Speech by Minister of State for Health, Dr Lam Pin Min, at the MOH Committee of Supply Debate 2016

STRONG FOUNDATIONS FOR BETTER CARE, BETTER HEALTH

(A)         INTRODUCTION

1             With your permission, Madam Chair, may I display some slides during my speech? Thank you. MOH remains committed to reinforcing the core pillars of a quality healthcare system for our population. This encompasses taking a closer look at the fundamentals of our healthcare system, including developing better preventive health services for our young, and strengthening primary care.

2             There is a rising prevalence of chronic diseases amongst our population. One in four Singaporeans aged 40 years and above has at least one chronic disease. We are concerned about this increasing prevalence, as these conditions can lead to serious complications if not well-managed. For example, complications faced by poorly-controlled diabetic patients include kidney failure, stroke, heart attack, blindness and lower limb amputations.

(B)         BETTER HEALTH STARTS YOUNG

3             The risk of chronic diseases in general can be lowered through simple lifestyle changes. Choosing to live healthily is a habit that we should inculcate from a young age. As pointed out by Ms Tin Pei Ling, it is vital that we go upstream and enhance preventive health services that encourage the formation of healthy habits in our children and youth, even as we continue to step up our efforts in promoting health screening among older adults. All of us have a role to play in keeping our young healthy and fit, especially parents and caregivers. They role-model healthy living, nurture a healthy home environment, influence and guide children to form healthy habits, which hopefully will continue through adulthood.

4             In Singapore, we have had a comprehensive school health service since 1921, which underpins the good public health achieved today. The HPB’s current strategies and close collaboration with the schools in encouraging students to adopt a healthy lifestyle have served us well. For example, trained professional nurses are stationed full-time in selected secondary and post-secondary institutions under the Student Health Advisor programme, or SHA programme, to provide advice on weight management and smoking cessation.

5             One successful story is that of Ms Tan Su Kheng. For many years, Su Kheng put up with jokes and comments about her weight, which affected her self-esteem. Last year, she joined her school’s weight management intervention programme, which helped to kick-start her journey towards a healthier life. On top of receiving many practical tips on healthy living, Su Kheng found additional support through her Student Health Advisor, who taught her how to incorporate exercise into her busy student life. Apart from exercising thrice a week, she walks home and takes the stairs every day, instead of taking the bus and using the lift respectively. The journey to staying healthy can be challenging. However, I am inspired by what Su Kheng relates to us about her experience. And I quote, “Whenever I feel like giving up, I will tell myself that although I may not be there yet, I am one step closer to success than yesterday.” I am happy to share that with her perseverance and encouragement from her Student Health Advisor, Su Kheng has lost over 20 kg in just one year. I hear that family and friends have even started approaching her for tips on healthy living. My heartiest congratulations to Su Kheng!

6             Despite these efforts, it worries me that we still see the proportion of overweight children and youth increasing over the past 5 years. Studies have shown that childhood obesity is likely to persist and progress into adulthood. This results in individuals being at higher risks of developing chronic diseases such as diabetes and hypertension. An overseas study revealed that those with childhood obesity are four times more likely to be at risk of developing hypertension in adulthood when compared to their non-obese peers. It is therefore critical that we curb the rising rates of childhood obesity.

7             A local survey showed that most students are engaging in less physical activities and becoming more sedentary – more than 80% of the students surveyed exceeded the recommended screen time of no more than 2 hours a day. This is exacerbated by inadequate physical activity. Based on past surveys, about 10% of mainstream or ITE students, and 20% of Polytechnic students had sufficient physical activity.

8             In addition, the prevalence of myopia in our children is one of the highest in the world. More than 60% of our Primary 6 students have myopia today. This is undesirable as poor eyesight from myopia can impact learning. And as the condition progresses, it may result in sight-threatening complications as well.

9             We have also found that about half of all our Primary 1 students have dental caries. Poor oral health affects the nutrition, growth and development of our children. We are concerned and are keen to tackle the pervasion of these trends among our young. Apart from their physical growth and development, we will also further strengthen our efforts to help our young to build up their mental resilience to better cope with the stressors of life.

