Speech by Minister for Health, Mr Gan Kim Yong, at the MOH Committee of Supply Debate 2016

BETTER HEALTH • BETTER CARE • BETTER LIFE

(A)         INTRODUCTION

1.            Madam Chairman, I would like to thank Members for their comments and suggestions. With your permission, may I display a few slides to facilitate the discussion.

(B)         STATE OF OUR HEALTH - WHAT WE HAVE ACHEIVED

2.            Madam, our healthcare system has served Singaporeans well. The average lifespan of Singaporeans born in 2014 is now 82.8 years, seven and a half years more than in 1990.  Life expectancy of Singapore is among the highest in the world and our Health Adjusted Life Expectancy, HALE for short, which measures years lived with “full health”, is among the top three globally. In short, Singaporeans can expect to live longer and healthier.

3.            There are encouraging signs that more Singaporeans are choosing a healthier lifestyle. The proportion of adult smokers fell from 18.3% to 13.3% over the last 20 years.  We are also choosing healthier foods. Today, more than a quarter of Singaporeans consume at least one serving of wholegrain products per day, more than three times the rate in 2004. But, the picture is not all rosy. There are some worrying trends which I will elaborate later.

(C)         UPDATES ON HC2020

4.            But first, let me give an update on our Healthcare 2020 Master Plan.

Accessibility

5.            First, on accessibility. Over the last five years, MOH has expanded our capacity in all sectors.

6.            In 2015 alone, we opened three new acute and community hospitals progressively and added over 900 beds - Ng Teng Fong General and Jurong Community Hospital in the West, and Yishun Community Hospital in the North. The three hospitals will continue their ramp up this year, and are expected to bring online another 270 beds.

7.            Mr Low Thia Khiang asked about wait times for our Specialists Outpatient Clinics (SOCs). From 2013 to 2015, SOC attendances increased by 5%; largely due to the increase in subsidised attendances by our seniors, which grew by 26%. These patients would have benefited from higher subsidies, especially for the Pioneer Generation. During the same period, private SOC attendances actually fell by 5.3%.

8.            Despite the increasing workload, the median wait times for subsidised new appointments remained fairly constant, at about 29 days over the past three years while 95th percentile wait times increased from 110 to 125 days. For private patients, median wait times stayed about the same at eight days while the 95th percentile wait times increased from 47 to 58 days. Nevertheless, we have made improvements in the P50 and P95 wait times for specialties such as Rheumatology and Immunology, Gastroenterology, Ophthalmology and Neurology despite increasing attendances at these SOCs.

9.            SOC wait times vary across hospitals. At Alexandra Hospital, for example, the overall median wait time is less than a week and, at the 95th percentile, 12 days. So, patients who need an earlier appointment can ask their doctor to refer them to hospitals with a shorter wait time.

10.         For patients with more serious and time-sensitive conditions, our hospitals and polyclinics have protocols in place to arrange for faster appointments at our SOCs. For example, the median waiting time for new subsidised appointments for urgent cardiac conditions and suspected cancers was around one week. In fact for cardiology and cardiothoracic surgery, the median wait times has improved from 14 days to six days.

11.         We have been managing the wait times for our SOCs in three ways. First, we optimise the SOC appointment system to give priority to urgent cases. We also reduce ‘no-shows’ by reminding our patients of their appointments by messages. Second, we are working with polyclinics and GPs to ensure that only patients who need a specialist's care are referred to our SOC, and for patients who have recovered and are well, to help them transition back to primary care. And third, we have added new SOC capacity through developments such as the NUH Medical Centre, National Heart Centre and the Ng Teng Fong General Hospital.

12.         Mr Low cited the case of a patient experiencing a long wait for an appointment and biopsy results. I would like to explain that the usual turnaround time for the laboratory biopsy results is around three days. So, I would be happy to look into the circumstances of the specific case if Mr Low can provide the details.

13.         Mr Low also asked about the time taken for CT investigations.  For the first quarter of 2016, the median wait time for a routine subsidised outpatient CT scan was between one and three weeks for most hospitals and has remained stable over the past three years. I should explain that the timing of the CT scans may be a result of scheduling to coincide with reviews by doctors. For conditions that require urgent scans, hospitals are able to fast track these cases, whether in the wards, in the SOCs or at the A&E, on the same day or the following day.

Long Term Care

14.         Other than hospital capacity, we have also added about 1,200 Nursing Home beds and 60% more home care, day care and home palliative care places between 2011 and 2015.

15.         Looking forward to 2020, we are on track to add more than 6,600 places in community care, home care, and palliative care, as well as 7,900 beds in acute hospitals, community hospitals and nursing homes.

