Mr Deputy Speaker Sir, I thank members for all your questions and inputs, and my Ministry of Health (MOH) colleagues for addressing most of them.
2. In closing, I will address the few remaining questions. I will then take a step back and share the broader perspective of the challenge ahead that are concerning.
3. When I came into MOH a year and a half ago, what struck me was the groundwork that has been laid by my predecessors – the IT systems, three clusters, medical protocols. I had an in-depth discussion with our three DMSes – Professor Kenneth Mak, Professor Benjamin Ong and Professor Tan Chorh Chuan on the next phase of healthcare. We zoomed in on preventive care.
4. On 23 May 2021, I made my first speech in MOH at the Work Plan Seminar which covered two topics: one was living with COVID-19; and the second was preventive care. That was when Healthier SG was first talked about. In December I was invited to an event by the Traditional Chinese Medicine (TCM) community and I spoke to them with the indication that if we focus on preventive care, we can make a breakthrough and feature TCM in preventive care. That was how the thinking first started.
5. The last two speeches were very recent, the last being in September last month. I made the speeches in Chinese, and it was widely covered by the Chinese press, but less so in the English media.
· MOH has always recognised the value of TCM.
· During the COVID-19 pandemic, I personally wrote to all TCM practitioners to advise their patients to take the vaccines. They were a great help and really helped us move the needle to get heartlanders to take the vaccine.
· But we also recognise the difference in the history and evolution of Western and Eastern medicines. They are two separate systems, disciplines and knowhow. They may intersect at some point and overlap but you cannot make one like the other. It is not possible, they are two complete holistic systems.
· For example, Western doctors will not likely profess to understand the balancing of the elements of the body over the long term. Most TCM doctors will not think they can substitute an urgent operation with traditional herbal medication. I think they respect each other’s space, strengths, and disciplines. The regulatory approaches have fundamental differences as well – Western medicine is about research, clinical evidence, efficacy, safety data. Drug treatment can be approved and is tightly regulated by law. TCM is passed down from generations, culturally and traditionally, and they trust the herbal medicine, not clinical evidence. To use MediSave, by today’s rules you must be certified by the Health Sciences Authority (HSA) with clinical data. For TCM, that is hard to come by.
6. What TCM is very strong in is preventive care. More than 2,000 years ago there was already the saying – 养生三法：“饮食有节、起居有常、不妄作劳”。It is difficult to translate but let me try. It means ‘there are three key aspects to health: to eat in moderation, have a healthy daily routine, and not to over-exert body, heart and mind.’
7. In the area of preventive health, Western medicine and TCM share a common understanding that early management of risk factors and disease can stave off problems and complications later in life. Therefore I believe when we focus on preventive care under Healthier SG, we hope TCM can play a part.
8. While we work out further how TCM can better complement Healthier SG, we encourage TCM practitioners to continue to do what you are good at – taking care of the health of their patients holistically. With Healthier SG, which is focused on preventive care, we hope TCM can play a role. But TCM is self-regulated, with varying standards of practice.
9. Over the past year MOH and the TCM community have established two workgroups, to work on issues such as enhancing TCM clinical training and improving career development. Once completed, it can be a basis to explore how to involve TCM in support of Healthier SG. But I do not think, as one Member suggested, that we should impose the regulation of western medicine on TCM. I think self-regulation for something that is traditional and cultural will be more appropriate. But we need to strengthen that self-regulation.
10. We have recently also finalised the succession plan of the Chairman of the TCM Practitioners Board. The incoming new chairman, replacing Mrs Yu-Foo Yee Shoon, will be Dr Teo Ho Pin. I have had several discussions with him. He understands the big shoes he has to fill, our position and thinking, especially in the context of Healthier SG, and his task as the Board Chairman.
11. Once we can feature TCM in Healthier SG, the suggestions that Leader of the Opposition has put forth will be considered, and there will be a certain natural forward movement in our policy thinking.
12. One last thing before I move to another topic. Mr Pritam Singh mentioned Psyllium and Fybogel. I think it is the same thing. It is not that one is Western and the other is TCM. Psyllium is the seed, Fybogel is psyllium with a brand. Both are not medicine, but dietary supplements, but like all things sold in the polyclinics, like the gauze to dress your wound, they will be be subsidised.
