Speech by Dr Lam Pin Min, Senior Minister of State for Health, at the MOH Committee of Supply Debate 2018

BUILDING CAPABILITIES FOR THE FUTURE

Introduction

1.    Minister Gan has highlighted efforts to ensure healthcare remains accessible, affordable, and of good quality. I will now elaborate on how we are developing capabilities and capacity for the future, ensuring that Singaporeans have access to good care, close to their homes.

Developing a Strong Primary Care Foundation

2.    The cornerstone of a sustainable healthcare system is strong primary care, where patients with chronic conditions are managed well in the community, with better health outcomes.

3.    In addition to our newly opened polyclinics in Punggol and Pioneer; there are ongoing polyclinic developments in Eunos, Kallang, Sembawang and Bukit Panjang; scheduled to be open by 2020.

4.    Minister has announced plans to develop a further 6 to 8 new polyclinics, which will enlarge our network to 30 - 32 polyclinics by 2030.  I am pleased to inform Members that two of the new polyclinics are expected to be operational by 2023, and will be developed in the northern region –  Nee Soon Central; and eastern region –  Tampines North. Residents in the West and Central regions can also look forward to new polyclinics.

5.    We are also renewing our existing facilities. Redeveloped Bedok and Ang Mo Kio polyclinics opened in Jul 2017 and Jan 2018 respectively. The redeveloped Yishun Polyclinic will open in mid-2018.

6.    Dr Chia Shi-Lu has asked for updates on our primary care transformation efforts. We are investing more resources to support our GP partners, through the Primary Care Networks (PCNs) scheme.  PCNs are networks of GPs delivering care via multi-disciplinary teams comprising doctors, nurses and primary care coordinators, who will provide holistic care. 

7.    The PCN scheme commenced in January this year with ten PCNs on-board, involving more than 300 GP clinics. We hope to eventually see 50% of CHAS GP clinics on-board the scheme.

8.    I have shared MOH’s vision for primary care, which is  “One Singaporean, One Family Doctor.” in previous COS debates. The PCN scheme forms part of our efforts to encourage trusting, long-term relationships between doctors and their patients.  Let me elaborate.

9.    Mdm Siti Saujana, a diabetic patient, has seen Dr Kwong Kum Hoong for the past six years. This continuous follow-up has allowed Dr Kwong to gain a deeper understanding of her needs.  For example, Mdm Siti’s high blood pressure was detected early as Dr Kwong had advised her to screen for other chronic conditions, as part of the plan in managing her diabetes.

10.    Mdm Siti has also benefitted from the team-based care offered by the NUHS PCN, which Dr Kwong’s clinic is a part of.  She received advice on her diet and lifestyle activities from the PCN nurse, as well as utilised diabetic eye and foot screening services provided by the PCN team.  The PCN care coordinator also ensured her appointments were well-coordinated.

11.    I am heartened by the strong rapport and trust forged between Mdm Siti, Dr Kwong, and the PCN care team; and encourage all Singaporeans to have a regular family doctor today.

Greater Accessibility to Care Across Settings

12.    To augment the primary care sector, we are also increasing capacity across various settings to ensure seamless care.  Since 2010, we have opened or expanded five hospital facilities – Ng Teng Fong General Hospital, Changi General Hospital–St Andrew’s Community Hospital Integrated Building, Jurong Community Hospital, Yishun Community Hospital, and Khoo Teck Puat General Hospital.

13.    The development of 3 more hospitals are underway. Sengkang General and Community Hospitals will open by the second-half-of 2018, while Outram Community Hospital will open progressively by 2020. Hospital bed capacity will increase further when the Integrated Care Hub at Novena and the Woodlands General and Community Hospitals open by 2022. In addition, the National Centre for Infectious Diseases will progressively open from end-2018.

14.    Aged care capacity will be increased to meet the demands of an ageing population.  By 2020, home care capacity will increase from the current 8,000 places to 10,000 places, while day care capacity will increase from the current 5,000 places to 6,200 places.  There are also plans to increase the number of nursing home beds from the current 14,900 beds to 17,000 beds.

15.    In tandem with the increase in infrastructure capacity is the need to ensure sufficient manpower.

16.    Mr Christopher de Souza asked if we are calibrating the training pipeline for specialists to meet medium-to-long-term needs.  We have increased the proportion of residency positions offered to specialties that are in greater need to address the demands of an ageing population.

17.    The number of residency positions taken up in Advanced Internal Medicine, Rehabilitation Medicine and Geriatric Medicine have doubled from 4% of the total residency intake in 2013 to 8% in 2017. MOH does regular reviews to calibrate the number of residency positions for each speciality based on projected needs.

18.    MOH periodically reviews the training requirements to ensure relevance to our local context. This includes instituting a mandatory Geriatric Medicine Modular Training Programme to equip residents with the skills to manage elderly patients. 

War on Diabetes – Disease Management

19.    However, we cannot indefinitely increase capacity and manpower. We have thus embarked on efforts to improve our care delivery.

20.    Mr Chen Show Mao and Mr Baey Yam Keng have asked for updates on the War on Diabetes (WoD). This is a whole-of-nation effort where everyone has a role to play.

