Speech by Minister of State for Health, Mr Chee Hong Tat, at the MOH Committee of Supply Debate 2016
18 April 2016
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ACHIEVING HEALTHCARE SUSTAINABILITY THROUGH HEALTHY LIVING, CARE TRANSFORMATION, AND INNOVATION
(A) INTRODUCTION
1. Madam Chair, with an ageing population, it is not feasible for Singapore to meet future healthcare demand by simply building more and more hospitals, hiring more and more healthcare workers and providing more and more subsidies. We must also focus on developing a sustainable healthcare system. If we shift too far to the right, we will not be doing right by our fellow Singaporeans. If we overspend and shift too far to the left, our children will have nothing left in the future.
2. Today, I shall talk about three areas to develop a sustainable healthcare system. First, promoting healthy living. Second, transforming our care models, by bringing care beyond hospitals into the community. Third, enhancing value through innovation and productivity improvements.
(B) HEALTHY LIVING
3. Let me start with initiatives to promote healthy living, and to reduce diabetes prevalence.
4. To fight diabetes, we need a supportive environment to encourage Singaporeans to eat healthily and exercise regularly. Under the Healthy Living Master Plan, we introduced healthier dining options and provided more exercise options in the community, workplaces, and schools.
5. One such initiative is the Healthy Community Ecosystem, which has been implemented in 6 neighbourhoods since 2014, including my own GRC in Bishan-Toa Payoh. Group exercises are held in 40 community spaces, with an average of 1,000 residents participating each week. Lifestyle modification programmes have reached 14,000 residents in these neighbourhoods.
6. To benefit more Singaporeans, we will be extending the Healthy Community Ecosystem programme to 9 more neighbourhoods this year, including Jalan Besar, Pasir-Ris Punggol, and West Coast.
Healthy Living - Eat Right
7. Eating right is key to fighting diabetes. Excessive consumption of sugar and refined carbohydrates can lead to weight gain and cause spikes in blood sugar levels. Such spikes increase the risk of developing type 2 diabetes, if they happen frequently over time.
8. Dr Chia Shi-Lu asked about measures to discourage consumption of unhealthy food products. Associate Professor Daniel Goh asked if we could introduce colour-coded labels for sugar content in processed food and drinks.
9. I thank Dr Chia and Associate Professor Goh for their useful suggestions. We will study their proposals as part of the fight against diabetes.
10. Many food manufacturers already practise back-of-pack nutritional labelling. HPB’s Healthier Choice Symbol, or HCS, helps consumers make healthier purchases, through an identifiable front-of-pack symbol.
11. There are currently 2,500 HCS products across 70 food categories. These products contain less sugar, saturated fat, or salt. A 2015 consumer survey showed a high level of awareness of HCS products – 9 in 10 said they recognised these products as healthier options. And 8 in 10 said they use HCS to guide their food purchases.
12. HPB has worked with close to 240 supermarkets on in-store promotions, such as lucky draws, food sampling and cooking demonstrations. I am glad to know that HCS products are gaining market share - sales of HCS products are growing at 9% annually. Our target is to increase the total market share for HCS products to 25% by 2020, up from the current 17%.
13. Some Members are concerned that healthier food may be more expensive. I understand these concerns. We need to work together with industry partners to provide affordable healthy options for Singaporeans. As of March this year, we have 52 F&B partners participating in the Healthier Dining Programme involving nearly 1,600 food stalls. Under the programme, we collaborated with restaurants to offer lower calorie meal options, and to incorporate healthier ingredients, such as whole-grains, fruits and vegetables, as part of their core menu offerings.
14. Major food court chains, including Kopitiam, Koufu and NTUC Foodfare, offer at least one dish below 500 calories at each stall, and they also promote reduced-sugar drinks. The number of lower-calorie meals sold has doubled from 7.5 mil in 2014 to 15 mil last year.
