Speech by Dr Lam Pin Min, Senior Minister of State, Ministry of Transport and Ministry of Health, at the Ministry of Health Committee of Supply Debate 2020, on Thursday 5 March 2020

Mr Chairman, for Singaporeans to continue to have good access to quality and affordable healthcare, we must press on to transform our healthcare system in the long-run, even as we face threats like COVID-19.

Expanding Primary Care Capabilities

Two New Polyclinics by 2030 – Bishan and Bidadari

2.            With Singaporeans living longer, primary care plays increasingly crucial roles in maintaining one’s health throughout their lives. Our Vision of, “One Singaporean, One Family Doctor”, remains relevant while we provide all Singaporeans with affordable and quality care, near their homes.

3.              I announced in 2018 that our network of polyclinics will be expanded to 30 to 32 polyclinics by 2030, from 20 today.

4.             Since then, we have announced ten new polyclinics, six of which will open by 2023. 

5.             In response to Mr Chong Kee Hiong’s feedback for a polyclinic in Bishan, and Mr Sitoh Yin Pin’s suggestion to build one in Bidadari, we are pleased to inform them that we will be developing a polyclinic in each of these areas by 2030. With Bishan and Bidadari polyclinics, we will achieve our target of having 32 polyclinics by 2030.

6.             To Dr Chia Shi-Lu’s query, the new polyclinics will offer similar services as existing ones, including medical treatment for acute conditions, chronic disease management, women’s and children’s health services, and radiological, laboratory and pharmacy services.

Update on Primary Care Networks

7.             Dr Chia also asked about our primary care transformation journey. This involves promoting a regular family doctor, which is important for continuity of care, especially for patients with chronic diseases who need long-term follow-up.

8.             To work towards this goal, we shared last year that polyclinics are scaling up team-based care, where patients with chronic diseases see a regular care team. 

9.             We are not far from achieving this goal in the private primary care sector too – two thirds of Community Health Assist Scheme (CHAS) cardholders with chronic diseases have a regular doctor. This demonstrates how integral private sector general practitioners (GPs) are to our primary care transformation efforts, which brings me to Mr Chong’s and Dr Chia’s queries about support for GPs in providing better, more holistic care.

10.          Besides supporting them in their professional development, I will share more about later, we have been partnering them to anchor and provide holistic chronic disease management through the Primary Care Networks (PCN). Similar to polyclinics, PCNs are embracing team-based care.

11.          Thanks to their support, we are on track to have at least half of CHAS GP clinics participating in the PCN by end 2020. More than 500 PCN GP clinic partners are caring for over 100,000 patients with chronic conditions, up from about 70,000 last year.

12.           One of these patients is Mdm Lam. She was diagnosed to have diabetes and hypertension in 2007, and started visiting Jurong Polyclinic to manage her chronic conditions.

13.          In 2015, she switched to Frontier Family Medicine Clinic (FMC) as she wanted to have one regular doctor to help manage her medical conditions holistically. She has also enjoyed having Frontier FMC closer to her home.

14.          Since then, she has been regularly consulting Dr Thia, whom she is now very comfortable with, and who is familiar with her medical conditions. With Frontier FMC joining the PCN in 2018, Mdm Lam also benefited from team-based care, including nurse counselling, and diabetic foot and eye screening.

15.          Now, Mdm Lam doesn’t have to run around for multiple appointments, as the PCN clinic coordinator ensures her screenings are done conveniently at the clinic, on the same day as her consultation with Dr Thia.

16.          She is grateful her care team has helped her understand her medical conditions better, and that has helped her improve and keep her medical conditions in check.

17.          With the continued expansion of the PCN, more patients like Mdm Lam will benefit from this scheme.

Improving Screening and Follow-Up

18.         Like chronic diseases, early detection and management of cancer can make a world of difference in health outcomes. We would like to thank Dr Lily Neo for her suggestions to improve screening and follow-up.

19.          The screening rate for breast cancer is about 39%, and the rate of late-stage breast cancer diagnosis has remained around 28% between 2008 to 2017. There is therefore room for improvement.

20.          Oftentimes, all that is needed is a change in mindset. Misconceptions and fears are common barriers – thinking that screening isn’t necessary when one feels healthy, that ‘it’s better not to know’, and that mammograms are painful, are just some of the examples.

21.          To counter these, the Health Promotion Board (HPB) holds annual breast cancer awareness campaigns, conducts on-the-ground activities and uses social media to expand their reach. They will continue to work with partners to encourage more women to go for screening regularly.

22.          To enhance the take-up rate, breast cancer screening must also be made accessible and affordable. In this regard, the Singapore Cancer Society (SCS), Breast Cancer Foundation (BCF) and the National Healthcare Diagnostic Group (NHGD) introduced the community mammobus programme, where the first mammogram is free-of-charge, and subsequent ones are $10, for Singaporeans. About 9,300 individuals have benefited from this programme since its launch in 2018. 

