Medicine as Social Science
Imperative and Impetus
Mr Chairman, let me start by answering Dr Tan Wu Meng’s question of COVID-19 excess deaths.
2. I reported in the House late last year that as of end-June 2022, our age standardised death rate throughout the pandemic was 549.9 per 100,000 person years. This is higher than the 2019 base rate of 525 per 100,000 person years.
3. As of end December 2022, the number has gone up further and slightly, at 555.7. This is expected, as mortality from all major infection waves throughout the pandemic would be accounted for.
4. This indicates an excess death rate of 30.7 per 100,000 person years. Nevertheless, due to the concerted effort of Singaporeans, we remain one of the countries with the lowest mortality and excess death rates in the world, during the COVID-19 pandemic.
5. Dr Tan also asked about strengthening our vaccine capability. This is something we are actively looking at, both in terms of building up local research and development and anchoring local manufacturing capabilities here. I will give a fuller update, as we are going to table our After Action Review in this House, not too long after this Committee of Supply Debate.
6. A major after-effect of the COVID-19 pandemic is that it inspired us to accelerate the changes to our healthcare system. As a result, the healthcare system is now at a very decisive stage of a major transformation, working off a foundation that took many years to build.
7. We are now looking at healthcare as three interlinked systems.
8. First, the acute care system which is mature and well-developed, treats people who are very sick, through hospitals and specialist clinics.
9. Second, the population health system that is in its adolescence. We are putting stronger emphasis on good health and preventive care, through Healthier SG.
10. Third, the aged care system that is a baby, and still developing. We need aged care to take place predominantly in the community, not nursing homes.
11. The imperative for this transformation is our rapidly ageing population, which I believe is the biggest social development of this generation.
12. The impetus to act now is COVID-19, which made things that were hitherto impossible to implement, possible. In a crisis, we made it possible, so do not waste the crisis. Most importantly, through the crisis, it brought to the forefront the power of preventive care like good hygiene, screening tests and vaccinations.
13. Mr Chairman, today, I will give the House an update on the three systems.
14. There are also a few common, foundational issues undergirding all three healthcare systems, which my colleagues in the Ministry of Health (MOH) will address.
15. First, we need the right size and quality of manpower. SPS Rahayu will be speaking on this but let me take some of your comments first. Based on our projections, we need to increase the number of nurses and support care staff by about 40%, from 49,000 now, to 69,000 in 2030.
16. I have explained in the House before, that with a rising population of seniors who will fall sick more often and a shrinking population of new local entrants to the workforce, the numbers simply do not add up. We will not have enough local healthcare workers to support our healthcare needs.
17. We will have to do whatever we can to develop our local pipeline of talent, including some of the suggestions that Mr Gerald Giam has put forward such as attracting retired nurses to return to serve as locum and increasing male participation which is most welcomed. But we still need to complement this with foreign healthcare workers, from varied sources.
18. Various members raised the issue about welfare of healthcare workers. I thank you for this. But fundamentally, the best safeguard for their welfare is to have sufficient manpower. When you have no sufficient manpower and people who are so responsible, they are going to burn their weekends and rest days for their patients. You simply have to beef up the manpower resources. SPS Rahayu will speak more about this.
19. For the foreign healthcare workers who become valuable members of our team and demonstrate commitment to Singapore, we should be prepared to integrate them into our society, like we do for many other foreign professionals.
20. At the same time, a few MPs have raised that society needs to appreciate and respect healthcare workers. The great majority of patients and their loved ones and their family members do. This is hugely motivating for healthcare workers.
21. But abuse and harassment by a small minority is a rising issue in our healthcare institutions. This is not acceptable, and we will need to take a firmer stand against this.
22. We need as Mr Ang Wei Neng suggested a consistent understanding across the healthcare system on what constitutes abuse of healthcare workers. We need to empower hospitals to take a firmer stand against such abuse.
23. We need to make hospitals feel confident that their management, the Ministry of Health, the Minister, and hopefully this House and the public, will stand behind them in protecting our healthcare workers against abuse.
24. MOH has convened a workgroup to study this issue. They have completed their work. We will be sharing the findings and MOH’s plans later this month. .
25. Second undergirding issue, we need the right IT tools and systems, to allow patients’ key health data to be collected and shared across healthcare providers safely and securely, to ensure seamless and integrated care. SMS Janil will elaborate on this.
26. Third, we also need to improve the support system and safety net for vulnerable groups, especially the lower income families. Minister Masagos will elaborate on this.
Expanding the Acute Care System
27. On the three healthcare systems, let me briefly talk about the one we are most familiar with – the acute care system.
28. We have about 11,000 public hospital beds today, and we intend to add 1,900 more public hospital beds over the next five years.
29. This will come mainly from Woodlands Health Campus, which will progressively start operations from end of this year, and Tan Tock Seng Hospital Integrated Care Hub will also start operations this year.
30. Preparation works for the redevelopment of Alexandra Hospital and the new Eastern Integrated Health Campus are also in progress.
31. While not part of acute care system, polyclinics are a very important part of our public healthcare ecosystem. The Sembawang and Tampines North Polyclinics will start operations this year. Another eight will come on stream by 2030.