15. I am encouraged by the industry’s efforts to produce versions of staple foods like bread and noodles, which are healthier and taste just as good. Gardenia for example, uses finely textured wholemeal flour to retain the health benefits of whole-grains, while keeping its bread soft and easy to chew.
Healthy Living - Exercise More
16. Besides eating right, we need to encourage Singaporeans to exercise regularly. The recommendation is to have at least 150 minutes of physical activity per week. These 150 minutes can be achieved through simple daily activities like walking to the bus stop, using stairs instead of the lift, doing household chores, or taking a brisk walk at the park.
17. In 2013, 1 in 4 Singaporeans between the ages of 18 to 69 did not meet the 150 minutes per week target, this was an increase from 1 in 5 in 2007. We need to reverse this trend. Leading an active lifestyle can be simple and inexpensive. It is also something we can enjoy with our family and friends.
18. Mdm Jessie Jee is a Pioneer and one of HPB’s Health Ambassadors. She is a regular participant at our Sundays at the Park programme. Every Sunday morning, she joins others in workout classes at the Firefly Park near her home in Clementi.
19. We hope to encourage more Singaporeans, including our seniors, to adopt active lifestyles like Mdm Jee. To support this, HPB will double the number of exercise sessions available in the community and workplaces, from the current 100 to 200 by the end of this year.
20. Another initiative is the National Steps Challenge. Through the use of wearable technology and simple data analytics, users can receive feedback on their daily progress and also receive rewards when they reach certain milestones.
21. The National Steps Challenge has been well-received since its launch in November 2015. 1 in 3 participants have clocked 10,000 steps a day on average. In addition, 70% of previously inactive participants now average more than 7,000 steps per day.
22. This is a good start, as studies have shown that walking at least 7,500 steps a day can contribute to lower blood pressure and cholesterol levels, and help those with diabetes keep their blood sugar levels in check.
23. Mr Mohd Aidil Bin Sufyan found the Steps Tracker easy to use, and a good way to motivate him to stay healthy. He now takes the stairs more often, and alights one bus stop earlier to walk home. He also brings his children for weekend walks. Praising the National Steps Challenge as a good initiative, Mr Aidil said he hopes this programme can be extended to more Singaporeans.
24. Thank you Mr Aidil for your support and active participation. We are preparing for a second season of the National Steps Challenge. So, akan datang.
Healthy Living – Screening and Follow-up
25. Apart from eating right and exercising more, it is important for Singaporeans to go for evidence-based health screening at recommended intervals. Under HPB’s Screen for Life programme, Singaporeans 40 years and above are recommended to be screened for diabetes once every 3 years. And very importantly, to follow-up with their family doctors after the screening.
26. Early detection and treatment are important in the fight against diabetes, to keep the disease under control and prevent serious complications. Individuals with diabetes can benefit from lifestyle changes, to prevent their condition from worsening. In addition, pre-diabetics could lower their risk of getting diabetes if they detect the problem early and improve their diet and lifestyle.
27. We plan to reach out to certain groups of Singaporeans below 40 years, for example those who are obese and those whose immediate family members have diabetes. They face higher risks of getting diabetes and may need to start their screening at an earlier age.
28. We will extend our screening outreach at the workplaces, to bring diabetes screening to more workers. These include those who may find it difficult to schedule a screening appointment due to the nature of their jobs. We will also review ways to strengthen post-screening follow-up, to initiate early treatment and care where needed.
(C) BEYOND HOSPITALS TO COMMUNITY CARE
29. Next, I will touch on efforts to move care beyond hospitals into the community.
30. MOH has co-located several community hospitals with acute hospitals, to facilitate care integration for patients. We are helping patients to shorten their stays at community hospitals and return home earlier. For example, by allowing them to do their rehab follow-ups at day rehabilitation centres. This is what many of our patients prefer. They do not want to stay in the hospital longer than necessary.
