COS Speech for Minister Of State for Health - Community Health: Working with and through the Community for Better Health Outcomes

Sir

Caring for the Vulnerable in the Community

1.As Minister Gan mentioned earlier, our healthcare landscape needs to transform to meet the challenges of a growing and ageing population. This would include the growing burden of mental disorders. As our population grows, the number of Singaporeans with schizophrenia is expected to increase by about 2% per year. As we age faster, the number of Singaporeans with dementia will increase significantly. We must enhance our mental health capabilities to cope with this increased burden.

Our strategy of keeping people healthy and managing their health conditions well to reduce the need for costly hospitalisations, also applies to those with mental conditions.

Enabling the Community

Community Mental Health

2.Several Members spoke on the issue of mental health. Since the National Mental Health Blueprint was rolled out in 2007, we have invested some $180 million in strengthening core services for mental health conditions. We enhanced early detection and access to treatment through programmes such as the Response, Early Assessment and Intervention in Community Mental Health (REACH), which helps to provide early detection and intervention to children with mental health issues, and trains school counsellors to better manage such children.

At the other end of the spectrum, the Community Psychogeriatric Programme provides home-based mental health services for the frail elderly, which has improved clinical outcomes and patients’ quality of life. Despite the progress that we have made, much remains to be done.

3. Several Members asked for a holistic approach in caring for persons with mental conditions in the community. This is indeed our intent. Over the next few years, we will be developing a new community-based mental health plan to complement our hospital-based services. Our goal is to build a network of care and support services that are integrated with our primary care and long-term care services.

4.To improve access to care for mental health patients, we will site specialist-led multi-disciplinary teams in the community, starting with the north and central regions this year. These Assessment and Shared Care Teams, or ASCAT for short, will be integrated with our primary care services, so that a person with a mental condition can visit a clinic near him to receive the care he needs, instead of having to see the psychiatrist in the hospital. We target to set up six ASCAT teams by 2016 to manage up to 9,500 patients at any point in time. In addition to the ASCAT teams, we will put in place more specialised teams to focus specifically on dementia patients. We will also expand counselling and psychotherapy services in the community to enable GPs to play a larger role in treating patients with mild to moderate mental conditions such as anxiety and depression.

5.Caring for someone with a mental condition calls for tremendous family and social support. To this end, community nodes such as Seniors Activity Centres and grassroots organisations play an important role in helping residents with mental health conditions. We will be piloting a helpline to provide information to such community organisations, to enable them to assist patients and caregivers to better navigate the range of services available. Mobile teams of mental health professionals will also provide early on-site response for potential crisis situations where intervention or closer assessment is needed. In tandem, we will work with the Alzheimer’s Disease Association to expand the reach of its Elder-sit and Home Intervention Services, to help more families care for their loved ones with dementia.

We are developing community case management to ensure that persons with mental illness adhere to their care plans and are connected to the services they need. Overall, we will spend over $100 million more to support such community mental health projects over the next five years.

6.Concurrent to our efforts to build up community-based mental health services, we will also grow some of the other hospital and institution-based services for those with more severe mental disorders. We will expand the capacity of the specialised outpatient memory clinics in our hospitals by about 60% over the next five years, to serve more dementia patients. Over the next five years, we will also build two new psychiatric nursing homes, one additional psychiatric rehabilitation home, and two more psychiatric sheltered homes at a cost of about $70 million.

This will increase the existing capacity of our psychiatric ILTC facilities from 1,000 beds to 1,700 beds.

7.We are committed to ensure that mental health services are affordable, which was an issue that Ms Tin Pei Ling and Mr Patrick Tay and Mrs Lina Chiam raised. Apart from subsidised treatment at the polyclinics, those who qualify for the Community Health Assist Scheme can also receive subsidised treatment at GPs for schizophrenia, major depression, dementia and bipolar disorder. Medisave can also be used for outpatient treatment of these conditions. Those who need inpatient psychiatric treatment or residential long-term care enjoy the same subsidies as other patients – up to 80% in Class C wards or up to 75% in ILTC facilities - and additional financial assistance via Medifund is also available for needy patients.

