading the public to undertake self-recovery if they are infected and experience mild or no symptoms, and imposing the very difficult "no visitor" rule in hospitals.

More than these clinical protections, we must stand up for them, against the abuse they suffer under the hands of a small minority of our population. I thank Members who have spoken up for healthcare workers on this. MOH’s instructions to the leaders of our public health institutions are clear – we must always protect them against abuse and insults. This is something that we must also do as a society.

There are now good indications that the Omicron transmission wave has peaked and starting to subside. With that, I hope, not too long from now, healthcare workers will finally have a well-deserved and lasting respite.

The men and women of the healthcare sector, are brave, dedicated, committed, big-hearted, professional and they deserve all the support, respect and understanding that we can give. [Applause.]

Mr Chairman, today, I would like to update Members on a major healthcare initiative to focus on preventive care. It is called Healthier SG. It will address the questions on preventive care from several Members – Dr Tan Wu Meng, Ms Ng Ling Ling, Mr Ang Wei Neng, Dr Lim Wee Kiak, Mr Henry Kwek and maybe others.

This is a journey started more than 10 years ago by previous Health Ministers, to focus on health, rather than cure. During this journey, we have built a very robust foundation for the Singapore healthcare sector. The changes I am about to announce are only possible because of all these past achievements. For example, from 2010 to 2020, the capacity and capability of the healthcare system have been strengthened significantly.

Let us take acute hospital beds which increased by 40%, as we opened three new acute public hospitals – Ng Teng Fong General Hospital, Sengkang General Hospital, Khoo Teck Puat Hospital. Nursing home beds increased by 70%. Senior Care Centre capacity expanded almost four times.

The number of doctors and specialists increased by 65% to almost 15,000 now; nurses increased by 45% to 42,000 now. As a result, the number of doctors per thousand population improved from 1.8 to 2.6 and that for nurses gone up from 5.8 to 7.4. These ratios are similar or higher than most Asian regions and territories, normalised to the proportion of older people in the population. But they are lower than ratios in OECD countries, as observed by Ms Mariam Jaffar. This is due to a variety of reasons, including the population age profile, the model of care in different countries, between western countries and in Asia, and also the way western countries fund, subsidise and insure healthcare.

In terms of policies, we implemented MediShield Life and CareShield Life; we rolled out the Pioneer and Merdeka Generation Packages; we introduced the Community Health Assist Scheme or CHAS.

In terms of structures, we established three healthcare clusters, centering around Singapore General Hospital (SGH), Tan Tock Seng Hospital (TTSH) and National University Hospital (NUH), each with significant economies of scale and capabilities.

Outcomes have improved. Between 2015 and 2020, there are fewer readmissions into hospitals within 30 days after discharge, fewer U-turns, from 11.5% in 2015; 2020 – it came down, 10.7%. Response time to cardiac and stroke care at our hospitals have also improved.

So, now, if you look across 204 countries in the world, Singapore had the highest life expectancy at birth – for men, at 83 years; and women, at 87 years.

After 10 years of foundation laying, plus a pandemic crisis, it is time for us to take the next big step. There is urgency to this, because in the next 10 years, long after the COVID-19 dust has settled, we will have to tackle our biggest healthcare challenge since our nation began – the deteriorating health of our population.

Dr Lim Wee Kiak asked what is driving cost increases. Deteriorating health is driving cost increases. What then in turn drives deteriorating health? Two major driving forces.

4.30 pm

First is ageing. Currently, about one in seven residents in Singapore are seniors aged 65 and above. By 2030, that number goes to one in five. An older person is more likely to fall sick or suffer from severe illnesses compared to a young person – it is a fact of life. We see this in our parents and grandparents and in time, we will feel it ourselves.

Second driving force, which is quite aside from age, Singaporeans young and old, are, generally, getting less healthy, even after adjusting for age. For example, in 2017, about two in 10 has high blood pressure. In 2020, this has become about three in 10. There are more of us with high cholesterol, from about three in 10 to four in 10, and I am one of them.

Fortunately, for diabetes, the prevalence rate has been constant, likely due to our efforts in the War on Diabetes.

More of us are getting obese. From 2017 to 2020, the obesity rate has gone up from under 9% to over 10%, undoing many years of progress.

The first factor of ageing, that is due to the march of time. There is very little we can do about.

The second driving force due to deteriorating health, this is due to the will of people, of which there is plenty we can do about it. Because deteriorating health is mostly a function of lifestyle – too sedentary, too much device time, too little exercise, too much sugar, salt and fat in our diet; and putting off looking after our health until it is too late.

And indeed, living unhealthily is often more carefree and often more enjoyable. But we do not realise that we are paying for these instant gratifications by instalments, with our long-term health – bit by bit – until we realise the snowballing cost later in life.

So, a young person who is obese, or has high blood pressure or high blood sugar, he may feel all right now, but actually, he may be a walking "time bomb". When he is older, there is a high chance of him being struck with a heart attack, stroke or require dialysis.