31. As our population ages, it is inevitable that some of us will become frail and disabled, and require support in activities of daily living. For some, this may be a few years before they pass on. For others, the duration could be longer, as Dr Lily Neo and Mr Louis Ng highlighted.
Greater Peace of Mind for Long Term Care Costs
32. I thank Dr Lily Neo, Mr Low Thia Khiang and Mr Louis Ng for their suggestions on ElderShield. There were also earlier proposals from the PAP Seniors Group. MOH will study these suggestions carefully, as part of our ElderShield review.
33. One point I wish to highlight is that increasing the payouts and coverage of ElderShield will require higher premiums for the scheme to remain viable. This higher cost will ultimately be borne by everyone, whether directly through ElderShield premiums or indirectly through tax-funded subsidies. Hence, there is a need to balance enhancements in ElderShield with the potential cost increases, so that the scheme can remain affordable for all Singaporeans. ElderShield pay-out is one important source of payment but it is not the only source. Pioneers, for example, can receive PG DAS (Disability Assistance Scheme) on top of ElderShield. So we will look at different ways of helping our seniors, especially those who are disabled.
34. Other important issues for the review include whether ElderShield should be made mandatory for every Singaporean, it is now an opt-out scheme; and how to provide coverage for older cohorts of Singaporeans who today may not have ElderShield.
35. Similar to how we enhanced MediShield into MediShield Life, MOH will need to carefully review ElderShield in consultation with experts and key stakeholders. Our end in mind is to provide Singaporeans with peace of mind when we grow old, while keeping the scheme affordable for all.
Enhancing Affordability of Palliative Care Services
36. Madam Chair, ageing well also means having access to affordable end-of-life care. MOH is working in partnership with the palliative care sector under the National Strategy for Palliative Care. Since 2014, we have ramped up capacity and improved the quality of palliative care in Singapore.
37. Dr Lily Neo asked for better provision of hospice care, including training of hospice care personnel. We have introduced guidelines for the palliative care sector, and we will work with the Singapore Hospice Council to encourage industry players to adopt these guidelines.
38. Dr Lily Neo and Mr Low Thia Khiang asked about the financing framework for hospices. MOH regularly reviews funding for the palliative care sector to ensure end-of-life care remains affordable for patients and sustainable for providers.
39. In July 2012, we raised the threshold for per capita household monthly income to cover up to two-thirds of Singaporean households, up from half previously. This has benefitted more than 1,000 additional patients. We will continue to review and adjust the income threshold like what we have done before.
40. We have also enhanced financial support for hospice care services. In 2014, we improved funding for home palliative care providers. Last year, we increased the Medisave withdrawal limit for inpatient hospice and home palliative care. Just last month, we increased subsidies for eligible inpatient hospice patients, and introduced subsidies for day hospice care.
41. Overall, with coverage from government subsidies, charity assistance and Medisave, most patients do not face out-of-pocket payments for hospice and palliative care. Let me share some date from FY 2011 – 2015 on the length of stay. For inpatient hospice, the median length of stay is 15 days. For home palliative care, the median period of care is around two months. And in terms of affordability, for inpatient hospice stays, 8 in 10 patients have zero out-of-pocket payments and for home palliative patients 9 in 10 did not have to make out-of-pocket payments. Last year, MOH received three appeals on hospice care costs.
42. Later this year, MOH will further enhance financial support for palliative care by extending the $2,500 Medisave lifetime withdrawal limit for home palliative care to include day hospice services. Similar to home palliative patients, day hospice patients diagnosed with terminal cancer or end-stage organ failure will not be subject to this withdrawal limit if the claim is made from the patient’s own Medisave account.
43. I agree with Ms Kuik Shiao Yin that it is important for end-of-life care to be provided with empathy. We do have training for our healthcare professionals in this area, and we will look at ways to further improve and do better.
44. In addition, MOH is supportive of other efforts to improve the quality of our end-of-life care. For example, Assisi Hospice’s new facility, where the design of wards resembles a home rather than an institution. Outdoor gardens and green spaces are also included as part of the development.