Primary Care

16.       Mr Leon Perera asked about wait times at our polyclinics. Polyclinic attendances have been growing over the years, from 4.5 million attendances in 2011 to 4.9 million in 2015.  Median consultation waiting times have improved from 32 minutes in 2011 to around 14 minutes in 2015.  Mr Perera is correct that wait times for patients with appointments is indeed lower than wait times for walk-in patients. Over the past few years, polyclinics have been encouraging more patients to use the appointment system.  Currently, all patients with chronic conditions, many of whom are elderly, are offered appointments for their next chronic visit. In 2015, 70% of these chronic patients visited the polyclinics by appointments. We will continue to help more patients use the appointment system.

17.         In the meantime, we are adding capacity and improving processes to meet the primary care needs of our population.

18.         The last four years, we redeveloped the Geylang and Tampines polyclinics and have just completed an expansion of Marine Parade Polyclinic. Currently, we are re-developing Bedok, Ang Mo Kio and Yishun polyclinics and are on track to open new polyclinics in Jurong West, Punggol and Bukit Panjang, and a new primary care facility in Sembawang by 2020.

19.         Madam, many Singaporeans choose to visit polyclinics instead of private GPs because of the significantly lower costs at polyclinics, as a result of government subsidies. Lower- and middle-income patients and all Pioneer Generation patients now have an alternative as they can tap on the PG package and the Community Health Assist Scheme or CHAS introduced in 2012 to enjoy subsidised primary care services at private GP clinics instead.

Quality

20.         Madam, our healthcare professionals are at the heart of delivering quality patient care. To meet increasing healthcare demand, we have grown the healthcare professional workforce of doctors, nurses, pharmacists, and allied health professionals by 24% from 46,000 to 57,000 between 2011 and 2015.

Affordability

21.         We have also made significant moves in addressing Singaporeans’ concerns over healthcare affordability.

22.         In 2014, we launched the Pioneer Generation Package which provided 450,000 Singaporeans with more help with their healthcare costs.

23.         For lower- to middle-income Singaporeans, we have raised the subsidies for outpatient drugs and specialist care. As of December 2015, 715,000 Singaporeans have benefitted from these enhanced subsidies.

24.         With CHAS, I spoke about this just now, about 1.4 million Singaporeans, including Pioneers, are able to benefit from government subsidies at participating private GPs and dentists, close to their homes.  Since 2012, we have more than doubled the number of participating clinics to 1,500.

25.         We have introduced more flexibility in the use of Medisave to help Singaporeans with their healthcare costs. Today, Singaporeans can also use up to $400 per Medisave account per year to pay for their outpatient chronic disease management.

26.         Last November, we introduced MediShield Life to provide better protection for all, for life.

27.         To date, many Singaporeans have benefited from MediShield Life. Take for example Madam Sung a Pioneer living in Ang Mo Kio.

28.         Late November last year, Madam Sung had a stroke and her family brought her to Tan Tock Seng Hospital where she was warded for 11 days. She continued her rehabilitation and recovery for eight days at the Ang Mo Kio - Thye Hwa Kwan Community Hospital, near her home.

29.         The total bill for the stay came up to $16,900 and after subsidies Madam Sung needed to pay $6,400. Before MediShield Life, Madam Sung, who was uninsured, would have had to pay the full $6,400, but with MediShield Life coverage, she only had to pay about $3,300, close to half the original bill. And, all of this was paid through her Medisave.  

30.         Today, Madam Sung is back to living with her son and his family. She has four children, ten grandchildren and six great grandchildren - a great example for population strategy. A few weeks ago, the whole family came together to celebrate her 85th Birthday. We wish Madam Sung and her family the best of health.

31.         Overall, from last December to February this year, MediShield Life approved about $136 Million for 95,000 claims or about $45.3 Million per month. This is a 29% increase, compared to the average monthly claim for MediShield in 2015. MediShield Life, together with government subsidies, Medisave and Medifund will continue to help many Singaporeans like Madam Sung, and low wage workers mentioned by Nominated MP Thanaletchimi in her budget speech, giving them greater peace of mind that their medical treatments will be affordable.

32.         Ms Sylvia Lim asked about coverage for overseas Singaporeans. MediShield Life was introduced to give all Singapore Citizens and Permanent Residents assurance of universal healthcare coverage, regardless of their health condition, situation and background. 

33.         MOH is aware that Singaporeans based overseas are concerned that MediShield Life coverage is mandatory.  We recognise that the overseas Singaporean community is diverse, and individual circumstances vary considerably.