21.    MOH is developing a Patient Empowerment for Self-care Framework to empower people with diabetes to initiate and sustain lifestyle changes, with the support of healthcare professionals, community-based providers, and other forms of social support.

22.    Under this framework, there will be a National Curriculum developed with educational materials for patients, caregivers and the public; and resources which healthcare professionals and community-based providers can use for patient empowerment.  The first tranche of materials will be available by mid-2018.

23.    MOH is concurrently enhancing our diabetes management programmes. As part of the Disease Management Workgroup, set up under the National Diabetes Prevention and Care Taskforce, we have rolled out initiatives targeted at eye and kidney complications. We will now address diabetic foot complications, as diabetes is the most common cause of non-traumatic lower extremity amputations (LEAs). In 2015, about 180 diabetes-related major LEAs were performed for every 100,000 adult Singaporeans with diabetes, compared to the OECD average of 60.

24.    MOH will be setting up a workgroup to review the national organisation of diabetic foot services, make recommendations on national care guidelines, and review the roles and training needs of healthcare professionals involved in diabetic foot care to decrease the lifetime risk of amputation for diabetic patients.

25.    Mr Speaker, let me now speak in Mandarin.

26.    糖尿病若不尽早治疗，或管理不善，将有可能导致多种长期并发症，如失明 ，肾衰竭和下肢截肢。

27.    在 2015 年，每 10 万名新加坡成年糖尿病患者当中就有将近 180 名遭受下肢截肢。这比经济合作与发展组织成员国高出许多。我们必须重视这个问题。

28.    卫生部将成立一个工作组，为新加坡制定一套减低糖尿病患者下肢截肢的策略。该工小作组将检讨我国目前为糖尿病患者提供足部医疗服务的情况，并就国家护理指导方针以及糖尿病足部护理相关医务人员的角色和培训提出建议。

29.    通过提升护理服务的质量，我们可以及时发现糖尿病患者的足部问题，并立即开始治疗，避免截肢。

30.    Mr Chairman, WoD is a shared responsibility. We have thus provided funding to support cluster-led, community-based diabetes prevention and management programmes.

31.    For example, in the Central region, the National Healthcare Group (NHG) has launched a Diabetes Community Intervention Programme (CIP) pilot with Toa Payoh Polyclinic to engage patients with, or at risk of diabetes, to take ownership of their well-being.

32.    In the East, Changi General Hospital (CGH) has worked with East Coast GRC to train volunteers as Health Peers to motivate residents with, or at risk of, diabetes towards behavioural change.

33.    Later this year, the National University Health System (NUHS) will launch the Patient Activation through Community Empowerment/ Engagement for Diabetes Management (PACE-D) programme in the West where patients will be assigned to dedicated multi-disciplinary care teams who will support them to take on proactive roles in disease management and lifestyle changes.

Future-ready Healthcare Regulations

34.    Even as we develop new initiatives, we need to ensure the delivery of safe and quality care.

35.    Ms Sylvia Lim has asked about how hospital complaints on patient care are handled. Hospitals have their own Hospital Quality Service/Patient Relations Office to deal with such complaints, and patients’ inputs are sought as part of the review process.  Mediation is another avenue for patients and their families to resolve their disputes with hospitals.

36.    Complaints escalated by patients to MOH are taken seriously and assessed in an independent manner for potential breach of the Private Hospitals and Medical Clinics Act.  A formal investigation will be initiated by the Regulatory, Compliance and Enforcement Division against the hospital once a potential breach is identified. The independent investigation by MOH will include opinion from the relevant appointed experts, and interviewing of all parties related to the case, including the patients and their next of kin.

37.    Under the Private Hospitals and Medical Clinics Act (PHMCA), institutions are required to report occurrences of Serious Reportable Events (SREs) to MOH and establish quality assurance committees (QACs) to review these SREs. Investigation reports are submitted to the Clinical Quality, Performance and Technology Division under the Healthcare Performance Group of MOH.  The priorities of this Division include Quality Assurance, Patient Safety systems and Quality improvement.

38.    One of the Division’s focus is to leverage on the reported serious events for improvement and cross-institution learning opportunities, similar to the approach of the UK’s Healthcare Safety Investigation Branch.  Anonymised information is shared amongst the healthcare institutions, and forums are organised for healthcare institutions to discuss gap closure measures.

39.    To future-proof our healthcare system, it is important that our laws stay current and flexible.

40.    As announced earlier, MOH is enacting a new Healthcare Services Bill to replace the current PHMCA this year.  The Bill will adopt a modular services-based licensing system to allow providers more flexibility in holding licences for any combination of healthcare services provided.  It will also appropriately regulate non-premise-based services, particularly as we want to encourage the outreach of community healthcare services such as home medical services.

41.    Regulatory clarity will be enhanced to make it easier for providers to understand and therefore comply with the legislative requirements.  New requirements and competency mandates will also be introduced, including an additional governance layer called the Clinical Governance Officer, to provide technical oversight over more complex services, such as clinical laboratories and radiological services.