23.          Mr Charles Chong asked whether there are plans to expand Screen for Life to include additional tests, and Dr Neo suggested alternative screening tests for selected cancers such as colorectal cancer and also mentioned the H. pylori test for stomach cancer. MOH and HPB refer to the Screening Test Review Committee’s (STRC)’s recommendations in deciding which screening tests to provide at a population level. These are based on robust scientific evidence to ensure that they are safe, effective, suitable and cost-effective.

24.          On colorectal cancer, both the Faecal Immunochemical Test (FIT) and the screening colonoscopy are recommended for population-level screening. However, the screening colonoscopy has risks due to its invasive nature. Conversely, the FIT kit can be safely and conveniently administered by the individual at home.

25.          Under Screen for Life, subsidised FIT is available at all CHAS GP clinics, and those who test positive are referred for subsidised diagnostic colonoscopies. Screening colonoscopies are still available at public sector hospitals, and are MediSave-claimable, should one choose to go for them instead.

26.          On cervical cancer, HPV-DNA testing for women aged 30 to 69 was introduced in mid-2019, following STRC’s recommendations due to its higher sensitivity, and lower frequency required, compared to the Pap smear.

27.          MOH and our partners will keep on striving to encourage more Singaporeans to go for early screening and follow-up, and update our strategies when new evidence arises.

Enhancing Youth Mental Health Services

28.          Mental well-being continues to be a top concern based on recent engagements with youths, which highlights the need to do more. Mr Melvin Yong and Dr Neo, amongst many others, have recognised this, and asked how we can improve youth mental health services and make them more accessible.

29.          Minister Indranee has announced the Ministry of Education’s (MOE)’s efforts to further support student well-being through mental health education and peer support cultures in schools.

30.          Complementing MOE’s efforts, we announced last year that we will work with the Institute of Mental Health (IMH), the Agency for Integrated Care (AIC), and our community partner, Care Corner, to develop an Integrated Youth Service (IYS), where youths at-risk can access coordinated mental health and social support services in the community.

31.          I am glad to update that the Integrated Youth Service will be starting in Woodlands this year.  Care Corner will reach out to youths at-risk and raise awareness on mental well-being and resilience. They will also provide individualised emotional support, needs identification and peer support services, and refer those who require further intervention to appropriate health and social services.

32.          Moving forward, we will continue to take a whole-of-society approach and work with other ministries to address youth mental health needs. This includes MOE, the Ministry for Social and Family Development (MSF), and the Ministry of Culture, Community and Youth (MCCY), including their National Youth Council (NYC), on the recently announced Youth Mental Well-being Network.

Keeping Healthcare Affordable

33.          As mentioned by Minister Gan, we must continue to move Beyond Quality to Value.  He shared that about 50% of the rise in healthcare costs is due to higher utilisation, and another 15% partly due to increases in costs of drugs and medical devices. We are therefore employing a suite of strategies to increase value and lower costs, so that all Singaporeans can access care without experiencing financial hardship.  Let me elaborate.

Update on Fee Benchmarks

34.          One of these strategies is the introduction of surgeon fee benchmarks for common surgical procedures in the private sector last year. Anyone, including doctors, patients and payers, can refer to them on the MOH website.

35.          I am glad to share that since its publication, surgical fees have generally converged, with the majority falling within range, and more than 80% below the upper limit. We also saw a slight reduction in the average fees.

36.          Our work does not stop here. We will keep monitoring the charges, seek feedback from stakeholders, and review the benchmarks with the Fee Benchmarks Advisory Committee (FBAC) so they remain relevant and effective.

37.          Building on this, the Committee is studying expansion to (i) surgical fees for the less common procedures, (ii) doctors’ inpatient consultation fees, and (iii) other fee components like anaesthetist’s fees, and plans to submit its recommendations later this year.

38.          With these efforts, all of us will be able to make more informed decisions, and benefit from greater transparency of fees.

Update on Generics and Biosimilars

39.         We have also implemented measures to reduce drug costs, including switching to generic drugs where possible.

40.          Generic drugs or biosimilars are medicines which are clinically equivalent to branded or originator drugs, and typically cost much less. If used appropriately, both patients and our healthcare system can benefit from cost savings, without compromising safety and quality of care.

41.          To encourage public healthcare institutions to use more of such drugs, MOH works with the National Pharmacy and Therapeutics (NPT) Committee every year to select a basket of drugs which can be switched, and reviews their utilisation annually.

42.          In 2018, the usage of generics in the basket increased to more than 90% by volume. We will continue to work with the Committee and public healthcare institutions to increase uptake, and therefore, cost savings.

Update on ALPS

43.         We have also set up the Agency for Logistics Procurement and Supply (ALPS) in July 2018, to pool together supply chain functions and resources across our three healthcare clusters to achieve greater economies of scale.

44.          With ALPS, 85% of drugs used in clusters were purchased on national group contracts in 2018. Today, this proportion has increased to 95%, resulting in clusters saving at least 5% in drug costs, benefiting our patients in turn. For example, the cost of drugs for epilepsy was reduced by up to 85%.

45.          Building on these efforts, ALPS will (i) work with relevant agencies to encourage greater entry of generics and new sources of drugs in Singapore, and (ii) launch different approaches in strategic sourcing and procurement to keep drug prices competitive.