When these illnesses strike, they are painful. They snatch away from us quality of life and happiness. They will burden family members and loved ones, emotionally and financially.

For this generation of seniors, many have several children, who can all chip in to help take care of them. And even so, it can be quite taxing.

But people around my age, slightly older, slightly younger, we have fewer children and we are likely to live longer. That means when we are in our 80s, 90s and if you are lucky, 100s. If you fall very sick, unable to walk, change, eat, shower, our children will be in their 50s or 60s and hopefully, they will be able to take care of us.

Beyond the immediate family, sickness across the population imposes a huge burden on the healthcare system and on our taxpayers.

We heard this sobering piece of data during the Budget debate and Minister Lawrence Wong mentioned – Government healthcare expenditure tripled over the last 10 years. Based on current trajectory, it will again, more or less triple in the next 10 years, to $27 billion in 2030. By then, healthcare budget may well be larger than that for defence and education.

To make healthcare affordable, the Government will have to continue to subsidise healthcare. And that is the key reason why additional revenue from GST increases is needed.

Even so, the two percentage-point increase in GST may not be sufficient given the rate at which healthcare costs are increasing. That is why we also need to control costs. We have been doing so through bulk buying of drugs, using cost-effective treatments, better clinical procedures, right siting patients and moderating the buffet syndrome caused by healthcare insurance.

But the more fundamental way to tackle cost is at its roots. That is, to make us healthier. It would not reverse the impact of an ageing population, but it can reduce the rate of increase and "bend the cost curve" downwards in the long run. It will still slope upwards but we can bend it downwards.

How are we doing this? Let me explain.

Many doctors that I have spoken to have always wondered: how did a patient become so stricken with chronic illness? Why did not he make lifestyle adjustments when he was younger? Why did he leave it too late? Why only now that he comes to me when he is so sick?

I can relate to that inaction. When I was younger, in my 30s and 40s, you feel almost invincible – you will never fall sick. And I did not feel the need to take care of my health too. Then, a doctor friend of mine kept nagging me to go for health screening. "Go for health screening." He sees me, he says, "Go for health screening." Since he is my friend, I listened to him.

Then, after the test, he found that I have quite high levels of cholesterol. Based on my risk level, he performed further tests and found a very small calcium deposit in one of my heart arteries. So, at his advice, I started taking some medication, adjusted my diet – nothing very austere. I have to cut down chilli crabs, prawns and sotong – not a huge sacrifice, as Mr Pritam Singh is acknowledging. That is austere? No, I can still eat them once a month. I just do not eat them every other day! So, eat in moderation but certainly not deprivation. If anyone wants to treat me to seafood, I will say yes!

I just went two weeks ago and my reading are now fine. More importantly, because of early intervention, I probably averted a major heart bypass surgery when I become old, or worse, a heart attack that may kill me and distress my family and my loved ones.

We usually associate better healthcare with fascinating medical technology or heroics in the operating theatre like when we watch Grey's Anatomy. Those are important but good health is more likely to come from an accumulation of the humdrum and the mundane, because as the saying goes, "prevention is better than cure."

We need to, as Mr Ang Wei Neng and Mr Henry Kwek said, maintain health, rather than treat sickness. That is why we are not called the Ministry of Sickness, but we are called the Ministry of Health!

The measures must be taken early, when the person is still healthy. It must identify the risk factors in our lives that will erode our health slowly and quietly, and then address these factors. It must be done in homes and in the community, not in hospitals or clinics.

It is best centred on the family doctors – in polyclinics and GP clinics – and less on surgeons and specialists in hospitals. Family doctors must then become the most important anchor of our healthcare system.

This new strategy centred around primary care is called Healthier SG. We have worked out the broad plan but still finalising the details. Over the next few months, we will be consulting different stakeholders, Singaporeans from all walks of life, GPs, healthcare workers and community partners to gather their inputs and views.

MOH will then flesh out the details in a White Paper and table it in this House for debate. Today, I will outline five key components of the Healthier SG strategy.

First, mobilise our network of family physicians and family doctors. Studies have shown that people who go to only one family doctor consistently, are generally healthier. They have fewer visits to the emergency department and fewer episodes of hospital care.

This is because the doctor and his care team know you well and can detect early signs of any problems in a timely and accurate way. The family doctor can do for you what my friend has done for my chronic condition. They can be what Dr Tan Wu Meng described as the "coordinating physician".

However, only three in five Singaporeans have a regular family doctor. The other two tend to doctor-hop. Go to doctor A for hypertension medicine, go to doctor B for cough and cold and get MC. So, there is no one family doctor who knows our overall health condition and family health history well enough to be able to see the link between different care episodes, even across different family members.

And we now have a golden opportunity to bring as many of our family doctors as possible into this long-term national public health programme – and that opportunity is made possible by COVID-19.

When we needed more people to get vaccinated against COVID-19, I personally wrote to the GPs and also to TCM practitioners and asked them for help. So, they heeded the call, explained the need for vaccinations and persuaded many of their patients to take the jab.