42.    Fundamentally, the new Bill will allow MOH to strengthen its legislative powers to achieve our primary regulatory objective – safeguarding patient safety and welfare, as well as continuity of care.  Such powers include prescribing a list of prohibited unsafe practices that providers cannot offer, as well as mandatory participation of all healthcare service providers in the National Electronic Health Record or NEHR I will elaborate more shortly.

43.    We have actively consulted stakeholders on the proposed policies in the new Bill and I am heartened by the generally positive feedback received.  Licensees appreciated the flexibility of the licensing approach to accommodate various care models.  The public was also supportive of the enhanced powers in the Bill to have “step-in” rights, tighter publicity controls and prohibition of unsafe practices.

44.    Specifically, on the mandatory contribution of summary clinical data to the NEHR, licensees and members of public were generally supportive and provided feedback on aspects such as the cost of digitisation, opt out procedures, and patient confidentiality issues. Dr Lily Neo has asked about patients who may prefer to opt-out of NEHR. I would like to assure her that patients can choose to have their records locked, which would prevent it from being viewed and accessed.  We are also studying a proposal where patient’s future records will not be stored in NEHR at all.

45.    However, patients should note that this would cause a permanent gap in their medical record history.

46.    To support licensees in this journey, MOH and IHiS have introduced financial, technical and clinical support to help licensees.  For example, $20 million under the Early Contribution Incentive scheme is available to help licensees defray the cost of upgrading their IT systems to contribute data to the NEHR by June 2019.

47.    Even with the introduction of the new Bill, current regulations may not be flexible enough for the emergence of innovative care models.  To address this, MOH will be rolling out the Licence Experimentation and Adaptation Programme (LEAP), which is a regulatory sandbox that will allow new services to be piloted in a controlled environment. During the pilot, MOH will ensure that these businesses maintain essential safeguards for patient safety, while relaxing certain regulatory requirements or introducing new ones.  Thereafter, successful pilots will be mainstreamed under the Healthcare Services Bill with appropriate regulatory requirements. 

48.    For a start, the sandbox will focus on piloting models in three areas: namely telemedicine, precision medicine and models of care that support ageing.  More details will be announced in the coming months.

49.    Mr Low Thia Khiang has asked about how precision medicine can be harnessed for patient’s benefit.  Worldwide, we have seen how precision medicine treatments can be costly without strong evidence for improved health outcomes.  Our end objective must be to support the development of precision medicine for positive health and economic outcomes. 

50.    To this end, MOH is coordinating a multi-agency effort to develop an integrated national strategy for precision medicine research and its subsequent implementation. This includes looking at enabling infrastructure, regulatory and ethical frameworks, as well as public education.  We will provide a thorough update at an appropriate time.

51.    MOH also ensures that human biomedical research is carried out ethically.  Gene editing is presently used in basic research in Singapore and is governed by the Human Biomedical Research Act, and guidelines issued by the Bioethics Advisory Committee and National Medical Ethics Committee.

52.    Mr Low has also asked about the standards for the provision of clinical genetic testing.  MOH conducted stakeholder consultations last September . The feedback provided will be taken into consideration when refining the Standards, which are targeted to be rolled out in Q2 2018.

53.    The sector will be given a sufficient ramp-up period before the Standards become legally enforceable.

Anticipating Public Health Challenges

54.    Part of developing a future-ready outlook is the task of preparing for anticipated healthcare challenges.

55.    Overuse of antimicrobials such as antibiotics in the human, animal and agricultural sectors has exacerbated the problem of infection-causing microorganisms developing drug resistance.

56.    Antimicrobial resistance (AMR) is an international issue as drug-resistant microorganisms in other countries can easily spread across borders into Singapore.

57.    MOH, AVA, NEA, and PUB had jointly developed Singapore’s National Strategic Action Plan on AMR, which was launched in Nov 2017 to chart out how agencies will work together to detect and arrest AMR through increased surveillance, education, management, research, and international cooperation.

58.    As a member of ASEAN, Singapore will continue to promote cooperation and innovative collaboration to strengthen ASEAN’s resilience against AMR.

59.    Besides AMR control, vaccination is important to prevent infection and reduce the risk of infectious diseases outbreaks. Mr Leon Perera has asked about MOH’s approach towards subsidising vaccinations.

60.    To ensure collective population-level protection (i.e. herd immunity) and encourage vaccine uptake, childhood vaccinations against highly infectious diseases with community outbreak potential (e.g. measles) are fully subsidised at the polyclinics.

61.    For diseases with low community outbreak potential (e.g. HPV-related diseases), vaccination is recommended for personal protection.

62.    The National Adult Immunisation Schedule (NAIS) was introduced on 1 Nov 2017 to provide guidance on the recommended vaccinations that persons 18 years and older should receive, and Medisave use is allowed for these recommended vaccinations.

Conclusion

63.    Mr Chairman, my Ministry will continue to build capabilities and increase capacity in the future to ensure that we have a future-ready healthcare system.

64.    This task cannot be achieved alone. I urge all Singaporeans and healthcare providers to partner us in these initiatives to make our healthcare system better and keep Singaporeans healthier.

65.    Thank you.