13. A few MPs – Dr Tan Wu Meng , Mr Yip Hon Weng, Mr Ang Wei Neng, and others expressed concerns that some GPs may be very popular, so residents get squeezed out by the huge demand.
14. As I said in my opening speech, we will try our best to manage this. We will ask GPs to set a limit on number of residents they can enrol. How many will depend on the clinic and doctor’s judgment on how many he can take. It will differ from clinic to clinic. We are implementing in phases; we will prompt residents to enrol with their usual GPs; and we encourage residents to enrol early and not wait.
15. I take comfort that we are discussing this because we are worried about overwhelming demand. It is a good problem rather than nobody enrolling.
16. But if GPs are to over time accept enrolment from the entire population, and help keep them healthy, then they must shift out of some current load and I am glad that members gave a couple of suggestions.
17. One way, as suggested by Mr Melvin Yong, is for employers not to insist on workers producing medical certificates (MCs) whenever they are sick. Many common ailments like cough and cold can be managed with more rest, drinking more water and perhaps some over the counter medication, including TCM medication. Ironically the disease where this is most practised is COVID-19!
18. But we insist to see a family doctor because we want to get an MC. It is not the best use of the doctor’s precious time and resources.
19. Many employers already do not insist on MCs for COVID-19. Mr Melvin Yong mentioned that our healthcare clusters today accept up to three days of sick leave without the need to produce an MC; the Civil Service grants officers up to two days of sick leave for mild conditions like cough and cold.
20. I hope this can become a prevalent practice.
21. Mr Gerald Giam asked a series of questions about our effort to substantively remove difference in drug prices between GP clinics and polyclinics for residents enrolled in Healthier SG.
22. As I said in my opening speech, the basis of subsidy for polyclinics and CHAS are different. The former takes into account age, the latter is means tested and largely based on income.
23. So we cannot remove the difference up to the last cent. For higher income households, the difference may well remain in dollars. But parity of drug prices is an important concern told to us by residents during our consultation. We will try our best, especially for the lower income.
24. A number of members talked about KPIs and outcomes and there was an exchange between Mr Gerald Giam and Ms Mariam Jaafar yesterday.
25. Of course we will have to measure outcomes and set targets. That is why we list short, medium and long term KPIs in the White Paper.
26. This work has just begun. Healthier SG is a dynamic and multi-year transformation eexercise, and there will be twists, turns and uncertainties along the way.
27. MOH is having extensive discussions with clinicians and other stakeholders, to set out technical definitions and our approach to data sharing and measuring these outcomes. From there we will establish baselines for different indicators, and determine what targets we seek to achieve and by when.
28. While it is important to measure outcomes and set targets, those who have run organisations before will know it is not a straightforward matter. I used to be involved in workers’ training and interacted with HR practitioners. HR practitioners always lament that employees are over-managed and under-led.
29. Because a manager who is in the middle of a big change management exercise will instinctively say ‘Let’s set targets and measure because whatever gets measured gets done!’
30. Ms Hazel Poa went further to say let’s measure the targets achieved by GPs and claw back the service fee if they don’t achieve it. But as Dr Tan Yia Swam cautioned, it is important for GPs and MOH to work together. GPs must feel that they are an integral part of this change. And I agree with Dr Tan.
31. Ms Mariam Jaafar, an experienced management consultant, also raised a red flag. She has seen enough organisational changes to notice the danger of blindly chasing KPIs and targets.
32. Because a leader that is driving the change will have a different starting point, which is to bring everyone on board, make sure everyone understands and buys into the mission and objective. Then we jointly set KPIs and targets, and do our best together to achieve them, in the right spirit.
33. If we don’t do that, we are not leading, only managing. And if in our zeal to over-manage we penalise people for not meeting targets in the middle of a big change, that is when people become cynical andlose heart.
34. And you get the perverse outcomes that Dr Lim Wee Kiak warned us of. Because if we claw back fees from GPs who do not meet targets, they will first refuse to participate in Healthier SG, or for those who participate, will cherry pick only healthy residents.