Patients can also withdraw up to $150 per day from their Medisave accounts for in-patient psychiatric treatment, which is generally less intensive than for other medical conditions. As Minister Gan mentioned earlier, we are considering extending Medishield coverage for inpatient psychiatric treatment.

8.The capacity expansion will require systematic development of mental health professionals. I would like to assure Ms Tin and Mr Low Thia Khiang that the Ministry is working actively on this. We have grown our psychiatry specialist training capacity to produce about 15 psychiatrists a year over the next five years, compared to only five a year currently. We have also increased the local pipeline for clinical psychologists, through NUS’s and James Cook University Singapore’s postgraduate programmes. The total intake will reach more than 20 per year by 2012 and will enable us to meet the projected national demand. In addition, over the past five years, close to 250 allied health professionals and nurses underwent advanced training in mental health-related disciplines under the Ministry’s Healthcare Manpower Development Programme. We will continue to support training opportunities for our healthcare professionals to pursue advanced training in areas relating to mental health, to ensure that we have sufficient numbers of adequately trained manpower to support our national mental health plans.

9.I would also like to assure Mr Low, Mr Chen Show Mao and Dr Lily Neo that there is a whole-of-government approach to meet the needs of persons with mental illness and their caregivers.

The Ministry works closely with other relevant ministries and government agencies such as MCYS, MOE, the Police and the Health Promotion Board (HPB) to do so, with AIC playing a crucial role on the ground to manage patient referrals and implement different programmes. An important part of their efforts is to help bridge the health and social service agencies in order to deliver more holistic care for patients with mental illnesses.

10.Dr Lam Pin Min and Ms Tin also spoke on the de-stigmatisation of mental health patients. This requires a change in mindset, and is not something that can be achieved in a short time. Siting of mental health services in the community, and allowing patients to seek treatment at a clinic near where they live, just like any other chronic disease, is one step in this direction.

In parallel, we will continue with our mental health education and promotion efforts. HPB reached out to some 170,000 people last year, and will continue with its efforts this year. Some notable efforts include empowering peer support networks among youths, and deploying a roving bus to provide integrated physical and mental health screening for the elderly. HPB has a workplace mental health promotion grant to build resilience and wellbeing of employees and facilitate early detection and support. From April this year, the maximum quantum of the grant will be raised from $2,000 to $5,000 to sustain and augment companies’ mental health promotion programmes. The grant is targeted to benefit 100,000 employees over the next three years, at a cost of $2.5 million.

Working With the Community, For the Community

11.Beyond working with the community to increase awareness of mental health issues, we will continue to work with the community and for the community in promoting personal responsibility for health.

Building a Health-Promoting Eco-System

12.We have stepped up our efforts to encourage Singaporeans to lead healthier lifestyles. This is not easy, as many work long hours and eat out. In 2010, 60% of Singaporeans ate out at least four times a week, up from 49% in 2004. With changing lifestyle patterns and an ageing population, we are seeing an increase in prevalence of diabetes and obesity.

13.Dr Teo Ho Pin asked about our health promotion efforts and advocated that we inculcate healthy lifestyle knowledge and habits in our people. I agree that we need to do so. However, simply arming Singaporeans with the skills and knowledge to lead a healthy lifestyle is not enough. The community and environment are powerful influences on individual behaviour, and we have tapped on these to further our health promotion objectives. Allow me to elaborate.

Leveraging Network of Health Ambassadors

14.Within our community, many people are passionate about living a healthy lifestyle, and they are eager to share this with others.

HPB has brought them together to form a Health Ambassadors Network. We now have 2,000 Health Ambassadors who have been trained and equipped to be mentors to their family and friends, and we plan to nurture up to 10,000 Health Ambassadors by 2015. This means that each constituency will have at least 100 ambassadors to support local health promotion efforts. I am also passionate about living a healthy lifestyle. Hence, having been appointed as Chief Health Ambassador, I will endeavour to lead the way and champion these efforts and I hope Singaporeans will join me.

15.Our Health Ambassadors have made a positive impact on the lives of their friends and neighbours.

