SPEECH BY DR LAM PIN MIN, SENIOR MINISTER OF STATE FOR HEALTH, AT THE MINISTRY OF HEALTH COMMITTEE OF SUPPLY DEBATE 2019, ON WEDNESDAY 6 MARCH 2019

Keeping the Public Healthy and Safe  

           Mr Chairman, with our high life expectancy, we are facing an increasing burden of chronic diseases, coupled with rising healthcare costs and emerging diseases. We need to be ready to meet these challenges.

2.            I will share more on the work we have done to keep Singaporeans healthy and safe, while keeping healthcare affordable for all.

Increasing Our Primary Care Capacity

3.            Primary care plays a crucial role as the foundation of our healthcare system. It enables good quality, comprehensive and continued care for Singaporeans near their home.

4.            We will continue to invest in our primary care to enhance facilities, and provide more resources for our General Practitioner (GP) partners.

5.            The Ministry of Health (MOH) had previously announced plans to enlarge our polyclinic network from 20 currently to about 30 to 32 polyclinics by 2030. Currently, these are slated for Bukit Panjang, Eunos, Kallang, Sembawang, Khatib and Tampines North.

6.            I am pleased to inform Members that in addition to these, two more polyclinics will be developed in Serangoon and Tengah, which are expected to be operational by 2025.

7.            Minister Gan earlier shared about our primary care transformation efforts, including the Primary Care Network (PCN) scheme, of which Dr Chia Shi-Lu has asked for an update. Please allow me to share more in Mandarin.

8.            卫生部在2018年推出了基层医疗护理网络计划，简称基层医疗网。这是卫生部推动基层医疗转型的策略之一。该计划目的在于促进私人诊所一起组成医疗网，共享医疗与行政资源，为慢性疾病患者提供更全面的医疗护理服务。

9.            去年，共有超过300家诊所参与这项计划，并组成了10个基层医疗网。这10个基层医疗网总共为超过70,000名慢性疾病患者提供服务。通过这项计划，糖尿病患者能够更便利地获得各种辅助医疗服务，例如眼部与足部检查。目前，已有超过5,000名糖尿病患者因此受惠。

10.         今年，参与的诊所已超过450家。参与诊所的总数量占社保援助诊所40%以上。为了让更多的慢性病患者受惠，卫生部计划在2020年实现过半数的社保援助诊所参与基层医疗网的目标。

(In English)

8.         In 2018, MOH launched the Primary Care Network scheme (PCN). This is part of our strategy to transform primary care. This scheme aims to support private GPs to come together to form networks with the sharing of clinical and administrative resources, and provide more holistic care for patients with chronic diseases.

9.         Last year, more than 300 GP clinics participated in this scheme to form 10 PCNs, and collectively are serving more than 70,000 patients with chronic disease. Through this scheme, patients with diabetes have enhanced accessibility to various ancillary services, such as eye and foot checks. To date, more than 5,000 patients with diabetes have benefitted from this.

10.       This year, there are more than 450 GP clinics participating in the PCN scheme. This number is more than 40% of Community Health Assist Scheme (CHAS) GP clinics. In order to benefit more patients with chronic disease, MOH targets to have half of all CHAS GP clinics participating in the PCN scheme by 2020.

11.         Mr Chairman, let me now share a success story from United PCN.

12.         Like many Singaporeans, Mr Adrian Chia, who is 38 years old, loves food. He used to drink a 1.5 litre bottle of sweetened beverage daily, and ate fried and oily food. He was diagnosed with diabetes by his general practitioner, Dr Kelvin Goh, who practices in a clinic under United PCN.

13.         Mr Chia took his diagnosis as a wake-up call. Working together with Dr Goh, the PCN nurse and care coordinator supported Mr Chia with managing his condition. He also received nurse counselling for his diabetes, as well as foot and eye screening checks through the PCN.