34.         The MediShield Life Council will conduct targeted engagements with overseas Singaporeans as part of the MediShield Life coverage review, while bearing in mind the principle of universal coverage.

Ageing

35.         Madam, the report on the Action Plan for Successful Ageing released in February outlined our strategy to develop a senior-friendly nation and a caring community. 

36.         The effort to pilot Community Networks for Seniors announced by Minister for Finance earlier, is a whole-of-government approach to “close the last mile” in supporting successful ageing for seniors in our community. As highlighted by Associate Professor Fatimah Lateef and Ms Tin Pei Ling, this pilot is not about introducing another new service for seniors in the community, but an effort to strengthen partnership and coordination among key stakeholders such as agencies and community organisations, so that we can work together, as a team, to better meet the needs of seniors and build a stronger community for our seniors to age in place.

Challenges and Key Directions

37.         We have studied the system in other countries. Many developed countries with ageing populations are facing similar challenges as us. One important lesson we can learn from them is that doing more of the same cannot be the solution. We need a paradigm shift in our approach to ageing and health.

38.         Singapore can and must be different. It will take time but we must start now. We must make good use of the next few years to plan ahead, and design a system that meets our growing needs in a cost-effective and sustainable manner beyond 2020. We can do so, with three paradigm shifts:

39.         First, to move beyond the hospital to the community. Second, to move beyond quality to value, and third, to move beyond healthcare to health. Let me elaborate.

(D)        BEYOND HOSPITAL CENTRIC TO COMMUNITY-BASED CARE - TRANSFORMING CARE DELIVERY 

40.         Beyond hospital-centric to community-based care, we are transforming our healthcare delivery system from one that is built around the hospital, to one that is directed at meeting the needs of Singaporeans.  We will make it easier for patients to access appropriate care, help them recover faster, and enhance health outcomes while keeping costs affordable and sustainable. To do this, we need to reshape our health delivery system.

RHS

41.         The first aspect in reshaping our system is to link up care through the Regional Health System or RHS. Over the last few years we have done this by building up the primary, intermediate, long-term and home care sectors - and the networks between hospitals and these care providers. These have helped to streamline processes, enable shorter hospital stays and support faster recovery for patients. We will need to further strengthen the integration of the RHS.

42.         An example of this is to develop structured care pathways to better care for patients across settings. Let me illustrate. The Eastern Health Alliance RHS has introduced an integrated care pathway for patients with hip fracture, across providers. Patients who have sustained hip fractures are quickly identified and put on the hip fracture care pathway. The pathway organises the different care providers in the RHS into a coherent workflow to efficiently care for patients, allowing for a more timely surgery, shorter acute hospital stays, and faster transition to rehabilitation at Saint Andrew’s Community Hospital next door. This is crucial, as starting the rehabilitation process early leads to better mobility outcomes. Upon discharge, patients attend day rehabilation near their homes, as needed, to optimise their functional outcomes.

43.         Such pathways require various partners in the RHS, and sometimes between RHSes, to work closely to deliver seamless care to patients, for better outcomes.

44.         Our vision of “One Singaporean, One Family Doctor” remains relevant. We want to transform primary care to be the first and continuous line of care so that Singaporeans can access good quality care in the community. As Dr Chia pointed out, the key is building a trusted relationship between GPs and Singaporeans, so that your family doctor has a deeper understanding of you and your family’s health needs, and can therefore provide better guidance and more appropriate treatment when needed. MOS Lam will elaborate on how we are strengthening the primary care later on.

Manpower

45.         As we reshape our health delivery system and move beyond the hospital to the community, we need to make similar shifts in how we develop and deploy our healthcare workforce. Our healthcare workforce must be future-ready – so that healthcare professionals can continue to enjoy fulfilling careers, and can readily acquire new skills and capabilities. SMS Khor will talk about how we are creating good healthcare jobs for Singaporeans and fostering industry relevant skills through the national SkillsFuture framework.

46.         MOH, together with our public healthcare institutions, will be looking into job re-design and the use of technology to not just simplify the work for our healthcare teams, but to work in a different way to deliver better care to patients. MOS Chee will share how productivity and innovation can support our healthcare workers and improve patient care.

End of Life

47.         Dr Chia said we must care for Singaporeans from birth to death, and I agree.  The issue of death is a sensitive one in our “pantang” Asian society.  These are difficult conversations which we must have, not just among family, but also at the national level if we want our loved ones and family members to have dignity, comfort and peace of mind as they walk through their last journey.  This requires a whole-of-society approach, and we are encouraged to see organisations, such as the Lien Foundation, raise these topics at the national level.