GPs are nodes of trust. Throughout the pandemic, they served as the first port of call for people who fell sick and suspected that they might have been infected by COVID-19.

Then, during the Omicron wave, GPs took on an even greater role – they assessed the severity of patients coming to them, placed them on home isolation if they have mild symptoms and low risk and then supported their recovery, often by telemedicine. And therefore, they demonstrated that rest and recovery at home is appropriate for many ailments and that telemedicine does work.

Our COVID-19 response would have been inadequate, even crippled, if not for the contributions of our family doctors. They have been a key component of the national crisis response.

MOH has been working in partnership with GP clinics for some time, started by my predecessors. They are part of our CHAS programme. They also serve as Public Health Preparedness Clinics (PHPCs) during pandemics. COVID-19 has deepened that partnership and now, we can leverage on this in order to implement Healthier SG.

We can leverage GPs to attend to more patients, not for coughs and colds, but devoting time to provide preventive care. MOH will support this, by building up the clinics' capabilities, such as telemedicine and IT systems. We will work with the GPs to develop the skills of clinic healthcare team and forge partnerships with hospitals to deliver more integrated team-based care.

The second component of Healthier SG is healthcare plans. Seeing our family doctor for preventive care is different from the occasional visit to their clinics when we do not feel well.

It means regular scheduled check-ins – at least once a year – so that the family doctor can assess your overall health condition, conduct necessary health screenings, track your results, administer vaccinations if need be, advise you on adjustments in lifestyles to help you achieve your health goals.

And this is especially useful if you are at risk of developing a chronic condition, like diabetes. A care plan can help prevent it. To support residents to follow through with the care plans, we need to make them accessible, attractive, maybe even rewarding.

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We will conduct public and stakeholder consultations to work out these proposals and incorporate them in a White Paper. I am very sure there will be no shortage of ideas and we have heard several today from Members. I do not think we can implement them all, but we will try to put together a package that is compelling, attractive and which we can afford.

Perhaps, some ideas: preventive care consultations with family doctors and recommended health screenings could be made free or costing only a nominal sum. Just to assure Dr Tan Yia Swam, this does not mean that GPs will not be paid, they will just be reimbursed elsewhere. Perhaps we can claim higher CHAS benefits for drugs if we go to the same doctor; perhaps we can tap on MediSave more for our care plan. Perhaps we can offer insurance premium discounts or vouchers if we diligently follow our care plans or even, better still, show good outcomes. These are all possible ideas.

By enrolling on Healthier SG, a resident will commit to see one family doctor and adopt one care plan.

Our third component is that we then need community partnerships. Preventive care plans involve lifestyle adjustments, which need to happen outside of the clinics and in our living environments. Doctors have a name for these. They call these "social prescriptions", as opposed to drug prescriptions.

We, therefore, need the support of agencies, many of them, Health Promotion Board, Agency for Integrated Care, People’s Association, SportSG, National Parks Board and community partners that oversee various social services. They run various activities and programmes in the community which we then get family doctors to tap on.

So, one analogy: if we have a major illness, we go to a doctor, the doctor often refers us to a few specialists or therapists. But in a preventive care plan, the family doctor may refer us to a qigong class, to a brisk walking group, or a community farming club, for example. Social prescriptions.

We already have such collaborations on the ground – some Members have mentioned it – in Queenstown and Tampines. We need to roll out such initiatives across every town to make good health not just a matter for doctors in clinics, but for all of us in everyday life and places.

That brings me to the fourth component. Once the first three components are in place, we will roll out a national Healthier SG enrolment programme. That is when I mentioned by enrolling into Healthier SG, a resident will commit to see one family doctor and adopt one care plan.

The national enrolment programme will be coordinated by our three healthcare clusters. Each will look after a region of up to about 1.5 million residents and work with the family doctors and other partners in the region to reach out to as many residents as possible.

We will probably start with people in their 40s and older, because that is when chronic illnesses may start to set in. Then, we will have to build up the participation base progressively.

When HPB rolled out the latest season of the National Steps Challenge, it recruited 900,000 participants. We hope Healthier SG can be even more successful than that.

I want to specifically highlight the importance of this collaboration between healthcare clusters and the family doctors. It is a very important nexus, because the family doctors will receive support from hospitals in looking after residents with more complex needs. Hospitals, after discharging a patient, can refer them back to the family doctor. This is exactly what we did during COVID-19. It works and there will be seamless coordination and continuity of care.

We have taken a geographical approach to enrol residents because this will cater to the needs of the great majority because, today, about nine in 10 residents will visit a family doctor or hospital near their homes. Nevertheless, individuals will have choice. You can choose whether to enrol or not. You can choose who to enrol with, even doctors who are far away from your home. There are a variety of reasons why some Singaporeans may decide to do that, because the clinic may be nearer to your workplace, near your parents’ place, or is a friend that you have known for many years.

Finally, the last component. We need the necessary support structures to make Healthier SG work and this is actually no small matter.

Manpower is a big part of this.