45. VWOs play an invaluable role in the end-of-life care sector to provide quality and affordable care. We want to preserve this strong community support and involvement.
46. Programmes by volunteers also help patients to live their last days fully. This includes befriending and psycho-social support for patients and their families. We will support innovations in palliative care and will continue to work with providers like Assisi Hospice and others, to pilot new ideas that can benefit patients and care-givers.
SOC Downgrading and Integrated Shield plan premiums
47. Madam Speaker, allow me to now respond to cuts from Mr Dennis Tan and Mr Pritam Singh.
48. Mr Tan asked whether existing private patients in Specialist Outpatient Clinics are allowed to switch to subsidised care without a polyclinic referral. Let me explain what our policy is.
49. If a private SOC patient wants to switch to subsidised care, a medical social worker will assess his request. These assessments are done on a case-by-case basis. This is to ensure that we target our subsidies at patients with the greatest financial need.
50. For new patients seeking subsidised specialist care, they will first go through a primary care doctor to assess if they need specialist care services. This can be done at a polyclinics or at a CHAS GP clinic, if he is a CHAS or PG card holder.
51. We know there are some private SOC patients who choose to be discharged from private SOC and go through this route to switch to subsidised SOC, instead of going through a medical social worker at the hospital. Strictly speaking, this is not part of the policy for patients to downgrade from private to subsidised SOC. This is perhaps why Mr Tan pointed out that the arrangement is not very neat and tidy. However, our hospitals want to be flexible and have accommodated these private patients, so that they are not treated differently from new patients who go through the polyclinic.
52. Taking a broader view, our priority is to transform the way we care for patients, by bringing it beyond the hospital into the community. I shared about how we are integrating care between acute and community hospitals. In addition, MOH is piloting new models where specialists work closely with polyclinics and GPs to co-manage patients who have chronic conditions and need ongoing care. We are also building up primary care so that more SOC patients who are stable can be discharged and cared for by the polyclinics or GPs. This is a more impactful and sustainable way to have a win-win arrangement for everyone.
53. Mr Pritam Singh asked about Integrated Shield Plans or IPs. These are private insurance plans which work together with MediShield Life.
54. IP premiums have two components: a MediShield Life component, which is sufficient for basic, subsidised healthcare services, and an additional private insurance component. MOH sets the premiums for the MediShield Life component, and we will keep MediShield Life premiums affordable for all Singaporeans.
55. The private insurance premiums are decided by insurers based on commercial and actuarial considerations. They will review and adjust these premiums based on factors such as claims experience. If claims increase significantly over time, the insurers will likely increase their premiums, as some have recently done so with the premiums for riders. Singaporeans who want to keep their insurance premiums affordable, including at older ages when premiums will increase, should carefully consider if you want to purchase private insurance like IPs and riders. Some of my residents in Bishan-Toa Payoh told me that they think MediShield Life is adequate to provide them with good quality subsidised care. It is an individual choice.
56. I agree with Mr Pritam Singh that it is important to guard against overconsumption or overcharging. These will exert upward pressure on healthcare costs and insurance premiums over time, a concern that was shared by Dr Chia Shi Lu. This is why MediShield Life and all IPs have co-payment features. We will work with insurers to review existing features in private insurance schemes to mitigate the risk of overconsumption and overcharging, while providing sufficient coverage and peace of mind for policyholders.
57. Other important initiatives to keep healthcare costs and premiums affordable include: promoting healthy living and active ageing because we know prevention is better than cure; finding ways to improve productivity in the healthcare sector; encouraging appropriate care to reduce over-treatment or over-prescription; and, providing more information on fees and charges to help patients decide which hospital and which doctor they want to visit.
58. Mr Pritam Singh also asked to increase the Medisave Additional Withdrawal Limits, or AWL, to be sufficient for Standard IP premiums at all ages.