10          Mr Darryl David raised concerns on the mental resilience and well-being of our youth. To comprehensively address the multi-faceted aspects of student mental health concerns, we have adopted a three-pronged approach, comprising knowledge and skills-building, facilitating access and referral to mental health services, and parental engagement. MOE and HPB have introduced programmes to provide educators with basic knowledge on common issues faced by our youth. Educators are also equipped with the ability to detect early warning signs, and skills to provide appropriate support and referrals to services and resources in the school setting. These programmes have also groomed youth opinion leaders on health, by arming them with knowledge on health and well-being, mental health concerns and youth advocacy.

11          Mr David also suggested having community-based mental wellness facilities. As Dr Amy Khor mentioned earlier, we are steadily building up our mental health services and support networks within the community to identify and help persons with mental health concerns.

12          It is important for us to work upstream to lay strong foundations for our young to lead healthier and more productive lives, starting from those as young as two years old. To this end, I will lead an inter-agency NurtureSG Taskforce with Minister of State for Education Dr Janil Puthucheary. The Taskforce comprises representatives from various Ministries, HPB, Sport Singapore and the Early Childhood Development Agency, as well as medical professionals and academics. It will guide the development of the NurtureSG Plan to enhance the health outcomes among our young.

13          The NurtureSG Taskforce will focus on three main areas. First, we will look into developing new strategies and strengthening existing programmes to address salient health issues and negative trends among children and youth. Next, we want to reinforce health promotion efforts at the tertiary institutions so that young Singaporeans will maintain healthy habits beyond the school-going age and well after entering the workforce. Last but not least, we aim to bring health promotion for the young beyond the school, and into their families and the community.

14          We will launch a public consultation later this month to seek ideas on how we can encourage and enable our young to adopt and maintain healthy lifestyles. In particular, we will engage students, educators, parents, caregivers and even the private sector, such as food establishments, to create a healthier environment for our children.

15          To Ms Cheng Li Hui’s comments, children are referred to the hospitals for both developmental and mental health conditions by polyclinics, GPs, paediatricians, primary schools and the REACH, or Response, Early Assessment and intervention in Community mental Health teams. Besides the Child Guidance clinics at Buangkok View and Outram Road, mental health services for children and youth are also available in other hospitals such as NUH, SGH and KKH. These services typically include assessment, diagnosis and multi-disciplinary management of patients up to the age of 18 years, but may continue to follow up with them beyond this, where appropriate. The subsidies for these services are in line with existing SOC subsidies. From 2013 to 2015, there were about 50,000 psychiatric SOC attendances for patients up to 18 years old, of which about two-thirds were seen in IMH.

(C)         PRIMARY CARE AS THE FIRST AND CONTINUOUS LINE OF CARE

16          Empowering and teaching our young to lead healthier lives is only one part of the equation. As our population ages and healthcare needs continue to rise, we must reshape the way we approach healthcare.

17          Primary care is the foundation of any healthcare system. We aim to strengthen its place in our healthcare system, to be the first and continuous line of care. Dr Tan Wu Meng asked about the role of the family doctor. My response is encapsulated in our vision – “One Singaporean, One Family Doctor”.

18          Overseas studies have shown that care continuity by a regular family doctor results in better care outcomes for our patients. These include decreased hospitalisations and emergency department visits. Our family doctor can be our partner in helping us stay healthy, and in providing us with good and affordable care close to us. Many Singaporeans see a doctor when we come down with an illness, such as a bad cold. With a regular family doctor, such visits can develop into a strong doctor-patient relationship over time. As our family doctor develops a holistic understanding of our family’s medical profile and health needs, they will become our health advocate in identifying risk factors and can offer more targeted, timely and individualised advice and plans to manage our health.

19         For those with chronic diseases, we can manage our condition better by having a family doctor who understands our condition well, and supports us with quality management and treatment. Our family doctor must also have some understanding of our family, social and work situation to advise us on making lifestyle changes, and adhering to treatment. They can also refer us appropriately if we require more specialised medical attention, and help coordinate our care with other providers.