35. The way one looks at KPIs always differentiates the leaders from the managers.
36. Since we are on the topic of outcomes, I want to respond to Ms Mariam Jaafar’s very thoughtful and insightful explanation of value-based healthcare. She cited a few good international practices.
37. I want to assure her that our hospitals have already been implementing value-based healthcare through many such initiatives too. We just did not feature them in the White Paper.
38. One example is all the community measures taken to help resuscitate out-of-hospital cardiac arrests – by making defibrillators available in the community, training members of public to perform CPR, alerting them through apps when there is a cardiac arrest nearby.
39. So far, the survival rate of out-of-hospital cardiac arrest has improved by 10 times, from 2% to 22% over the years.
40. Changi General Hospital has set up a Post-Acute Myocardial Infarction clinic to support patients in their post heart surgery recovery. The idea is to review the patient’s condition early, within two weeks. This has resulted in a reduction of 30-day readmission rate from 14.3% to 9.6%. There are many such examples and I hope Ms Mariam Jaafar and the House will be comforted that our clinicians are always thinking of better ways to deliver better clinical outcomes.
41. I agree with members on the benefits of capitation funding, but we are doing it step-by-step and carefully. I explained how we are doing it at the GP level in my opening speech, by extending them a standard base fee per enrolled resident.
42. At the healthcare cluster level, we have changed the basis of calculating their budgets to be capitation-based. They receive fixed capitated budgets for residents of different age bands, so for the very young they have to do a lot more work at a higher capitation rate. Young adults have lower capitation rate. For the older, capitation goes up again. Age band is a good proxy for workload and health risks. Ms Sylvia Lim asked if we can publish the rate. I think better we keep this as internal parameters at MOH. In any case, annual reports and financial reports of clusters are available from ACRA.
43. Clusters will cascade down Healthier SG KPIs, but have not capitated the budgets of hospitals, polyclinics or community hospitals. Healthcare institutions will still be funded the same way for now.
44. Capitation funding is a direction we want to move towards. But this is a big change, and we will have to study and plan each move carefully, and make sure every partner is ready before we do so.
45. When it happens, it must be accompanied by significant granting of autonomy, so that healthcare institutions can make the proper right siting decisions.
46. Taking a sector like palliative care for example, a capitated service provider could receive a standard base fee for each patient they take care of. They then decide which services are in the best interests of each patient, whether inpatient hospice care, home or day care. They should not have to worry about separate funding for separate services under separate settings. So that is where we have a lot of potential.
47. Several members – Dr Tan Wu Meng, Dr Tan Yia Swam, Ms Mariam Jaafar, Mr Dennis Tan and Ms He Ting Ru – raised issues concerning manpower.
48. The key challenge is to have sufficient nurses, allied health professionals and support care staff, to operate hospitals, clinics and Eldercare Centres. These few groups number about 58,000 now, and MOH estimates that this will need to grow to 82,000 in 2030.
49. We will also broaden training for existing nurses, allied health professionals, and pharmacists, so that they can take on crucial roles alongside doctors. For example, nurses in the community will be trained in lifestyle coaching, to empower residents to make good choices according to their care needs. Undergraduate allied health courses comprise specific modules on population health, health promotion, and chronic disease management. Our community pharmacists are now able to provide smoking cessation and weight management services, and there are plans to train them in influenza vaccination.
50. But first there must be enough people to train.
51. There is a certain narrative going around that hospital staff are leaving because they are overworked, attrition rate is at a record high, people are avoiding the healthcare sector and we must do campaigns, reduce workload and raise salaries to attract more people.
52. There are some elements of truth in this narrative, such as how there is indeed a manpower crunch and hospital staff have been working very hard, especially during the pandemic.
53. But the rest is less than factual, propagates negative energy and may not help us tackle the actual problems.
54. Take the attractiveness of the healthcare sector. Are young people really avoiding the sector? Ten years ago, ITE, our polytechnics and universities took in about 1,500 nursing students a year. Now, this has gone up to 2,100, and we are trying to increase it further, to 2,300. Our education institutions receive many more applications than there are places.
55. At this number, we are attracting 4% of the student cohort into nursing. And if we maintain the number despite falling cohort sizes, the percentage will drift up maybe closer to 5%.