Ms Mariam Jaafar asked for our workforce transformation plans. So, let me share briefly.

We need to build up and optimise our primary and community care workforce further. Today, a fifth of doctors and nurses are in primary and community care. By 2030, we will need to increase this to at least a quarter. But besides growing the number, we will further build up the competencies and skills of our healthcare workforce. For doctors, family medicine should feature even more strongly in the curriculum of our medical schools. We now encourage new graduates not to become a specialist and do your residency straightaway but get exposed more broadly in medicine and build up confidence in dealing with chronic illnesses. Postgraduate training in family medicine will be strengthened, too.

For nurses and other healthcare professionals, the potential for skills upgrading is even greater. We need to broaden interdisciplinary training and empower them to practise at the highest level of their licences. For example, once we roll out Healthier SG, I expect preventive care efforts to be implemented in communities and these efforts can be led by nurse clinicians and pharmacists, not necessarily by doctors. So, I foresee Healthier SG opening up many new job roles for our healthcare workers.

Finance is another major support system. We have been funding our healthcare clusters, largely by their workload, such as the number of treatments, number of surgeries and operations. We will change this to a capitation model, where healthcare clusters get a pre-determined fee for every resident living in the region that they are looking after. Under the new system, the absolute budgets of each healthcare cluster will not be affected. In fact, the budgets will go up a little bit. What will change is the basis of calculating the budgets. Appropriate surgeries, procedures and treatments will always be provided when required. But with this shift in the basis of funding, there will be a natural incentive for hospitals to try to keep residents healthy through preventive care.

Complementing this new basis of funding is a set of KPIs, a set of health outcomes. Some salient indicators are quality of care, uptake of healthy lifestyles and habits, prevalence of chronic illnesses, cost effectiveness of treatments and so on.

The last critical support structure is IT. Family doctors in the frontline of Healthier SG will need good system and data support. They must have access to patients’ medical records. They must have the IT tools to track their patients' conditions and progress over time.

They must also be able to share their records with other healthcare providers. We want to work towards a scenario that no matter where you are receiving care, for example, at the GP or dental clinics, polyclinics, hospitals, SOCs, nursing homes, eldercare centres, the same data can be retrieved to support your care. That is why MOH has been enhancing and rolling out the National Electronic Health Record (NEHR) system. We then need to ensure that such data sharing is secured and users take greater responsibility for data access. We would need new legislation to govern this and we intend to put in place a Health Information Bill in the next couple of years. Mr Chairman, let me now say a few words in Mandarin.

(In Mandarin): [Please refer to Vernacular Speech.] Chairman, in the next few years, we will be putting in place a major healthcare reform.

We will focus on preventive health care for two reasons. First, ageing population. As we get older, we will inevitably have more illnesses. Second, Singaporeans are actually becoming more and more unhealthy.

What we should do more, we do not do enough and vice versa, what we should do less, it is not sufficiently less. Not enough physical activity, not enough exercises on a daily basis, over-use of electronic gadgets, consuming too much sugar, salt and oil. Hence, there are more people with chronic diseases. If we do not change our lifestyle and habits, we will suffer more illnesses in the next 10 years.

If you are sick, your quality of life will be compromised. After retirement, you may have plans to try something new, or spend time with your family, but should you become sick, you will be unable to achieve your aspirations. Once we fall ill, we have to rely more on our families, children and grandchildren for simple daily living or medical expenses, and this will add to their burden.

Apart from this, the healthcare system will also be under more pressure, so will Government healthcare spending.

Fortunately, many chronic diseases can be prevented. We know the saying "prevention is better than cure". TCM practitioners also often say that "illness is best treated at an early stage".

But this requires lifestyle and diet changes, even before you fall sick. The Chinese idiom of “preparing for rainy days before the torrential rain” is most appropriate to use on healthcare. Therefore, our top priority is to help you stay healthy, instead of going to the doctor only after you fall sick.

In any healthcare system, prevention and treatment are equally important. But with an ageing population, we need to recalibrate and tilt the balance towards preventive healthcare.

Hence, we are going to launch the Healthier SG strategy. This is a national strategy that focus on preventive health – a strategy that will provide health check-ins for Singaporeans and improve their lifestyle and habits.

We will encourage middle-aged Singaporeans to sign up with their family doctor. After that, the family doctor will work with public hospitals to assist you in disease prevention and stay healthy. The doctor will also help you do health screening on a regular and scheduled basis and get you vaccinated. They will work with community partners, including the People's Association and SportSG, to help you improve your eating habits and diet, quit smoking and do more exercises.

But preventive care means that you see a doctor, go for regular check-ins and even health coaching when you are feeling fine. This is not the habit of Singaporeans. We tend to think "why do we see a doctor for no reason?".

To encourage people to do so, we need some incentives. Over the next few months, MOH will conduct public consultation to gather views and inputs and come up with an attractive and affordable package.