20         I would like to share a story of a family doctor being one’s trusted health partner. Mr Tan Heok Lim has been seeing his family doctor, Dr Leong Choon Kit, for the past 14 years. He feels comfortable with Dr Leong’s care, and has continued seeing him for his medical needs. This enables Dr Leong to care for Mr Tan holistically – from health screening to diagnosis and management of chronic conditions such as hypertension. With deeper understanding of the family, Dr Leong has recommended suitable health screening for Mr Tan’s wife, who has a strong family history of diabetes. Mrs Tan was found to be borderline diabetic and Dr Leong was able to intervene early through advice on lifestyle modifications, to prevent the progression of diabetes. Currently, Dr Leong manages the chronic conditions of Mr Tan, his wife and son. I am happy to hear that both Mr Tan and his son have also successfully quit smoking, with encouragement from their family members and Dr Leong!

21        I believe that there are many such positive stories to illustrate the benefits of having a regular family doctor. However, only two in five Singapore residents aged 18 to 69 years old have a regular family doctor today. We want to call on Singaporeans, especially those with chronic conditions, to take the first step in identifying and sticking with a regular family doctor.

22        To facilitate this, we will review our policies to help strengthen doctor-patient relationships in primary care. As we progress on the journey to realise our vision of “One Singaporean, One Family Doctor”, we will continue to engage our General Practitioner (GP) and polyclinic colleagues to co-create the future primary care landscape, in particular to achieve better chronic disease management in the community.

23         We are mindful to ensure sufficient primary care capacity with the ageing of the population and a growing chronic disease burden.

24         Our polyclinics will continue to play a key role, especially in the management of complex chronic diseases. In recent years, we have announced the development of new polyclinics and redevelopment of existing ones.

25          Since 2012, we have also strengthened partnerships with private GPs to provide subsidised care to Singaporeans. Today, the Community Health Assist Scheme, or CHAS, provides lower- to middle-income Singaporeans and all Pioneers access to subsidised care at private GP and dental clinics. 900 GP clinics and 650 dental clinics island-wide have signed up for CHAS. We value their partnership.

26         We have also developed new models of primary care, such as the Family Medicine Clinics, or FMCs, since 2013. The FMCs are multi-doctor practices, with on-site nurses and other allied health professionals, delivering comprehensive team-based care especially for chronic disease management.

27         As part of our continual efforts to better serve our residents, we have been re-developing existing polyclinics. The new polyclinics in Punggol and Jurong West will open in 2017. I am pleased to announce that we will build another polyclinic in Eunos, in response to A/Prof Fatimah Lateef’s query on new primary care facilities. The new polyclinic is expected to be operational by 2020 and will be designed to cater for future primary care needs.

28         Today, there are seven FMCs in operation. By early 2017, we will develop two more FMCs; one in Tampines and another one in Keat Hong. We will continue to review and evaluate FMC development as part of our efforts to strengthen and improve primary care.

29         With these range of developments, we have tried to support the growing needs in primary care. To address Dr Tan Wu Meng’s concerns, residents in the West can look forward to three new facilities – the new polyclinics in Jurong West and Bukit Panjang, as well as a new FMC in Keat Hong. These will help to relieve the load in existing polyclinics in the West, such as Clementi Polyclinic.

30         We will continue to review the regional primary care needs of our population, and work closely with URA and HDB to review and ensure the adequacy of the space needed for primary care facilities in HDB estates.

31         A good primary care system can help to reduce costly interventions in the hospital setting. To keep primary care affordable, CHAS and PG cardholders at the FMCs and CHAS clinics receive government subsidies for their care. Dr Tan Wu Meng and Assoc Prof Daniel Goh commented on enhancing subsidies for primary care. Since 2012, we have significantly enhanced CHAS so that more Singaporeans can benefit. In 2013, we raised the income criterion from per capita monthly household income of $1,500 to $1,800. In 2014, the age floor of 40 years was also removed. These changes have helped more Singaporean households benefit from CHAS.

32         I thank Assoc Prof Goh for his suggestion to change the qualifying criteria for CHAS. Assoc Prof Goh suggested that we change the per capita household income criterion of $1,800 to an individual’s prevailing median monthly income of $3,900. The current CHAS income criterion of $1,800 ensures that lower to middle-income Singaporeans, or Singaporeans in about half of all resident households, can qualify. This means that a household of four, with the breadwinner earning $7,200, is eligible. A household-based approach ensures that subsidies are equitably distributed to extend more benefits to individuals with more dependents.  In determining our income criterion, we will need to strike a balance, bearing in mind the need to target subsidies at those who need it most, and the government budget availability. We will review CHAS regularly, and will enhance the scheme where needed to ensure that care remains affordable.

