SPEECH BY MR GAN KIM YONG, MINISTER FOR HEALTH, AT THE MINISTRY OF HEALTH COMMITTEE OF SUPPLY DEBATE 2019, ON WEDNESDAY 6 MARCH 2019

EVERYONE CAN PLAY A PART FOR BETTER HEALTH

1.          Mr Chairman, I would like to thank the Members for their thoughtful comments. Dr Chia Shi-Lu asked for an update on our overall healthcare system.

Current State of Health

2.            Let me begin by reviewing our overall state of health. Singapore’s overall health outcomes are generally good. The Global Burden of Disease 2017 Study published in The Lancet ranked Singapore favourably as the country with the highest life expectancy.

3.            Our life expectancy at birth has risen from 83.2 years in 2010 to 84.8 years in 2017. Health Adjusted Life Expectancy (HALE) at birth also increased from 72.9 years to 74.2 years over the same period. These figures also show that we are living about 10 years of our life in ill health. For every 10 years we live, we spend more than a year in illness.

4.            These findings are not surprising. The mortality rates due to cancer, stroke and heart diseases have reduced significantly by 16%, from 2010 to 2017. This was made possible in part due to early prevention, better treatment and disease management, which have contributed to our increase in life expectancy.

5.            However, it is not time for us to celebrate yet. The recent Bloomberg report also reminds us we need to keep up on our efforts. Data also shows that many of us are living with chronic illnesses. From 2010 to 2017, the prevalence rates of diabetes, hypertension and hyperlipidaemia among Singapore residents aged 18 to 69 have increased by 4%[1], 14%[2] and 33%[3] respectively[4]. This is partly due to an older population, but also due to unhealthy lifestyles and habits. If these chronic conditions are not managed well, more serious conditions may follow further down the road.

6.            On capacity and accessibility, we have stepped up our building programmes. We have completed seven hospitals since 2010 which will add up to about 3,800 beds when fully opened. In 2018, we opened the new Changi General Hospital Medical Centre, Sengkang General and Community Hospitals. Earlier this year, the new National University Centre for Oral Health Singapore commenced operations. 

7.            We also injected a significant supply of aged care services, especially in home and community care to encourage ageing in place.

8.            We have been training and recruiting healthcare professionals to meet our manpower demand. The number of registered doctors rose significantly, by 52%[5] over the period from 2010 to 2018. Local Medicine intake increased by some 60%, from about 300 to about 500 today. Together with Dentistry and Pharmacy, the total intake now exceeds 700 a year and contributes to a strong local pipeline, reducing our need for foreign-trained professionals.

9.            Registered nurses have also increased significantly by 44%[6]. While we had a record local nursing intake of over 2,100 students last year, we will still need more, especially in the critical community care sector. Senior Minister of State Amy Khor and Senior Parliamentary Secretary Amrin Amin will share more about opportunities for nursing and allied health professionals later.

10.         Our expenditure on healthcare has increased too. Since 2010, Singapore’s national healthcare expenditure has almost doubled, from $11 billion to reach $21 billion in 2016. Government Health Expenditure increased even faster by 2.4 times, from $3.9 billion to $9.3 billion. We have more than doubled the amount of direct government subsidies given to Singaporeans from about $2.6 billion to $5.6 billion over the same period and this has helped to keep healthcare affordable, especially for needy Singaporeans.

11.         However, it is unsustainable for us to continue increasing our national healthcare expenditure at this current rate. Our healthcare system has to transform the way it delivers care and we must continue to refine our way of funding healthcare expenditures. As individuals, each of us must also take responsibility for our own health.

Transforming Healthcare

12.         Our healthcare institutions are doing their part to transform their healthcare models.

Primary Care Transformation

13.         Polyclinics, for example, have been experimenting with new ways to enhance chronic disease management. The National Healthcare Group Polyclinics (NHGP) have piloted a teamlet care model since 2015. By assigning patients with chronic diseases to the same team comprising family physicians, nurse care managers as well as  care coordinators, there is better continuity of care. As a result, patient outcomes have improved, with more regular preventive health screenings done and visits to  doctors and emergency departments reduced. SingHealth Polyclinics and National University Polyclinics are also rolling out team-based care models.

14.         Private General Practitioners (GPs) are our key partners in primary care too. The Primary Care Network (PCN) started as a ground-up initiative by GPs from the Frontier Healthcare Group to share resources and improve chronic disease management. SMS Lam Pin Min will share more about the progress of the PCN scheme.

Community Care Transformation

15.         Similarly, we are working towards transforming care at the community level to better integrate social and healthcare services.

16.         Community care providers are also doing their part and some of them are piloting innovative ways to enhance patient care and safety. For example, several of our community care providers, such as All Saints Home, have introduced new sensor mats to monitor residents’ movements so as to  prevent falls and provide better care.

Acute Care Transformation

17.         To catalyse efforts on care transformation, we set up the MOH Office for Healthcare Transformation (MOHT) in 2018. MOHT has been working with partners to design innovative healthcare pilots, such as the new Integrated General Hospital (IGH) model piloted at Alexandra Hospital (AH). This model particularly benefits patients with multiple active conditions, who would typically be attended to by  a few specialists during each admission. Under this IGH model, one care team will look after each patient for better integrated care.