48.         Through the Agency for Integrated Care, we have also been working with our hospitals and community partners to raise the awareness of Advance Care Planning or ACP. ACP allows individuals and their families to better understand their preferences towards the end of life and to fulfil their wishes.

49.         Take for example, the late Mr Phang who was admitted to Dover Park Hospice after being diagnosed with terminal cancer. Through ACP, the hospice staff were able to establish that his preference was to pass on at home so that he was able to spend his last days in a familiar environment with his wife. This was a great source of comfort to his wife. She was very grateful to the hospice staff for establishing his end of life wishes.

50.         Madam, we need to continue this conversation, and MOS Chee will be elaborating on further enhancements we are making in palliative care.

(E)         BEYOND PROVIDING QUALITY TO ENHANCING VALUE – KEEPING OUR SYSTEM SUSTAINABLE

51.         As we transform our healthcare system, we have to be mindful of the long-term implications on sustainability. Our healthcare budget has more than doubled from $4.7 billion in FY12 to $11 billion this year.  This has come about partly because of ageing, and the need to invest in infrastructure, but also because of Government’s policy shift to take on a greater proportion of healthcare costs.

52.         The current challenging economic outlook is a timely reminder of the need to ensure sustainability. Not just for ourselves but for future generations.

53.         Therefore, we need to choose care that is appropriate to needs, so that we can make the best use of our limited resources.

54.         It is for this reason that we have a co-payment feature throughout our healthcare system. For example, MediShield Life has co-payment features like claim limits, deductibles and co-insurance to help guard against over-consumption or over-provision of services. However, many Singaporeans have private Integrated Shield Plans that are “as-charged”, which means they have no claim limits, and some buy extra riders to cover the deductibles and co-insurance. Such features could lead to a ‘buffet syndrome’ since all the cost will be paid for by third parties, by someone else. This contributes to rising healthcare costs for everyone and eventually pushes up premiums. We will need to study this carefully to ensure sustainability.

Appropriate Care

55.         Emerging healthcare technologies are becoming increasingly expensive and we need to ensure that the outcomes derived from these technologies are commensurate with these costs.

56.         As part of the “Choosing Wisely” campaign, medical bodies in the US, Canada, UK, Australia and Japan have identified 400 areas of unnecessary or low value tests and treatments.

57.         We too, recently set up the Agency for Care Effectiveness, or ACE for short, to expand our capacity in evaluating the clinical and cost effectiveness of health technologies. ACE will look into high cost treatments and technologies, systematically evaluate and develop guidance to (1) guide the proper use of such treatments and technology, and (2) encourage providers to manage costs while providing quality care.

58.         This will help patients, caregivers and physicians make more informed treatment decisions on treatments and avoid over-provision of services that will drive up costs.

(F)         BEYOND HEALTHCARE TO HEALTH - A FOCUS ON DIABETES

59.         As we move beyond hospitals to the community and beyond quality to value, we also have to move beyond delivering healthcare, and focus on providing good health – to nurture a healthy nation and a healthy people. To do this, we need to arrest the causes of ill health early and reduce the progression of long-term chronic diseases.

60.         While the HALE has improved over the years as I mentioned earlier, Singaporeans are also living with ill health longer - 1.5 years longer than in 1990. We have observed several worrying trends in recent years. Decreasing activity rates across all age groups and the increasing consumption of excessive calories and fat leading to a rising obesity rate. Obesity is the major risk factor for chronic disease, such as Type 2 Diabetes.

61.         As noted by Dr Lily Neo and Dr Chia Shi Lu, diabetes is indeed fast becoming a major global healthcare concern. The World Health Organization recently announced that the global number of adults living with diabetes has quadrupled since 1980 to over 400 million in 2014. And of these 400 million, 400,000 are in Singapore - they are Singaporeans. Among Singaporeans, about 400,000 have diabetes, and one in three Singaporeans have a lifetime risk in developing diabetes; a 30% lifetime risk.

62.         Of those who have diabetes, one in three Singaporeans have not been diagnosed. And among those diagnosed, one in three have poor control of their condition. The following images may be graphic but they are examples of what some Singaporeans endure daily. Left undetected, untreated or poorly managed, diabetes can lead to heart disease, stroke, kidney failure, blindness and amputations. In fact, four Singaporeans a day lose a limb or appendage due to diabetic-related complications. These complications reduce the quality of life for the patient, and increase the burden on individuals, families and society as a whole. A Saw Swee Hock School of Public Health study estimated the total economic burden of diabetes for working-age adults at more than a billion dollars a year. However, the long-term costs of diabetes, taking into account the psycho-social burden, is far more than this.