14.         Mr Chia began to take small steps, and started to exercise daily. Through much perseverance and self-motivation, he has progressed to participating in Iron Man races. He also changed his eating habits to include healthier food choices such as oatmeal and fruits.

15.         Today, Mr Chia’s condition is now under control, and may not even require diabetes medicine if he maintains his new regime.

16.         Dr Chia has also asked about our efforts to support PCN clinics in tracking and monitoring patients’ progress. A key feature of the PCN scheme is the provision of resources to maintain a chronic disease registry that tracks the care processes and patient outcomes. By aggregating resources through PCN networks, GPs in the PCN scheme also stand to benefit from greater economies of scale.

17.         For example, NUHS PCN in the Western region has worked with major laboratory providers to provide common laboratory tests for chronic disease management at reduced prices, and facilitate the electronic collation of laboratory results for the chronic disease registry, reducing the need for GPs to manually compile these.

18.         Such systematic data collection allows PCN GPs to reflect on their professional practice and work with the PCN HQ to implement quality improvement programmes and improve patient outcomes.

19.         Learning from the experience of the PCNs, MOH will study how to help CHAS clinics better track their patients’ progress and outcomes. MOH will also continue to encourage more GPs to join CHAS, though there are always some who choose not to, such as those who prefer not to take on additional load.

Empowering Singaporeans to Better Manage Diabetes

20.         At the same time, we have continued our efforts in the War on Diabetes. Mr Melvin Yong and Mr Abbas Ali have asked for an update on this.

21.         We should recognise that our fellow Singaporeans with diabetes do not have to journey alone; we all play a part in supporting them to better manage their condition, and avoid long term complications from diabetes.

22.         Patient empowerment has emerged as a new paradigm that can help improve medical outcomes for lowering costs of treatment. This concept seems particularly promising in the management of chronic diseases, including diabetes. As such, the Diabetes Prevention and Care Taskforce has developed a new Patient Empowerment for Self-Care Framework that aims to empower patients to co-own their care journeys for better care outcomes. It helps patients initiate and sustain lifestyle changes for better disease management, prioritising what is of greatest importance to them. This is done with the support of their families, healthcare professionals, community-based providers, as well as other forms of social support.

23.         We have developed the national diabetes reference materials for patients, caregivers and the public. The first tranche of materials is largely pictorial and easy to understand. A beta version of the introductory section, which is mainly targeted at newly diagnosed patients, has been available on HealthHub since December 2018. The full set of materials will be published on HealthHub in four languages in the second half of 2019.

24.         We will also be seeking public views from mid-2019 on specific diabetes-related topics for more in-depth materials to be developed, and published online for reference.

Equipping Our Healthcare Family for the War on Diabetes

25.         Besides empowering our patients, our healthcare workers can look forward to more training and resources to improve their delivery of care.

26.         MOH will be developing a care team training framework to equip healthcare professionals, and lay volunteers in the community, with essential skills to empower their patients and caregivers more effectively. This will be developed in consultation with various stakeholders, and rolled out progressively from end-2019.

27.         Last year, I shared about the high rate of diabetes-related amputations of the leg and foot. MOH formed the National Diabetic Foot Workgroup in April last year to develop a strategy to reduce such amputations.

28.         A key recommendation of the Workgroup is a risk-stratified diabetic foot screening, management and escalation framework, which aims to streamline diabetic foot care services across primary and tertiary care, and provide healthcare professionals with clinical guidelines for timely and appropriate care.

29.         This framework will be progressively launched in our polyclinics and public hospitals from the second quarter of 2019. MOH will continue to closely track the rate of amputations among patients with diabetes.

Upholding Standards of Practice and Public Confidence in the Medical Profession

30.         Aside from equipping our healthcare professionals, MOH also seeks to uphold the standards of practice and public confidence in the medical profession.

31.         The medical disciplinary process is specified in the Medical Registration Act (MRA) and aims to protect both the public, and ensures fairness to the doctors.