18.         Take Mr Kang Swee Hiang for example. Mr Kang is an 81-year-old senior who lives alone and was recently admitted to AH for uncontrolled hypertension. He has a number of active medical conditions[7], but he was looked after by one care team, without transfers across wards and doctors.

19.         The care team found that Mr Kang's cataracts made it verydifficult for him to take his medications and may increase future fall risks. The team then reduced the pills he had to take, and counselled him on how to take them properly. He also underwent cataract surgery and received physiotherapy too. They also engaged community partners to schedule befriending and home care services, and connected Mr Kang to the Social Service Office for post discharge assistance and support. AH is now working to consolidate his outpatient care under one principal doctor.

20.         About 4,000 patients have benefitted from Phase 1 of the IGH model which focuses primarily on inpatient care. While efforts under Phase 1 will continue, MOHT and the National University Health System have commenced Phase 2, which aims to better integrate hospital care with community services required by the patients living around Queenstown. It is still early days and these efforts will need to be fully developed and evaluated before scaling up.

Looking Ahead

21.         MOH will continue our care transformation journey in line with our strategy to move Beyond Hospital to Community, Beyond Quality to Value and Beyond Healthcare to Health. However, there are a few key challenges ahead of us.

Health IT Systems

22.         First, we have to strengthen the robustness of our healthcare IT systems, including data privacy and security. As highlighted by Mr Christopher de Souza, IT and data play an important role in our care transformation journey as they help to better inform policy, ensure continuity of care, and allow innovative care models to evolve. The National Electronic Health Record (NEHR) system, for example, is an important, large-scale national system designed to better support patient care. Prof Daniel Goh and Ms Sylvia Lim asked about the safeguards in place for NEHR to ensure patient confidentiality. Broadly, there are three levels of safeguards.

23.         The first is protection against cyber attacks and unauthorised access. There are several lines of defences before the NEHR database, with intrusion detection at each line. Regular security audits are conducted, with the most recent penetration test done in October last year. In addition, there are ongoing robustness tests conducted by the Cyber Security Agency (CSA), GovTech and an independent third party, PwC. At the user level, the NEHR should only be used for direct patient care. There are strict controls to protect against unauthorised access. The NEHR system also does not allow users to download records onto workstations.

24.         As highlighted by Mr de Souza, having well-trained IT and cybersecurity specialists familiar with healthcare is key. MOH, with CSA’s support, is working to ensure that technical training for our cybersecurity specialists meet industry’s best practices and standards. Good cyber-hygiene practices are regularly shared with all public healthcare staff.

25.         But we must assume that persistent attackers will not give up and will eventually get through, despite the strongest protection. Therefore, the second level of safeguards is having effective detection and enforcement measures to pick up any breaches quickly, and escalate to the appropriate level for prompt investigation and containment. All NEHR accesses are logged and subjected to monthly audits, using analytics to detect unusual usage patterns. The Integrated Health Information Systems (IHiS) plans to roll out a feature that allows patients to view accesses made to their NEHR records so that they too can report any suspicious access.

26.         The third level is deterrence. We must take stern action against anyone who is responsible for data  breaches, including our staff who have failed their duties. This way, we can ensure a strong data protection system.

Healthcare Financing

27.         Our next challenge as highlighted as many MPs is to keep healthcare affordable. All stakeholders must work together, to ensure that our healthcare system will be sustainable not just for our current needs, but also for the needs of our future generations.

28.         [Government] As the Minister for Finance has announced in his Budget speech, we will be launching the Merdeka Generation Package (MGP) this year. The MGP is our way of honouring the Merdeka Generation for their unique contributions in shaping the nation during our formative years. The package is designed to support MG seniors in leading a healthy and active life as they age, and to provide assurance that they will be able to afford their care expenses. SMS Khor will share more details on MGP later. 

29.         SMS Edwin Tong will update on our proposed enhancements to the Community Health Assist Scheme (CHAS) so that  all Singaporeans will have access to affordable, quality primary care especially for their chronic conditions.

30.         [Private and Public Providers] Healthcare providers and professionals too, play an important role in keeping healthcare costs in check, through ensuring efficient operations and abiding by appropriate pricing and clinical practices. We have introduced fee benchmarks last year to provide all stakeholders with a useful reference on appropriate fee levels. We have also studied best practices and approaches on value-based healthcare in the United States and elsewhere, which Mr Leon Perera asked about, and adapted it to our local context.

31.         Since 2017, MOH has appointed a National Value-based Healthcare Workgroup to look into this. By comparing standardised clinical quality indicators and cost data across our public healthcare institutions, it will help our healthcare providers to identify best practices among them as well as identify opportunities to improve clinical outcomes, in a cost-effective way. More work will need to be done and we are continuing to explore this.