63.         We need to tackle the Diabetes challenge. Therefore, I am declaring War on Diabetes. We want to help Singaporeans live lives free from diabetes, and for those with the disease, to help them control their condition to prevent deterioration.

64.         This is a multi-year effort. We will engage stakeholders and develop detailed action plans together, but let me outline our broad strategy:

65.         First, we will work on upstream prevention – To promote a healthy lifestyle and reduce obesity rates in order to cut down on new diabetes cases. Broadly, we are doing this by ramping up our health promotion efforts through a twin food-and-exercise strategy. We will improve the dietary quality in schools, communities and workplaces, and learn from successful international regulation strategies. To encourage more people to exercise, we will expand ongoing programmes such as the National Steps Challenge and Sundays@The Park, as well as introduce new programmes and bring them to schools, workplaces, and our community. The risk of developing diabetes is 30-40% higher among active smokers than non-smokers and we will be doing more to curb smoking rates as part of this plan.

66.         Healthy habits start young, and MOS Lam will be leading our effort in developing the NurtureSG Plan to tackle many of the preventable risk factors for our youths. We will be working closely with MOE to develop and implement this plan.

67.         Second, we will strengthen early screening and intervention – to identify the disease early, especially those at risk. Screening plays an important role in our War by picking up cases earlier, starting interventions and thus reducing the likelihood of the gory images I showed you previously. This is like intelligence in warfare. But, follow-up after screening is equally important.

68.           We hope that earlier intervention, and basic lifestyle changes, can even reverse the pre-diabetes state and get such individuals back to health. In a US study published in the New England Journal of Medicine, pre-diabetics can reduce the overall incidence of diabetes by 58% through diet, exercise, and behaviour modification. That’s why I say we still have hope. These lifestyle changes worked particularly well for participants aged 60 and older, reducing their risk by 71%. So, you are never too old to make lifestyle changes and take back your health.

69.          Third, we will support better disease control – To slow disease progression, and reduce complications. For those with diabetes, we need to do our best to help them have a good quality of life, at all stages, by having good control over their disease. This can help to reduce or delay complications and give patients better quality of life. Madam, let me speak in Mandarin.

70.        今年我们将向糖尿病宣战。 同僚问我，为什么这么严重， 还要搞到宣战这么暴力。

糖尿病的问题是日益严重。我国人民患糖尿病的终生风险为三分之一。患病的机率也随着年龄提高。患病者不但饱受疾病的折磨，他们的家庭和亲人也会受影响。

所以，我们别无选择，必须全民动员向糖尿病宣战，而且不可以纸上谈兵。一来，我们每个人都应该在饮食和运动方面下功夫，保持健康。二来，我们需要提倡保健和尽早做体检的重要性。三来，我们应该鼓励每个病患尽早求医，并和医药团队合作更有控制病情。

让我们全国上下齐心齐力，战胜糖尿病， 让国人过着更健康的生活。

71.         The key to winning the War on diabetes is for all Singaporeans to be engaged in the battle. The key partners in this War are the individuals, his family and the community. By working together, we hope to create an environment that makes healthy choices easy, but Singaporeans also need to play their part by eating healthily, exercising often, and going for the recommended screenings and follow-ups. We can also play a part in encouraging and helping others to do so. We will be increasing public awareness about diabetes and empowering individuals to take control of their health.

72.         To coordinate the strategies on the War on Diabetes, I will be co-chairing a Diabetes Prevention and Care Taskforce, together with Mr Ng Chee Meng, Acting Minister for Education. The Taskforce will include representatives from Government agencies, the private sector, patient advocacy and caregiver groups and will: (1) develop and implement a multi-year action plan for the war on diabetes, (2) reach out and mobilise the nation to fight this disease together and (3) monitor and evaluate the outcomes of our efforts.

73.         The War on Diabetes will not be a quick battle, but a long war requiring sustained effort. Results of our efforts can only be seen in the long term, but we must persevere. And if we are successful in shifting mindsets and changing habits, we will be able to curb not just diabetes but other related chronic diseases such as heart disease as well, and we will improve the lives of Singaporeans and reduce the burden on their families.

(G)        CONCLUSION

74.         Madam, health is ultimately a personal responsibility.  All Singaporeans need to play an active role in their health journey and in the War on Diabetes. We all need to make sensible lifestyle choices and informed decisions in our health.  Government will do its part to provide a supportive environment but we cannot do this alone. If we are able to do this together; we will be able to achieve Better Health, Better Care and a Better Life for all Singaporeans. Thank you.