56. That means that for every 20 local students, one is training to become a nurse. Healthcare has a very fair share of the local talent pool considering so many sectors are vying for talent.
57. Or on attrition rate – is it really at record highs? If we look at local nurses, the normal annual attrition rate has been about 6.4%, which is not high by any industry standard. In 2020, when the pandemic struck, it went down to 5.4%. Because many of our nurses who were planning to retire or resign stayed on and join the fight against the pandemic. In 2021, there was a slight rebound, to 7.4%. In 2022 so far, the numbers have reverted to that of normal years. There was no mass exodus of local nurses. Nurses have remained dedicated and steadfast, and bravely stood their ground in the face of the pandemic.
58. But what has gone up is the attrition of foreign nurses. From about 8.9% in normal years, to 14.8% in 2021. This is where there is record high attrition, at least over past few years.
59. We know the main reason, and Dr Tan Yia Swam talked about it – which is that the pandemic has increased the demand for nurses all over the world, and our foreign nurses are being poached by other countries. They go to New Zealand, Australia, the UK, the UAE etc.
60. So if we want to tackle the manpower crunch in healthcare, the starting point is to hold on to our foreign nurses in the face of heightened international competition. Only then can we reduce the workload of all nurses, which many members have called for. But we must be clear where is the starting point of our action.
61. Remember, healthcare is directly impacted by the significant demographic shift that is happening in Singapore. An expanding aged population needs more healthcare and manpower. A shrinking young population limits the number of new local talents we can bring into healthcare.
62. If we are honest with ourselves, we know the numbers simply will not add up if we only rely on local manpower, no matter how hard we try to expand the pipeline. Therefore, if we want to take care of our seniors and the sick, if we want to reduce the workload of healthcare workers or make it manageable, we must expect foreign healthcare workers to play a bigger role in the coming years. This is especially so in areas that are facing a bigger manpower crunch, like aged care or palliative care.
63. The great majority of the nursing workforce will still be locals. But the number and role of foreign nurses will need to grow. MOH is therefore securing various pipelines of good foreign healthcare workers from different source countries, to bring them here, then further train and develop them.
64. Some may leave us after a few years, but we will try to keep the majority, especially those who have become an integral part of our care teams. Dr Tan Yia Swam suggested granting the good performers PR, and MOH is supportive of this. ICA always assesses PR applications holistically, including taking into account economic and social contribution of the applicant. When it comes to evaluating applications from foreign healthcare workers, they will certainly consider the important contributions of healthcare workers, and MOH’s support for the applicants.
65. At this juncture, I would like to say a few words to our healthcare workers. I believe the great majority of Singaporeans respect and appreciate our healthcare workers. We have seen the outpouring of public support in the recent past for the sacrifices made by frontliners as they steadfastly battled the COVID-19 pandemic.
66. However, many of our healthcare workers have also experienced abuse by patients and family members who lash out at them, as hospitals and clinics can be high-stress environments. I hope that you will look past a small minority that show disrespect, and have faith that the great majority salute you, which includes everyone in MOH. And I believe I speak for every member of this House, and we too respect them and their work, whether they are men or women, young or old, local or foreign.
67. Abuse against healthcare workers cannot and should not go unaddressed. We hope to raise public awareness of abusive behaviour that should be stopped, and equip healthcare workers to better handle such situations.
What Ageing Means to Us
68. Mr Deputy Speaker Sir, ultimately, we need to squarely tackle the challenge before us – our society is ageing fast.
69. It is a worldwide trend. By 2030, the old will outnumber the young – the first time in recorded human history. East Asia, in particular, is ageing faster than any other region, due to declining fertility and people living longer lives. And within East Asia, the countries ageing the fastest are Japan, South Korea, and Singapore. We are called the “advanced agers”.
70. Members have heard this statistic many times – by 2030, about one in four Singaporeans will be aged 65 and above, up from one in six today. This is not just a statistic. This number translates into real impact on our lives. And we have yet to feel the full brunt of it.