One of my residents visited the health corner at the Residents’ Committee in Hong Kah North and was found to have a high blood pressure reading. We found out that she had stopped her medication for high blood pressure, and advised her to see her doctor as soon as possible. Mr Tan Kin Teo, one of our Health Ambassadors, visited her the next day and found out that she was not taking her medication due to financial difficulties. Mr Tan got in touch with Southwest CDC and the resident is now receiving financial assistance.

Building an Enabling Environment that Supports Healthy Lifestyle Choices

16.The health corners at Community Clubs and Residents’ Committees are just one of many supporting structures that we are co-developing with the community to support healthy living.

We have also sought to improve access to healthier eating in the community and dispel misconceptions that healthier food options do not taste good or are expensive. Following the successful launch of the Healthier Hawker Programme in April 2011, we worked with the Bukit Batok East constituency to set up the first Healthier Coffee Shop last month. Over the next year, we plan to have 20 more Healthier Coffee Shops and 20 more Healthier Hawker Centres in different parts of Singapore. HPB has also worked with shopping malls, community clubs, and MRT stations to create opportunities to remind and encourage people to live healthy lifestyles. We are working to integrate these efforts to form Health Promoting Constituencies.

17.Mr David Ong and Dr Janil Puthucheary noted the recent uptrend in smoking rates, including among youth, and asked what we could do to address this. Singapore has successfully combined multi-pronged, cross-agency measures – ranging from education and smoking cessation, to taxes and legislation to bring smoking rates down to under 15%, which is one of the lowest in the world. However, even as rates decline, it is challenging to maintain our gains with each succeeding cohort of youth, and to push the boundaries. The increase in prevalence of smoking since 2004, as noted by Mr Ong and Dr Janil, is driven by young adults aged between 18 and 29 years taking up smoking.

18.To bring us to the next stage in tobacco control, beyond top-down legislative measures, we will focus on stronger, ground-up efforts that together, will de-normalise tobacco use and establish smoke-free living as the default style of living or as the social norm.

To this end, HPB launched the Blue Ribbon movement last weekend, to promote a smoke-free environment. Last year, the ground-up “I Quit” movement inspired smokers to quit through real-life testimonies of smokers who have successfully quit smoking.

19.These new initiatives complement our long-standing educational efforts in partnership with primary and secondary schools. HPB has also tapped on the Youth Advolution for Health (YAH) peer-led advocacy network to champion the ‘Live it Up without Lighting Up’ movement to reach out to teenagers outside school. These youth programmes have shown results; the rates of youths aged 13 to 16 years old smoking on at least one day in the past month decreased from 11% in 2000 to 6% in 2009.

20.As announced two weeks ago, the Ministry is also banning misleading terms on tobacco product packaging and labelling, and lowering cigarette tar and nicotine limits. Graphic Health Warnings will be replaced with a new set to ensure continued impact. These changes will take effect from 1 March 2013.

21.I would like to assure Members that we will press on with our tobacco control efforts, with a sharpened focus on youth. We will also work with NEA on the long-term goal of banning smoking in all public places other than designated smoking areas, to further de-normalise tobacco use. Later this month, Singapore will host the 15th World Conference on Tobacco or Health. We will exchange ideas with experts on strengthening tobacco control in Singapore.
We share Dr Janil’s vision of eliminating tobacco from Singapore one day, but when that day will come, we cannot be sure. But we will work towards it.

22. Mr Ong also asked how we could limit the consumption of trans fat. I agree with the need to do so, because of the link to heart disease. In Singapore, three in ten adults exceed the World Health Organisation’s daily limit of trans fat intake, and two-thirds of these are younger adults under the age of 40. HPB has actively engaged food manufacturers to reduce trans fat in their products and voluntarily label trans fat content. Since 2009, foods that have less than 0.5g of trans fat per 100g can carry HPB’s enhanced Healthier Choice Symbol. We are now ready to move one step further, to regulate trans fat in our foods.

In collaboration with AVA, we will limit trans fat to no more than 2g per 100g product for fats and oils supplied to local food service establishments and food manufacturers, as well as fats and oils sold in retail outlets. We will also require labelling of trans fat levels on packaging of retail fats and oils. The amendments to the Food Regulations will be gazetted in May this year by AVA.

National Integrated Screening Programme

23.Several Members asked about improving our screening programmes and screening coverage. Screening is a key part of our health-promoting ecosystem.