Within the package, perhaps, preventive health screening can be free, or at a nominal cost. Perhaps, more Medisave can be used to pay for medication. Perhaps, if you stay healthy according to your family doctor’s care plan, there could be MediShield Life premium discount. This is like car insurance. If your car is accident-free and no repair is needed, then your insurance premium will be reduced. After designing the package, we will draft a Healthier SG White Paper and table it in Parliament for debate.

With the strategy direction in place and with the support and cooperation of hospitals, family doctors and the public, we can all lead healthier and more fulfilling lives, and the elderly can enjoy their twilight years happily.

5.00 pm

(In English): Mr Chairman, a central issue of the Budget this year has been the increase of GST, because we need to meet the rising healthcare expenditure of an ageing population. Healthcare expenditure will increase because we are committed to make healthcare affordable to those who are sick by heavily subsidising healthcare bills.

After subsidy, there is still a remaining sum that needs to be paid. We can cover most of them through MediShield Life. And then there is still a smaller remaining sum, which the patient can pay through his MediSave. And if there is still a small sum that the patient cannot afford, he can apply for MediFund. So, subsidy, then MediShield, MediSave and MediFund – that is, essentially, the S+3M framework – a multi-layered safety net for healthcare and it will continue.

However, it is important to understand that spending on health is quite different from spending on, say, education, which is always forward-looking, moulding the future of Singapore. Healthcare spending is critical, it is essential but mostly about treatment – trying to restore a sick person back to where he was in the past and, often, imperfectly. Sometimes, we hear comments, including in this House, that healthcare spending is an investment in our people. If we are honest with ourselves, we know it is not the same as education. It is driven by deteriorating health that can be prevented. It is often about paying for unwise lifestyle choices of our past.

But there is a component in our healthcare spending that is forward-looking and about investing in our future and, that is, preventive care. Healthier SG will grow that component. What we are saying here is that as healthcare spending inevitably grows in the coming years, let us have the discipline to always set aside enough to invest in keeping our people healthy for the future.

Our multi-layered safety net in healthcare, embodied in the S+3M policy, will always be universal. That is, we will not have a situation which happens in other countries, where a patient comes to a hospital and gets turned away because he is unable to pay, because he is not covered by insurance. We will not let that happen. That universality will now expand in coverage, beyond medical treatment, to preventive care and population health.

The more well-off and better-informed are already taking better care of themselves, with coaches, therapists, personal doctors and diet plans. We want to extend these interventions to the broad population, which will benefit most those with lower incomes who do not have the time, resources or wherewithal to do this.

I have been lucky to have a highly-trained and well-meaning doctor friend who nagged me and helped me. We hope everyone in Singapore will have such a friend, too – a family doctor to advise and nag us to do what is right for our long-term health and for our family. We want to make it easier and affordable for everyone to stay healthy.

We will have a fuller debate on Healthier SG in the House later this year when we present the White Paper. I seek the support of Members to translate Healthier SG into a healthier Singapore population. [Applause.]

The Chairman: The Guillotine Time is 5.35 pm. Any clarifications? Dr Lim Wee Kiak.

Dr Lim Wee Kiak: Chairman, I thank the Minister for showing the healthier way forward. I have three clarifications.

First is on infrastructure. Over the next 10 years, will new hospitals be built, just like the last 10 years that the Minister has just painted? So, if there are going to be new hospitals, how about the private sector-wise? Will there be new private hospitals as well? So, that is something I would like to know.

Second, since we need more medical manpower, from that itself, will current medical school enrolment numbers increase? There are many Singaporeans who aspire to study medicine but just because they cannot get into our local medical schools, many of the parents have to spend lots of money to send them overseas. So, will that be expanded?

Third, regarding the S+3M framework, I agree with the Minister that that is the bedrock for healthcare financing now. But as healthcare cost goes up, how will this structure change? When was the last time we reviewed this framework? Will we review it again?

The Chairman: Minister Ong Ye Kung.

Mr Ong Ye Kung: Let me talk about S+3M and I will invite Senior Minister of State Janil Puthucheary to talk about new hospitals and manpower.

The Member is right to describe that it is a bedrock and it is also very robust, designed and evolved over the years. I took Members through the process of subsidy; insurance; remaining, use your own savings in MediSave which is also contributed by your employers; and then, for those with low income, MediFund.

There is longevity in this framework. But having said that, even today, as Members read out your cuts, there are several suggestions: how to activate them better to help make things easier for the population to take care of their health. We will take them in, we will continue to review and, as you can see, over the years, the rules are always being refreshed, improved and strengthened to better support Singaporeans.

The Chairman: Senior Minister of State Janil Puthucheary.

Dr Janil Puthucheary: Sir, I thank Dr Lim Wee Kiak for his questions. He asked about whether there would be further hospitals, further healthcare capacity. We watch the issue of healthcare capacity quite closely and, as Minister Ong Ye Kung has laid out, the key thing that we want to achieve going forward is better utilisation of the healthcare capacity that we have, integration into the community facilities that we have and where care can be sited outside of the hospital, if possible. Studies have demonstrated quite clearly that this is going to be better if we can go upstream and better integrate recovering patients into the community. So, we will watch the need for healthcare capacity quite closely, but we are hoping that the solution to the healthcare capacity issue is not just more and more acute care hospitals. We are hoping to be able to reduce the need for them.