59. Medisave is sized for basic healthcare expenses. MediShield Life premiums can be fully paid by Medisave. Singaporeans who wish to purchase private insurance can use their Medisave to pay for the additional private insurance component, but up to the AWL. We need to set a limit for the use of Medisave for private insurance, including the Standard IP, so that Singaporeans will have sufficient Medisave balances to support their healthcare needs when they grow old.
(D) ENHANCING VALUE THROUGH INNOVATION
60. Let me now touch on the final area of enhancing value in healthcare through innovation. MOH will work closely with our healthcare institutions and the Healthcare Services Employees’ Union to encourage and support ideas that can enhance patient care and service quality, improve the work environment for our healthcare workers and make our healthcare system more productive and sustainable.
Leverage Technology to Improve Healthcare Outcomes
61. Dr Tan Wu Meng asked about enhancing the use of Information Technology, particularly in the sharing of medical records. I agree with Dr Tan that this will help to improve productivity and patient care.
62. We rolled out the National Electronic Health Record, or NEHR in 2012, for participating healthcare institutions to view their patient’s events and summary health records.
63. As at March 2016, there are more than 900 healthcare institutions with access to NEHR. And we would like to include more healthcare institutions over time.
Technology to Improve Productivity and Reduce Manpower Requirements
64. Technology is a key enabler to improve the work environment for healthcare workers.
65. When I visited National University Hospital, I saw their pilot project to remotely monitor patients’ vital signs. With this system, the time nurses spend monitoring patients’ vital signs has reduced by half.
Technology to Improve Work Environment
66. I am also very happy to know that there are other areas where we can support such technology, including this chair that I saw. It is a portable toilet from Japan. It looks like a normal chair, but when you use it and press a button, it will automatically wrap and seal the waste products.
67. This makes it easier for the nurses and care-givers, as there is no unpleasant smell and the waste disposal can be done more conveniently.
Process and Role Redesign
68. Ms Thanaletchimi asked about the training for healthcare workers, as we implement automation and robotics. The public healthcare employers are committed to redesigning jobs and supporting our workers to gain new skills so that they can stay employable.
69. In fact through technology and productivity improvements, we want to enable healthcare workers to remain longer in service by making the work less physically demanding for them. This is a win-win arrangement – workers can continue working for more years, while patients can benefit from their service and experience.
70. Jamiyah Nursing Home is a good example. They partnered with the Agency for Integrated Care to do a job redesign, and through the various changes they have made, the staff were able to save up to 20% of their time.
71. They also introduced flexi-work arrangements so as to allow staff more flexibility in managing their work hours.
72. Our healthcare workers play a pivotal role in supporting productivity initiatives, and we appreciate and recognise their efforts.
73. Ms Thanaletchimi suggested extending the Progressive Wage Model, which we currently have in the healthcare system, to other groups of healthcare workers. I fully support her proposal. MOH will work with the Union on this. We want to retain our healthcare workers and upskill them to provide quality care for our patients.
(E) CONCLUSION
74. Madam Chair, we have made steady progress over the years to provide quality healthcare for all Singaporeans. This is reflected in the improvements in our life expectancy and health outcomes.
75. Credit must go to our committed healthcare workers, who have put in a lot of dedication and hard work to care for their patients. They do it with caring hearts. We must continue to show appreciation for their efforts, support them in their work and also to stand by our workers during difficult times.
76. Credit must go to our committed healthcare workers, who have put in a lot of dedication and hard work to care for their patients. They do it with caring hearts. We must continue to show appreciation for their efforts, support them in their work and also to stand by our workers during difficult times.
77. For future generations of Singaporeans to continue having affordable, accessible and quality healthcare, we need to transform our care models and keep our healthcare system sustainable.
78. To succeed, it will require the involvement of all Singaporeans - from individuals, families and the community. It will require changes in habits and behaviours. And most importantly, it will require all stakeholders to work together in close collaboration and partnership. Thank you.