32.         Mr Leon Perera has given some feedback and asked about the review of the medical disciplinary process. MOH is currently looking into making amendments to the MRA, which was last amended in 2010. This will include looking at the issues raised by Mr Perera.

33.         In addition, as announced over the weekend, my Ministry will form a Workgroup to undertake a comprehensive review on the taking of informed consent by doctors. The Workgroup will also review the medical disciplinary process with a view to enhance the regulatory framework. This ranges from the filing of complaints, to the structure, composition and processes of the complaints committees and the disciplinary tribunals, and the use of expert evidence. The Workgroup will consult widely in evaluating the issues raised, and make appropriate recommendations to the Ministry. MOH will take into consideration these recommendations from the Workgroup.

34.         To ensure consistency and fairness in the sentencing of disciplinary cases, a separate committee, which is the Sentencing Guidelines Committee, was also appointed by the Singapore Medical Council in January 2019 to develop guidelines on the appropriate sanctions to be meted out.

35.         My Ministry will continue to engage the medical community and carefully consider what steps are necessary to improve the medical disciplinary process.

Keeping Healthcare Affordable

36.         Minister Gan highlighted the need for all of us to work together to keep our healthcare system sustainable for future generations. While MOH continues to provide subsidies, this will be unsustainable if we do not manage increases in healthcare costs. A significant part of managing such increases is to aid patients and providers to choose care which is appropriate to the patient’s medical conditions and needs.

37.         Ms Joan Pereira has asked if we can explore having more subsidies for a wider range of generic drugs. Back in 2017, to encourage the use of generic drugs, we introduced a basket of clinically and cost-effective generic drugs which can replace the more expensive branded equivalents.

38.         MOH reviews the generic drugs basket annually with the National Pharmacy and Therapeutics Committee. We will also actively monitor new generic drugs from overseas, and work with the Health Sciences Authority to introduce them locally.

39.         By volume, the usage of the generic drugs in the basket has increased from 87% in 2013 to 99% in 2017.

40.         Currently, clinically and cost-effective drugs are eligible for subsidies. When generic alternatives of these subsidised drugs become available, prescribing of generic alternatives is encouraged to provide more savings for patients.

41.         Ms Pereira also asked about the Medication Assistance Fund (MAF), which was introduced to help needy patients pay for non-standard drugs which have been assessed to be clinically necessary.

42.         Since October 2018, MOH has streamlined the MAF application process such that eligible patients, with the assistance of hospital staff, can receive the MAF assistance upfront, without a separate financial assessment by the medical social worker. The public hospitals will be enhancing their systems to support this simplified process.

43.         To ensure costs are kept affordable, patients should also be informed of the estimated charges before making a decision. Mr Charles Chong has asked about the measures to empower patients to make informed decisions about private hospital fees. Since 2003, MOH has been publishing historical transacted hospital bill sizes. More conditions were covered over the years and in 2014, we further published total operation fees for common procedures to enhance transparency of healthcare charges. As shared by Minister Gan earlier, we have since introduced fee benchmarks in November last year for professional fees for common surgical procedures.

44.         These fee benchmarks provide a useful reference to guide private healthcare providers in charging appropriately, and enables patients and payers to make more informed decisions. Both the bill size publication and fee benchmarks are available on MOH’s website.

45.         Doctors should take reference from the benchmarks in setting their fees and advising their patients. They should also be prepared to explain to patients where their charges exceed the range, such as when addressing a highly complex case, or in exceptional circumstances.

46.         Patients are encouraged to use the benchmarks to have a conversation with their doctor on their treatment, the complexity of their condition and the fees charged.

47.         We will monitor the bills and charging practice following the release of the fee benchmarks, and consider the approach for periodic updating of the fee benchmarks to ensure they remain relevant and updated.