For the point on medical schools, indeed, medical manpower is important and a lot of people who are interested in pursuing a career in healthcare, we need healthcare workers from many, many degrees and many, many domains and many, many disciplines, and we would encourage people who are interested in a career in healthcare to explore a wider variety of possibilities.

The Chairman: Senior Minister of State Koh Poh Koon.

Dr Koh Poh Koon: Thank you, Mr Chairman. I will just add a couple of points about the possibility of increasing medical school intake. In fact, over the last five years, the number of doctors has increased by about 30%. We are talking about registered doctors with the Singapore Medical Council – from about 13,400 to 15,400. We will continue to monitor the manpower pipeline needed to support our healthcare needs. And, as I have said earlier in my speech, we are looking at care model changes and how care delivery in hospitals ought to be changed. So, it is not just going to be a single-track increase in numbers to meet needs but, actually, evolving a model so that we can do more with less. And also the manpower projections will change based on the kind of care model that we are going to put in place in the hospitals.

The Chairman: Mr Yip Hon Weng.

Mr Yip Hon Weng: Chairman, I welcome the Healthier SG plan and working closer with GPs. I have two clarifications.

First, how will MOH measure the outcomes of success under this plan, especially since some of the interventions for seniors involve not so much medical care but rather social prescribing like exercise activities and so on and also working with social care agencies?

Second, under this plan, will we encourage GPs to work together to share resources and for better demand aggregation to serve residents better?

The Chairman: Minister Ong Ye Kung.

Mr Ong Ye Kung: Yes, we will have to measure the outcomes of success. I mentioned earlier that we are moving to capitation and, along with the funding model, there will have to be a set of KPIs and these will have to be outcome-based. I have mentioned some of them, such as prevalence of chronic illnesses, as well as the driving factors that lead to these outcomes, such as re-admission and various clinical effectiveness, cost effectiveness of treatments. I can tell you, as of now in MOH, we have developed such a long list of KPIs. We need to whittle it down to a more manageable set and, in time, I think we can share them.

As to the Member's second question whether GPs are encouraged to work together, the answer is yes, because a third of our GPs are now already in PCNs or primary care networks and that is a very important resource and very important starting point to bring them into Healthier SG.

The Chairman: Dr Shahira Abdullah.

Dr Shahira Abdullah: Thank you, Chairman. I think the Healthier SG initiative is a very exciting development. As a dentist myself, I would also like to say that oral health is very important. It is intricately linked with good health and dental treatment is also quite expensive. So, may I know if this initiative will be extended to preventive dentistry as well? And is the Ministry planning to engage with the dental fraternity for the White Paper?

The Chairman: Minister Ong.

Mr Ong Ye Kung: Thank you for reminding us. We will do so. I should inform Members that, in Singapore, for our young children below 12, we have one of the best oral health in the world and that is because of a very strong collaboration between MOH and MOE schools. When we were in Primary schools, we all dreaded the dental nurse coming into the classroom and reading out our names, because that means we would be going to the dentist. But because of that, preventive care was done and executed very well for children. As we get older, bad habits set in and then dental hygiene and dental health deteriorate. So, actually, the dental programme is a very good story about how effective preventive health or preventive care can be.

The Chairman: Mr Leon Perera.

Mr Leon Perera: Thank you, Mr Chairman. I just have two clarifications.

The first one to Minister Ong. As the Minister observed, preventive healthcare has been a long journey. HPB was founded in 2001 and we have been spending, I think, about $300 million a year for quite some time. But over the last 10 years, I think the outcomes for chronic conditions seem to have not done very well and perhaps, even gone in the opposite direction. I noted in my Adjournment Motion speech on preventive healthcare that the proportion of older adults with three or more chronic conditions almost doubled between 2009 and 2017. I think the Minister and others have also elaborated on some data points.

So, my question is, will the Ministry reflect deeply and, perhaps, audit all the efforts that have gone into preventive healthcare in the last 10, 20 years to find out why there has been this disconnect between the investment and the efforts and the kind of outcomes that we have seen in the last 10 years of chronic conditions. Will that be factored into the preventive healthcare plan going forward?

My second clarification is to Senior Minister of State Dr Koh. It is a narrower one. I just wanted to confirm what he said on the COVID-19 Healthcare Award for cleaners. I actually filed a Parliamentary Question on 14 February about whether cleaners were eligible for the COVID-19 Healthcare Award. The answer seemed to be no. It did not exactly say no, but it did not say yes and it said that there are other schemes for cleaners. So, I just wanted to confirm if I heard the Senior Minister of State correctly that now the position is that cleaners in healthcare institutions are eligible for this $4,000 COVID-19 Healthcare Award.

The Chairman: Minister Ong.