Heart diseases, stroke, cancer and diabetes contribute nearly half of the total burden of disease in Singapore, so early detection and management of these conditions and their risk factors are important in keeping our population healthy for longer.

24.The Integrated Screening Programme (ISP) was launched in 2008 to encourage Singaporeans to be screened for obesity, diabetes, high blood pressure and high blood cholesterol, which are all risk factors for heart disease and stroke. Singaporeans are also encouraged to be screened for selected cancers. Ms Ellen Lee quoted Prof Gilbert Welch’s article about the perils of over-diagnosis – that “there might be screening for diseases too frequently or we might be looking for diseases too hard”.

This is a valid concern, but I would like to reassure Singaporeans that the screening tests used in our programmes, as well as the targeted age group of 40 and above, are based on good evidence, guided by recommendations of the Screening Test Review Committee, an independent expert committee under the Academy of Medicine.

25.When Singaporeans turn 40, HPB sends them invitations to go for the recommended screening tests based on age and gender. The letter indicates eligibility for subsidised screening, and lists GPs in the vicinity of their home that offer the Integrated Screening Programme.

26.To date, 45,000 people have been screened under this programme, 54% of which were women and 46% were men.

53% of those who have gone for screening were detected with one or more chronic diseases. We will continue to encourage more people to go for screening, as well as more GPs to support this programme. Under this programme, Singaporeans pay only $8 for screening tests for diabetes, high blood pressure, blood cholesterol and obesity. Low income Singaporeans do not need to pay for tests at all.

27.The Ministry has also worked with HPB on a “one-stop” enhanced integrated screening programme in the community. This programme adds on the screening of seniors for functional decline. GPs and dentists in the local community will also be on hand to provide on-site follow-up where required.

This “one-stop” enhanced programme will be launched in Marine Parade this month, and we plan to roll it out to the rest of Singapore within the next three years.

28. Dr Lily Neo and Ms Lee will be happy to hear that I have asked HPB to convene a Women’s Health Advisory Committee, which I will chair, to improve screening and follow-up rates amongst women. This Committee will help HPB plan and implement a holistic Women’s Health Programme, which will adopt a life-stage approach and seek to equip women of all ages with the necessary knowledge and skills to improve their health. In addition, we will build up a pool of women Health Ambassadors who focus on women’s health issues.

We plan to launch this on Mother’s Day this year, and we target to reach out to 1 million women in Singapore, over three years

29.Let me address Dr Lam Pin Min’s point on the applications of cancer genetics testing. The use of genetic testing in cancer is a complex issue. While genetic testing is established as part of the care of certain individuals who are at hereditary risk for cancers, not all genetic tests are useful or accurate. As Dr Lam alluded to, there are concerns that the results of genetic tests could be used against the individual, for example by employers or insurance companies. While we acknowledge the potential benefits of cancer genetic testing, there is the potential for misuse.

However, legislation may not be the answer to the problem of discrimination by employers. The underlying mindset needs to be addressed. We will ride on on-going tri-partite efforts to encourage employers to adopt fair employment practices. Employees should be recruited on the basis of merit, such as skills or experience; other factors unrelated to the worker’s ability to do his job should not be considered. Furthermore, the Singapore Life Insurance Association has, on the recommendation of the Bioethics Advisory Committee, put in place a moratorium on the use of predictive genetic information for life and health insurance products. The Ministry will continue to monitor the evolving evidence for cancer genetic testing and review our policies accordingly.

Empowering the Community

30.A health-promoting ecosystem as I have described requires both top-down and ground-up initiatives. There are several good examples of ground-up health promotion efforts in our constituencies today. To foster and strengthen such community health promotion initiatives, we will pilot a new Constituency Health Promotion Grant from April this year. Each constituency will be given up to $10,000 a year for grassroots leaders to co-plan, co-develop and co-implement health promoting activities for their local residents, such as health talks, healthy cooking demonstrations, exercise programmes or other health interest groups. HPB will develop a toolkit with simple guidelines and checklists to help grassroots leaders with planning and implementation.

We believe that this will empower the community and energise the ground-up social movement for healthy living.