71. For companies, a shortage of workers, requiring them to move into automation, and adopt less manpower intensive business models, while using foreign workers judiciously. For schools, shrinking student intake, which is why MOE had to merge schools and some of us lost their alma maters. Within communities, we need to make sure estates are barrier-free, traffic lights cater enough time for seniors to cross the road. Drivers need to slow down in our residential estates and we already have Silver Zones. For families, more couples will find that they have to take care of two sets of aged parents, in addition to their own children.
72. For healthcare, we see rising disease burden, with escalating demand for hospitals, clinics, doctors, nurses, budget, etc.
73. Most importantly, seniors themselves will be asking, ‘How do I live purposefully and healthily, with dignity, in my old age?’
74. Mr Henry Kwek, Ms Tin Pei Ling, Ms Cheng Li Hui and Ms Carrie Tan raised these concerns, and warn us of the danger of isolation of seniors. We should fully heed their warning.
75. Ageing is a major topic, and its impact spans various sectors. Today, I will just address the implications on healthcare. Our basic premise must be this – ageing may be an inexorable trend. But a rapid escalation of disease burden and suffering need not be a given. We can manage this, provided we stay healthy.
76. Many of us, myself included, are guilty of being caught in the old mould where life stages are determined by age – 5 years old, enrol into preschool; 12, take PSLE; 20+, graduate; around that time apply for BTO with boyfriend or girlfriend; late 20’s, get married; 50’s, beware of onset of chronic illness; 60’s, retire; beyond 80, likely to become frail.
77. The age markers remain relevant and can continue to guide us in understanding life stages, key events and risks throughout our lives. But we need not be straitjacketed by them, especially when it comes to health and ageing. For example, there is no reason the onset of chronic illnesses must happen in our 50s, if we lead a healthy lifestyle. There is no reason why once you cross 65, you should fall onto the wrong side of the dependency ratio. And we can delay frailty for as long as possible, way beyond our 80’s.
78. Policy planners will continue to monitor the statistics based on age, but as individuals we can choose to differ from these widely accepted assumptions. And the Government can make policy changes and reform our systems to help individuals achieve that.
Three Healthcare Systems
79. To do so, we need to recognise that our healthcare system is actually not just one system, but three inter-connected systems, working together to deliver good health outcomes.
80. The first is the acute care system. This is what typically comes to mind when we think of our healthcare system. It comprises hospitals, specialist clinics, emergency departments – the places that cure and treat us when we are sick. We are expanding this system, building more acute and community hospitals in the coming years.
81. The second is the public health system. One important part of this system is the control of infectious diseases, which we could see this system springing into rigorous action during COVID-19. Another fundamental part of the public health system is that which improves the health of our population. This comprises the policies and processes for preventive care, including the network of family doctors, their long-lasting relationships with residents, the practice of regular health screening, and the culture of good lifestyle habits, all of which keep people healthy. This is the system we are building up and strengthening through Healthier SG.
82. We have seen the two systems complementing each other during COVID-19. The public health system strengthened surveillance of the virus, got people to adopt good hygiene habits, receive vaccinations, stay home when unwell. The acute care system took care of those who got infected and experienced more severe symptoms.
83. Still, two systems are not enough. In an ageing society like ours, the third system is equally critical, and that is the aged care system. This is the support system for the large segment of people who are advancing in age. And it is not only about nursing homes.
84. The nursing homes serve an important purpose, which is to care for seniors who are very frail and unable to live independently, whose families cannot support them. But nursing homes are not and cannot be the mainstream solution to ageing. We are building nursing homes very quickly, from 16,200 beds now to 31,000 beds in 2030. I am sure we need them as our population ages, but the projected pace of expansion is worrying.
85. In our Asian culture, we value caring for our seniors at home. Our seniors also prefer to age in a familiar environment. We should not lose this. As a society, we must guard against the assumption that seniors will always become sick and frail, and unable to take care of themselves. That is a risky mindset that will exacerbate the challenge. Because over time society will, perhaps unintentionally, push more older people to become isolated.
86. Our instincts backfire from time to time. We would have come across such stories. Let’s say a senior fell at the wet market, and the family discouraged him from going out and hired a domestic helper to watch over him. A senior forgot to switch off the stove after cooking, and fortunately it was discovered early. The family told her not to cook anymore, and got food delivered to her every day. We might do such things out of concern for our loved ones, but in so doing we deprive them of physical activity, a sense of agency, and dignity.