32.         [Insurers and Patients] Insurance allows risks and resources to be shared across all members in the pool, helping patients to cope with large and unexpected healthcare costs. This is why we have MediShield Life and soon CareShield Life. We will continue to explore how we can further strengthen the role of insurance as we move forward. 

33.         Lastly, individuals have the responsibility of saving for our own healthcare needs during our working years, including through MediSave, to meet our future needs when we grow old. We also have the responsibility to make well-informed decisions to choose appropriate healthcare services.

Healthy Living

34.         But the most effective way to keep healthcare affordable is to stay healthy.  The next challenge is therefore to take more decisive steps to encourage healthy living.

35.         Three years ago, I declared War on Diabetes in this House. We have made some progress but we do need to push harder. We had aMinisterial Conference on Diabetes last year and one of the key takeaways is that to tackle diabetes, we need a coordinated effort from all stakeholders, not just MOH. In the years ahead, we will step up our efforts on several fronts: reducing diabetes-related amputations, empowering patients and healthcare professionals to better manage diabetes and minimise complications. In particular, we are also recommending the use of non-fasting screening test for diabetes to increase screening rates, and will make early screening more convenient for women with a history of gestational diabetes. My colleagues will elaborate more on these efforts later.

36.         Smoking is another area that we need to move more swiftly and strategically on. Tobacco use is the second-highest contributor to Singapore’s disease burden. More than 2,000 Singaporeans die prematurely from smoking-related diseases each year, and the social cost of smoking in Singapore has been estimated to be at least $600 million annually.  We will continue to work on reducing smoking rates.  

Caregiver Support

37.         However, despite our best efforts to stay healthy, we may still fall ill and become frail as we age. Caregivers will need greater support, as they will play a key role in caring for the sick and frail among us. With an ageing population and longer life expectancy, caregiving needs will rise, with family and informal caregivers playing an increasingly important role. Many will have to balance their work and family responsibilities. There is therefore greater urgency for society to come together and collectively support our caregivers, and ensure that adequate “hardware” and “heartware” are in place.

38.         Please allow me to share the story of Mr Tang in Mandarin. 42岁的陈顺如先生是一位企业开发主管。过去的一年多，陈先生一家共同照顾81岁失智的父亲。虽然母亲是主要的看护者，陈先生兄弟俩连同他们的妻子都会轮流协助母亲照顾父亲。父亲因为失智行为上有所转变而不容易照顾，还好因为陈先生的妻子从事医疗保健行业，知道可以透过哪些管道获得适当的资源。然而，不是每位看护者都有相关知识，或有其他亲人可以分担照顾年长者的责任。随着社会老龄化，看护者的负担将会加重。因此，我们必须加强对看护者的支持，提高大众对于看护支援的意识，并更系统化地为有需要的看护者提供相关支援。

(In English)

39.         Mr Andrew Tang Soon Joo, who is 42 years old, heads the business development department of his company. Over the past year or so, Mr Tang has been a joint caregiver to his 81-year-old father with dementia, together with his mother, brother, wife and sister-in-law. Even though his mother is the main caregiver, the other family members also take turns to spend time with his father. Mr Tang and his family initially faced challenges adapting to his father’s behavioural changes due to his condition. He counts himself fortunate to have a very supportive wife who works in the healthcare sector. Through his wife, the family was able to identify various support channels and help. Nonetheless, not every caregiver is equipped with such knowledge, or have other family members to share the caregiving responsibility. With our ageing population, the caregiving burden will grow. Therefore, we need to provide greater support for caregivers, increase awareness of the support available, and more systematically match these caregivers to the help they require.

Conclusion

40.         I have spoken about our progress in our healthcare development, transformative initiatives that can change our care models, and MOH’s focus areas for the next three to five years. But at the heart of our healthcare strategies, is people – like you and I. MOH and our healthcare providers can only do so much.  For every “top-down” programme, we need many “ground-up” support and initiatives. Each of us must actively take charge of our health, and come together as a community, or just as a group of friends, to support one another.

41.         That is why I find the example of “Team Strong Silvers” so inspiring. Team Strong Silvers is small, but mighty. It is a group of friends with a common interest in health and fitness who decided to form a senior citizens’ interest group in 2013. Just like its name suggests, the members build up their strength through callisthenic exercises. The team hopes to encourage more senior citizens to age actively, and to inspire younger generations to invest in their health from an earlier age. I am glad to see the team actively spreading the healthy lifestyle message via social media and even carrying out on-site fitness training sessions for other seniors. With more seniors like them, I am hopeful that we will add more years of healthy life to our growing life expectancy.

42.         When we replace “I” with “We” anddo it together, “Illness” can become “Wellness”.

[1] From 8.3% in 2010 to 8.6% in 2017

[2] From 18.9% in 2010 to 21.5% in 2017

[3] From 25.2% in 2010 to 33.6% in 2017

[4] Source: National Health Survey 2010, National Population Health Survey 2017

[5] From 9,030 in 2010 to 13,766 in 2018

[6] From 29,340 in 2010 to 42,125 in 2018

[7] Active conditions include hypertension, hyperlipidaemia, ischaemic heart disease, chronic obstructive pulmonary disease and cataract.