Other Matters

Special Needs

31.Before I conclude, let me address some specific issues raised by Members. Ms Denise Phua spoke on children with special needs. Managing children with special needs is a complex issue requiring close multi-agency coordination across the social, education and healthcare sectors. Early detection touch-points include parents and care-givers, pre-school educators and healthcare professionals.

HPB has worked with clinicians to revise the Health Booklet that is given at birth to every child, to include a more comprehensive checklist of developmental milestones. The latest revised edition now provides development checklists at 4 – 8 weeks, 3 – 5 months, 6 – 12 months, 15 – 18 months, 2 – 3 years and 4 – 6 years. This will help parents detect potential developmental problems in their child. Parents are encouraged to track their children’s milestones and take them to the polyclinics, GPs or paediatricians for the recommended developmental screenings. Our clinicians also train early childhood educators on basic child development issues so that the educators can help detect anomalies. This would strengthen the first tier of detection, which are parents and caregivers. Given their close proximity to their children, they would be the most likely ‘first touch-point’ to identify developmental problems.

We will continue to work with MCYS and MOE on further raising awareness and educating parents, early childhood educators and healthcare professionals to enable better and earlier detection of children who display signs of developmental problems.

32.Ms Phua also asked about the use of MediShield and MediSave for people with special needs. Today, MediShield and MediSave are primarily designed to cover hospitalisation expenses and expensive outpatient treatments such as chemotherapy. As Minister Gan mentioned, we are exploring MediShield coverage for congenital conditions, while keeping premiums affordable. MediSave currently also does not cover hearing aids and other physical aids and health items.

We would need to weigh any further liberalisation of MediSave use against the adequacy of Medisave for one’s post-retirement needs. The hospitals also tap on their endowment funds to offer financial assistance to persons with special needs to help them purchase hearing aids and other health equipment.

Medical Surveillance

33.Dr Lam Pin Min asked about our national disease surveillance system and pandemic preparedness, and Prof Fatimah Lateef asked about syndromic surveillance. The Ministry maintains vigilance against infectious diseases and other public health threats through a comprehensive system of local and global surveillance, in partnership with healthcare providers and other government agencies.

We collate syndromic surveillance information on acute respiratory disease, diarrhoea and conjunctivitis from polyclinics and hospitals on a weekly basis, although this can be done daily if necessary. If a threat has been identified, healthcare providers can be alerted quickly via email and SMS, and the public will be alerted through print and broadcast media as well as the Ministry’s online platforms.

34.Singapore has a National Influenza Pandemic Readiness and Response plan, which has been developed and refined based on our experience with SARS and H1N1. We regularly exercise the plan with public and private hospitals, as well as primary and step-down care facilities.

We have also stockpiled sufficient antiviral drugs for the treatment of infected persons during an influenza pandemic, and H5N1 pre-pandemic influenza vaccine for the protection of frontline essential service personnel and high risk groups including the elderly.

Regulation of Traditional Medicines

35.Prof Fatimah also asked about the regulation of traditional medications. Dealers and manufacturers of Chinese Proprietary Medicines, or CPMs, have to ensure that the safety and quality of their products passes Health Sciences Authority’s pre-market approval process, prior to sale and supply in the local market. This includes ensuring the absence of prohibited substances and excessive toxic heavy metal limits, and objectionable or fraudulent claims on the labels.

Other Traditional Medicines, or TMs, are not currently subject to pre-market approval but dealers and manufacturers are responsible for the safety of such products in the market. This is complemented by ongoing post-market surveillance by HSA, which monitors adverse events and conducts regular sampling and testing of CPMs and TMs to assure consumer safety. HSA is currently in the process of reviewing the need to implement a risk-based pre-market approval process for Traditional Medicines, taking reference from international best practices of overseas regulatory agencies, including in Canada and Australia.

Conclusion

36.Sir, we need to work with and through the community to achieve better health outcomes for all. While healthcare providers have a part to play in caring for the vulnerable, we also want to tap on the wider community and build strong social networks and support structures to encourage more Singaporeans to lead healthy lifestyles. We welcome ground-up initiatives to promote healthy living. Together, we can achieve our vision of a health promoting ecosystem which will benefit all residents.

37.Thank you.