87. We want to protect them, but we unintentionally expose them to an even greater risk of isolation and loneliness. That is when the spirit wears out, and the body gives way. If that mindset becomes entrenched, then over time, seniors become a problem to be contained and put aside, such as in nursing homes – out-of-sight, out-of-mind. One day, that room will burst.
88. We must support as many seniors as possible to continue to live in the community, independently or with some help, contributing to the best of their ability, able to choose their own activities, and having a full social life with friends and family.
89. I visited Block 115 that Mr Henry Kwek talked about. It is not run on a big budget but by passionate volunteers, doing such heavy lifting and making such a huge difference to the seniors living in that block. I came across a piece of research, which estimated that the health impact of loneliness for a senior, is equivalent to smoking 15 cigarettes a day.
90. We estimate that today, 97% of seniors above 65 can either live independently or with some help, in the community. We must maintain or improve that share, and not inadvertently give them the equivalent of 15 cigarettes a day, and weaken their health and ability to live independently.
91. For the large majority of seniors, what they need most is social care more than just healthcare. And the way to deliver that is to enable ageing in communities. We will need a range of solutions to anchor ageing in communities. These include building more Community Care Apartments that Second Minister Masagos talked about and releasing land for private assisted-living facilities.
92. But the greatest asset for managing ageing is right before us – our HDB estates. Most estates already have ample shared spaces for interaction and activities – coffeeshops, void decks, supermarkets, heartland shops, RC centres, community clubs etc. We did not specifically build them as infrastructure to support ageing, but they are extremely valuable in our ageing society.
93. That is why MOH is rapidly expanding our network of Eldercare Centres, to activate existing spaces and create more shared spaces and social networks for seniors. We are working closely with the Agency of Integrated Care to provide training opportunities for our centres to take on an expanded role under Healthier SG.
94. As a social worker told me, a very effective initiative is to simply bring the seniors to a shared space to cook and enjoy a meal together every day. From there, they will make friends, look out for one another, and do many other things together. There is no risk of anyone forgetting to switch off a stove! And we can definitely improve the way Eldercare Centres work.
95. And as suggested by Ms Janet Ang, for those who are in the last lap of their life journey, we are expanding palliative care, especially at home, to allow our loved ones to pass on as comfortably and with as much dignity as possible. This is the wish of most seniors, and we should try our best to fulfil it.
96. Ageing in communities will be the next major area of reform in healthcare that we need to work on. When all three systems – acute care, public health, and aged care – work together synergistically, healthcare happens everywhere, and not just in medical facilities.
97. I thank Dr Tan Wu Meng for sharing the story of Ah Ma, and pointing out that the healthcare subsidies should not be tied to services being delivered in brick and mortar facilities. This will naturally have to be reviewed as we shift our paradigm.
98. Mr Deputy Speaker Sir, let me conclude.
99. Some countries may place a stronger emphasis on just one of the three systems or organise them in such a way that they end up working in silo. For example, Japan as a super-ageing society has a great focus on aged and institutional care. The US acute care system is state driven, while public health is driven at the federal level.
100. In Singapore, we take an integrated approach. Acute care, public health, and aged care all come under MOH. The Minister for Health is also the Minister in charge of ageing issues, and chairs a multi-ministry taskforce going beyond healthcare. This is an important advantage for us. MOH is in a position to develop a cogent and comprehensive plan, muster resources to transform and fire up all three systems, to deliver health outcomes for our people.
101. Healthier SG is a key effort to activate and reform the public health system, empower individuals to choose health, and lay the foundation for the aged care system. We need all stakeholders – family doctors, community partners, healthcare clusters, employers, residents – to join us in this effort, to shape a healthier Singapore. We do this for ourselves, for each other.
102. All societies, at some point, will have to confront population ageing. It is an urgent and stern test, and some societies end up with bankrupted healthcare systems or let healthcare cripple their society and economy. We are determined to overcome this test.
103. We have the resources, ability, organisation and determination to do this. I seek the support of this House and of the people of Singapore, to endorse this Healthier SG effort as the basis to transform our healthcare system, so as to strive towards the vision of long and healthy lives for Singaporeans.