(D)         GREATER TRANSPARENCY OF HEALTHCARE CHARGES

33         Dr Chia Shi Lu asked for measures to improve transparency in the charging of healthcare services. We have implemented various measures to this end. Hospitals are required to provide financial counselling to patients, to ensure that they are informed of the charges likely to be incurred for their treatment. For outpatient care, patients are also provided with information on estimated charges for consultation.

34         Since 2013, hospital bill sizes for common conditions and procedures at both public and private hospitals have been progressively published on the MOH website. In 2014, the publication of “Total Operation Fees” for common procedures in public hospitals was introduced. I am pleased to announce that the publication will be expanded to cover “Total Operation Fees” for private hospitals later this year. There will be further breakdown of the “Total Operation Fees” into “Surgeon Fees”, “Anaesthetist Fees” as well as “Facility Fees”. The expanded publication will provide added transparency on the private hospital bill components attributed to performing the procedure, and serve as a point of reference for both healthcare professionals and the general public.

(E)         MEASURES TO SAFEGUARD PUBLIC HEALTH

35         Safeguarding public health is another fundamental aspect of maintaining population health. Even as we tackle the increasing prevalence of chronic diseases, we need to remain cognisant of our external environment.

36         In line with Minister’s call for us to remain vigilant, we need to constantly improve our public health system to promote health, prevent diseases and prolong life among our population. Dr Chia Shi Lu asked about the measures that we are taking to protect Singapore from emerging diseases. We have adopted a three-pronged approach to external public health threats, namely, reducing the risk of importation, early detection, and containment. We perform local and global surveillance to ensure situational awareness for endemic diseases, such as Tuberculosis and Influenza, and emerging diseases overseas, such as MERS and Zika. We also fund research to evaluate the effectiveness of surveillance and response plans to infectious diseases. These include looking at potential areas for collaboration with the relevant institutions on Zika virus diagnostics, transmission and its association with microcephaly and Guillain-Barre Syndrome. We conduct regular preparedness exercises to practise our responses and identify potential areas for improvements. We also maintain a surge capacity for isolation beds and a national stockpile of personal protective equipment.

37         In the community, we work with about 640 GP clinics which have volunteered as Public Health Preparedness Clinics, or PHPCs, to help manage public health emergencies, such as haze and influenza pandemics. While all GPs play important roles to provide care in such situations, the PHPCs take on additional roles such as providing subsidised care for conditions related to the public health emergency.

38         Coordinated efforts across multiple government agencies, as well as with other countries and international organisations, are also vital in protecting Singapore against external public health threats.

39         In relation to Ms Tin Pei Ling’s query regarding dengue vaccination, HSA has received the regulatory filing for Sanofi’s dengue vaccine in March 2016 and is expediting the review, given the dengue situation in Singapore and recognising that this is the first dengue vaccine available.  The key focus in HSA’s review is to ensure that the vaccine is safe, of good quality and effective for use in our local population, taking into consideration the local prevalent strains of dengue and its potential risks and adverse effects. Nonetheless, there is currently no vaccine that confers 100% protection against all known strains of the dengue virus. If it is found to be efficacious locally and subsequently introduced, dengue vaccination should be coupled with other dengue control and healthcare strategies in Singapore, such as having a strong disease surveillance system and maintaining effective vector control measures to keep the mosquito population low. All of us still have a part to play in staying alert and fighting dengue.

(F)          CONCLUSION

40         Madam Chair, we see an increasing need to shift the focus from healthcare to health. However, we cannot do this alone. Let’s encourage one another, including our children and youth, to adopt a healthy and active lifestyle to keep chronic diseases at bay. Our regular family doctor shall be our trusted health partner throughout the different stages of our lives.

41         At the same time, we introduce further measures for greater fee transparency at the hospitals. Not forgetting our vulnerabilities in an increasingly connected global community, we will remain vigilant in responding to public health emergencies. On this note, I urge Singaporeans to partner us in building strong foundations for better care and better health.

42         Thank you.