Mr Ong Ye Kung: Healthier SG has been something we had been talking about for the last few months. When I came to MOH in May last year, my first speech was about preventive care. And I spoke to the healthcare community and the leaders of both private and public healthcare institutions, from then on, we have been talking about Healthier SG and consulting many people.

What I announced today, in the healthcare sector, it is not a secret – except the name "Healthier SG" which we came up with a few weeks ago. But the capitation model, IT system, preventive care, enrolment process are some things we have been talking about. So, I am not surprised that Mr Leon Perera filed an Adjournment Motion talking about this topic, because it is a very live topic within the healthcare sector. And I thank him for that contribution.

5.15 pm

But when he mentioned the outcomes going the other way, I think that argument is counter-factual. Imagine if we had not had HPB, imagine if we had not had "Step Challenge", imagine if we had not had the Primary Care Network (PCN), Public Health Preparedness Clinics (PHPCs) – I think that the outcome today would be far worse. Because we know what drove unhealthy populations are lifestyle, food, devices, sedentary lifestyle, all kinds of things that we are also guilty of.

Fortunately, we have all these interventions. But in the last 10 years, could we have, as he mentioned, thought deeply about it and come out with Healthier SG? I think the ideas would have been there, execution would not be ready. It took 10 years, more than 10 years of work from my predecessors: set in place the structure, three clusters; put in place the basic IT system, without the IT system you cannot implement this. Think through the funding process, communicate and talk to the clusters, build up the PCN structure, so that we have a basis to work on now.

That 10 years of hard work enabled us to implement Healthier SG today. So, I think we need to get that perspective correct.

As for the COVID-19 Healthcare Award (CHA), the intention is and has always been, to also distribute to outsourced workers who are full-time, working in the healthcare institutions. It has always been the intention, but the details took a while draw up. And so, shortly after this, it will be announced and they will get to know when and how much they are getting.

The Chairman: Ms Ng Ling Ling.

Ms Ng Ling Ling: I thank the Minister for sharing about the Healthier SG initiative. Indeed, in the healthcare sector, many have been thinking that is very important to pivot to primary care. And community care is a very important part of managing our ageing population, with a growing chronic disease burden.

I have two clarifications. I know there will be more consultations and a White Paper later on, but I hear Minister mention the National Health SG enrolment programme would likely be through the three clusters. I am wondering for residents who may have GPs that they have been seeing that is outside the cluster, would they be allowed to choose and would they still get the potential incentives? In some countries that have similar systems, they have, in fact, allowed residents to have up to a choice of two GPs because a lot are working; so, they have a GP when they are in their workplace and one nearer their homes.

The second clarification I have is that, when I speak with my senior residents about where they get chronic care, their chronic disease management and when I ask them about whether they go to the nearby GP clinics, many of them still feel that the out-of-pocket expense can be higher than if they go to a Public Health Institution. So, I just wanted to check whether that is an area of focus during the White Paper consultation?

The Chairman: Minister Ong.

Mr Ong Ye Kung: The short answer to the first question is yes. Choice will be preserved. And I mentioned in my speech: there are residents who for various reasons, see a doctor that is not near their home and in fact, out of the cluster that they come under. So, choice will be preserved as a principle.

Second question: during our consultation, we will not prejudge what we want to include, or what we want to exclude. If the Member feels that out-of-pocket expenses for consultation is an issue, by all means, let us know. I assure you it will not be the first time we hear that feedback and certainly will have to consider. We want a package that is compelling, attractive and that we can afford.

The Chairman: Dr Tan Yia Swam.

Dr Tan Yia Swam: Thank you. I want to thank Senior Minister of State Dr Koh for the reply that MOH will monitor the situation of TPAs. But I have done the research and I am sure that in 2016, Mr Desmond Choo raised a Parliamentary Question and the reply then by Mr Chee Hong Tat was that MOH will monitor the situation regarding TPAs. So, in these five to six years, what have we understood about the situation? May I ask for a more proactive review, including consultation of the professional bodies, so that we can at least better define the problem.

The Chairman: Senior Minister of State Dr Koh.

Dr Koh Poh Koon: Sir, I thank Dr Tan for her question. As I said in my reply, we will continue to watch this, but we will be happy to also engage with the Singapore Medical Association (SMA) to see if they have insights on areas that we need to focus a bit more attention on.

Let me also say that a lot of these arrangements are private contracts between the GP and a third-party provider. Which is why our emphasis always has been that the GP entering into a contract with a service provider ought to be clear that the boundaries of ethics and ethical behaviour ought to be observed. Otherwise, it is very hard for us to police every single private contract between the GP and a third-party provider. I think that the principle must be observed.

But if there are unsavoury practices that GPs have engaged in and if SMA is aware, we will probably take some investigative action and advise the relevant parties to not undertake such actions to the detriment of patients.

As we evolve the primary healthcare landscape based on Healthier SG, some of these arrangements between GPs and third-party service providers, like TPAs, may also need to be relooked at as well to see how they should reshape themselves in the larger landscape of primary care changes.