48.         Mr Abbas Ali has asked about having reduced co-payment for patients with Integrated Shield Plan riders who are treated at public hospitals. Co-payment is a tenet of our healthcare financing framework that encourages prudent and appropriate use of healthcare services, both in the private as well as the public sectors. This helps to ensure that healthcare costs and health insurance premiums remain affordable and sustainable for Singaporeans in the long-term.

49.         All new Integrated Shield Plan riders are required to have a co-payment of 5% or more. The co-payment amounts can be paid using MediSave, up to the applicable limits. MediFund is also available for those who require assistance with their healthcare bills.

50.         Mr Low Thia Khiang has asked for an update on precision medicine research and implementation.

51.         Work is ongoing. However, I am glad to inform Mr Low that MOH’s Health Regulation Group together with the Genetic Testing Advisory Committee introduced a Code of Practice for the Standards for the provision of clinical and laboratory genetic/genomic testing services in July 2018. The Code addresses key issues such as competency and training of personnel delivering the services, and the appropriateness in the ordering of genetic tests. An IT architecture is also being conceptualised to pull together, store, and analyse the information from healthcare institutions in a robust and secure manner.

52.         Precision medicine has been deployed in our public healthcare institutions. For example, approximately 240 Singaporean and Permanent Resident children with Acute Lymphoblastic Leukaemia have benefitted from personalised treatment in the past 15 years.

53.         Currently, gene editing involving human subjects is regulated under the Human Biomedical Research Act. Research of a nature similar to that cited case in China is strictly controlled, and cannot be conducted without explicit approval from MOH.

54.         As precision medicine is an emerging field, we will need to carefully consider many factors, such as ethical, legal and social implications, and weigh the investments required against the potential benefits, before systematically implementing the strategy to maximise the benefit to the population.

55.         We will continue our efforts to keep our healthcare system sustainable for the long term, and ensure that all Singaporeans can receive appropriate and affordable care.

Staying Vigilant in the Fight Against Infectious Diseases

56.         Beyond keeping healthcare affordable, we need to keep Singapore and Singaporeans safe from infectious diseases.

57.         MOH regularly reviews existing legislation, policies and capacity to safeguard public health and prevent the spread of infectious diseases.

58.         The Infectious Diseases (Amendment) Bill was passed in January 2019 and will come into effect in the subsequent months.

59.         Key amendments include strengthening processes for infectious diseases notifications and surveillance, powers to disseminate health advisories more expediently, and enhancing powers for national public health research.

60.         In addition to enhancing legislation, we have also increased public health education and protection by providing guidance on recommended vaccinations through the National Childhood Immunisation Schedule and the National Adult Immunisation Schedule.

61.         Dr Chia Shi-Lu asked about the vaccination take-up rates. Childhood vaccination rates remain high. Measles and diphtheria vaccination rates, at age 2 years, have been around 95% or higher in the last decade. The take-up of recommended vaccinations for adults has been encouraging, with more using MediSave for them. For example, MediSave use for influenza vaccinations has increased by about 60% - from about 32,000 between November 2016 and October 2017 to about 52,000 in the same period a year later.

62.         However, there is still room for improvement, as the numbers represent a small proportion of the at-risk population for which vaccination is recommended. MOH will continue to educate the public on the importance and benefits of vaccination to encourage uptake, but ultimately, we should all take responsibility for our own health by going for the recommended vaccinations.

63.         Minister Gan mentioned that MOH has developed the National Centre for Infectious Diseases (NCID), a 330-bed national facility designed for containment of dangerous infectious diseases. It is expected to be fully operational by May 2019.

64.         During an outbreak, NCID will centrally manage the screening, isolation and treatment of infected patients.

65.         NCID also houses public health capabilities such as the National Public Health Laboratory to support the detection of infectious diseases. NCID will also conduct training and research to strengthen national preparedness against outbreaks.

Conclusion

66.         In conclusion, my Ministry will continue to grow Singapore’s healthcare capabilities while keeping costs affordable for all. We must work together as one to tackle the challenges, and ensure that Singaporeans can enjoy many more years of health to come.

Thank you.