Update on ACE

46.          We must not only reduce costs, but ensure that our limited resources are spent on care that is of value.

47.          The Agency for Care Effectiveness (ACE) conducts health technology assessments (HTA) to facilitate clinically-effective and cost-effective care, and negotiates with manufacturers to attain fair prices for selected health technologies.

48.          Their work has improved access and affordability for over 50,000 patients. Of note, they managed to cut down the prices of medicines such as those for Hepatitis C by more than half.

49.          ACE is on track to deliver savings of $75 million over five years, and will work on benefiting even more Singaporeans.

Update on the Value-Driven Care Programme

50.         MOH also introduced the Value-Driven Care (VDC) programme to deliver good health outcomes in a value-conscious manner. We are extracting value for the 17 high-volume, high-cost, and therefore, high-impact conditions under this programme.

51.          Since May last year, we have been sharing data across providers to identify areas of improvement and facilitate sharing of best practices. As we are still at early stages, we will continue to monitor the programme’s impact.

52.          At the same time, we are expanding our scope by identifying additional conditions and increasing the period of analysis.

53.          MOH and healthcare providers will work together on these ongoing efforts to contain costs, and ensure that all Singaporeans can access quality care. As individuals, we can play our part too, by discussing with our healthcare providers on appropriate treatments for our conditions, and financial support available, if needed.

Supporting Healthcare Development for Better Outcomes

54.         MOH is committed to supporting the development of healthcare professionals. Today, ACE publishes Appropriate Care Guides (ACGs) to help healthcare professionals optimise patient outcomes.

55.          To support them further, ACE will be launching a national educational visiting service known as ACE Clinical Update Service (ACE CUES) in the second half of this year.

56.          While educational visiting may be a new term to many, it has been made available in a number of countries, including Australia, the United States, Canada, and Norway, and shown in many studies to improve patient care and outcomes.

57.          Through educational visiting, best available evidence and information materials on patient care are brought to healthcare professionals at their workplace, where one-to-one, focused and customised discussions are held at their convenience.

58.          A range of clinical topics will be covered over time, the first being asthma, which affects many people of all ages, most of which are being managed in the primary care setting by GPs.

59.          As there have been recent major developments in asthma treatment, it is timely for ACE CUES to bring these updates to GPs nationwide to benefit their patients, starting with those in the PCNs.

60.          Dr Chia asked for an update on integrating personalised medicine into our healthcare ecosystem.

61.          In Singapore, healthcare demands are changing fundamentally, driven by a rapidly ageing population and increased chronic disease prevalence. MOH is examining ways to be future-ready to ensure that healthcare delivery evolves to address these demands, and adopts innovative approaches to transform healthcare, while mitigating costs.

62.          Precision medicine is one such promising area. Work on the national strategy for precision medicine research and implementation has been ongoing. It aims to accelerate health research and develop peaks of research excellence for Singapore, and ultimately, to improve health by identifying clinical applications that are cost-effective, sustainable and relevant.

63.          The official launch of the precision medicine strategy and research programme is currently planned for the third or fourth quarter of this year, and more details will be made available later.

Staying Vigilant in the Face Of Infectious Diseases

64.         Let me come to antimicrobial resistance. Ms Irene Quay asked for an update on the National Strategic Action Plan on Antimicrobial Resistance (NSAP), and the measures MOH is taking to optimise antibiotic use and enhance surveillance.

65.          Following the launch of the Action Plan in 2017, we set up the Antimicrobial Resistance (AMR) Coordinating Office (AMRCO) under the National Centre for Infectious Diseases to oversee its implementation.

66.          To enhance surveillance, AMRCO is extending AMR surveillance and tracking of antimicrobial utilisation, already in place for public hospitals, to private hospitals and primary care. Guidelines for healthcare professionals on the management of infections and antimicrobial use are also being developed.

67.          In addition, AMRCO, together with MOH and partner agencies the Singapore Food Agency (SFA), National Parks Board (NParks), National Environment Agency (NEA) and Public Utilities Board (PUB), is examining an integrated approach to surveillance.

68.          As a first step, the First Joint Report of Antimicrobial Utilisation and Resistance in Singapore will be published this year. Singapore also enrolled in the World Health Organisation’s Global AMR Surveillance System (GLASS) to contribute surveillance data and learn from other countries’ experiences.

69.          All of us have a role to play in preventing AMR too, by using antimicrobials appropriately. HPB will continue its “Use Antibiotics Right” public education campaign to address common misperceptions, increase awareness, and encourage patients to discuss appropriate antibiotic use with their doctors.

70.          We generally take a collaborative approach for public health programmes. We have benefited from close cooperation with the public and our stakeholders, and will continue to work together to improve public health for all. 

Conclusion

71.          While much has already been done, our healthcare transformation journey does not end here.

72.          As we continue to move beyond Healthcare to Health, beyond Hospital to Community and beyond Quality to Value, we need to keep in mind that success goes beyond having the right policies in place – the backing and invaluable cooperation and contributions of healthcare providers and citizens are paramount.

73.          With that said, let’s continue to work towards achieving our shared goal of accessible, affordable and quality care for all, so that we can remain a healthy nation for generations to come.

74.          Thank you.