The Chairman: We still have some time before the Guillotine Time of 5.35 pm. Are there any more clarifications from Members? Yes, Mr Leong Mun Wai?

Mr Leong Mun Wai: Chairman, thank you. I would like to thank the Minister for sharing with us such an exciting plan. One of the reasons that the Progress Singapore Party (PSP) has rejected the Budget is that we want the Government to concentrate more on cutting healthcare cost. We hope that this plan would realise that in the future. I have three supplementary questions with regards to the plan.

One is, a lot of feedback from the ground about our current healthcare system is, not so much of the poor being not given medical, healthcare services or treatment, but more of the middle class who can pay. When they get into a healthcare situation, it somehow drains their finances very fast, although we talk about S+3Ms and all that.

The first question I want ask is: will the new plan that the Ministry is coming out with take care of that as well, that means give more relief to the middle class? There are many, many areas like, for example, they do not get so much subsidies compared to the lower income, certain medicines are not included and so on. So, that is one point.

The second point is that the Minister mentioned about outcome. That is a concept in healthcare for quite some time already. So, I look forward to seeing how the Minister is going to present the plan that take cares of that. One of the things that I thought of in the past when I was running a healthcare fund, that we have also talked about, is how to incentivise the —

The Chairman: Excuse me, Mr Leong, a clarification is really about you raising a question regarding what a person has already said. It is not a licence to give another speech.

Mr Leong Mun Wai: I will try.

The Chairman: I will give you some leeway, please ask your points two and three quickly, so that the Minister can reply. Thank you.

Mr Leong Mun Wai: Okay. So, the second point is: can the Minister enlighten us a bit more on what kind of outcome, what kind of incentive, just a little bit, how is it related to incentivising the individual patient to take more care about his health?

The third point is: healthcare is a very resource-intensive thing. I have read that overseas, people are activating community resources to help. So, in Singapore today, when I walk the ground, there are a lot of Singaporeans who are prematurely retired. Are there plans, in the plan that the Minister is putting up, to tap into this resource?

The Chairman: Minister Ong.

Mr Ong Ye Kung: Thank you. Mr Leong said three questions, but I counted quite a number. I will just try to address them. First, he said PSP recommend "cutting" healthcare costs. It is not the right description of what we are doing here. We are trying to make people healthier. By making people healthier, it is less likely they will get chronic diseases and, so, healthcare costs can be moderated. It will still increase due to ageing, but we can moderate the increase. But we are not "cutting" healthcare cost per se. When treatments, operations, surgeries are required, they will be given.

As for the middle class, how will Healthier SG take care of their current issues, where if they have a catastrophic illness, it will wipe out a lot of their cash? We are all responsible for our own health and in some sense, our own finances too. We are helping, not just the middle class, but everyone else, it has to be universal. We want to help every Singaporean take care of their own health, through Healthier SG.

Outcomes delivered by our healthcare system, is not a new concept. I mentioned about setting outcome KPIs, but they have always been there. I mentioned some of them, today we have the highest life expectancy at birth for men and women, across 204 countries. That is a major outcome, delivered over the decades. And we will continue to focus Healthier SG on delivering right outcomes.

But now, because of the design of that programme, we have to look at specific outcomes that we are driving at. How many percent taking up enrolment, taking up healthcare plan, how many percent have one single doctor, what is the subscription of doctors into this plan, how many doctors are in our national IT system, because those are essential. So, some of these outcomes, drivers have to be captured as well.

Mr Leong also mentioned incentive. I think I have answered that in my speech, which is we will have a consultation, we will put in the package, we will describe the package in the White Paper to be tabled in this House later. I think I have answered all his questions.

The Chairman: If there are no further clarifications, may I invite Dr Tan Wu Meng, if you like, to withdraw your amendment?

Dr Tan Wu Meng: Mr Chairman, we have seen around the world challenges from the pandemic and what has been at stake. What has happened to those healthcare systems that broke under pressure. And thankfully, we did not. And some of this is through the policies and effort of the MOH team – the civil servants, the Director of Medical Services (DMS), everyone working, policies that lay the groundwork for healthcare workers to be able to do their best as far as possible.

The Healthier SG announcement is significant and will be an important part of the next bound for Singapore healthcare. It will shape us a generation from now.

So, I would like to thank Minister Ong, Second Minister Masagos, our two Senior Ministers of State, Senior Minister of State Dr Koh Poh Koon, Senior Minister of State Dr Janil Puthucheary, Parliamentary Secretary Rahayu, our Permanent Secretaries, our DMS – the whole team at MOH. And in particular, I want to again thank every single healthcare frontliner, whose effort and sacrifice has kept Singapore afloat and in one piece through this pandemic. Mr Chairman, I beg leave to withdraw my amendment. [Applause.]

5.30 pm

The Chairman: Is the hon Member given leave to withdraw his amendment?

Amendment, by leave, withdrawn.

The sum of $17,840,315,300 for Head O ordered to stand part of the Main Estimates.

The sum of $1,447,569,700 for Head O ordered to stand part of the Development Estimates.