32. We need to have adequate hospital capacity. But we should not overbuild or worse, think that the solution to the future challenges of healthcare lies only in infrastructure and the number of beds. Ultimately, with an ageing population, we want our people to be healthier.
Enhancing Population Health Through Healthier SG
33. This brings us to the second system, which is the population health system. We are building it up through Healthier SG.
34. Dr Tan Wu Meng, Dr Lim Wee Kiak, Mr Ang Wei Neng, and Ms Ng Ling Ling and probably a couple of others have asked for updates on Healthier SG. Let me provide them by walking through the experience of Healthier SG.
35. We want each of our residents to enrol with a family doctor, to build a long-term patient-doctor relationship. We believe that the family doctor is best placed to guide a resident to better health. That makes family doctors the lynchpin of Healthier SG -the most important component. That is why we have been engaging our private sector GPs to co-develop Healthier SG.
36. We are supporting GPs in many ways – IT grants, annual service fees for Healthier SG when they take care of enrolled participants. This is a new stream of revenue for the GPs for managing the health of enrolled residents.
37. We will also be fully funding preventive services like nationally recommended vaccinations and health screenings for enrolled Singaporeans. So GPs will very likely have to deliver more of these services which is another source of revenue.
38. We have been explaining to GPs that with greater investment in preventive care, primary care will grow in both size and importance. I thank Ms Ng Ling Ling for reminding me of that very simple back of envelope calculation. The GPs will incur more costs, but they will also earn more fee-based and services-based income from the Government.
39. It is voluntary for GPs to be a Healthier SG clinic. We have about 1,600 GP clinics in Singapore focused on primary care. Our assessment is that the great majority appreciates the objective of Healthier SG and wants to be part of it.
40. MOH is working with the GP community on this and we hope to secure the partnership of the great majority of our GPs eventually.
41. I announced last week that we will launch Healthier SG enrolment for Singaporeans aged 60 and above in July this year.
42. I also announced that we will launch a pre-enrolment exercise in May 2023. This is an early bird exercise, to enable those aged 40 and above with chronic illnesses and regularly visit their GPs. But their GPs need to sign up as a Healthier SG clinic and if they have not signed up, please try to persuade the GPs to do so.
43. This will ensure that these group of patients who need Healthier SG the most will not get crowded out.
44. Mr Ang Wei Neng suggested using health carnivals to encourage sign-ups and volunteered for Pioneer Division to be the first. We are certainly keen and will want to work with you and all our community and grassroots organisations.
45. From July 2023, the first tranche of Healthier SG benefits will also kick in. This includes:
· A first Healthier SG doctor consultation which will be fully subsidised by the Government.
· Once the first consultation is completed, you will be awarded 3,000 Healthpoints worth $20. I did a check – to earn 3,000 Healthpoints using Healthy365, you must walk 5,000 steps for 300 days. 3,000 Healthpoints are quite a lot. This is MOH’s way of saying ‘Well done! Welcome to Healthier SG!’
· Nationally recommended health screenings and vaccinations, like Influenza vaccination or mammograms, will be free of charge for eligible residents.
· After seeing the doctor, you want to heed his advice and be more physically active. Our community organisations will be organising more activities near your home. Participation will earn you Healthpoints.
46. But we know the best payback is better health for everyone.
47. In early 2024, a second tranche of benefits, which require more operational preparation, will kick in.
48. This includes enhanced subsidy for chronic drugs at GP clinics. Today, CHAS already provides significant subsidies for patients who have lower chronic medication needs. These patients already pay $0 or very little for their chronic visits and medications.
49. However, for patients with complex chronic diseases and who need several medications, the current CHAS benefits are not enough. Hence, these patients tend to go to the polyclinics to get their subsidised drugs.
50. Under Healthier SG, they have the choice to get their supply of polyclinic chronic drugs at Healthier SG GP clinics, at around the same price as the polyclinics.
51. This is because we will provide a new Healthier SG CHAS Chronic Tier subsidy, for selected drugs at your enrolled Healthier SG GP clinic. I should emphasise that the Healthier SG Chronic Tier is an option for these patients.
52. We know of some patients from this group who are used to certain brands of drugs, which they prefer to get from their GPs even though they are not subsidised.
53. We now make the subsidised and cheaper alternatives used by polyclinics available to these patients, through their private GP clinics. But they are not compelled to switch. They can stay with the unsubsidised drugs that they are used to.
54. Another benefit is the removal of cash co-payment when using MediSave for chronic treatment. Patients can use MediSave to pay their bills fully, up to the withdrawal limit. This will also be effective early 2024.
55. Finally, Ms Ng Ling Ling also asked about Traditional Chinese Medicine (TCM). We are working closely with TCM practitioners by providing more support on research and development, to generate evidence on the efficacies of TCM. There will be more developments in this area, which I will update the House when ready.
Ageing in Communities with Love and Friendship
56. The third system is the aged care system. Several MPs asked about this.
57. We are building many more nursing homes, doubling the number of beds from about 16,000 in 2020 to over 31,000 by 2030.
58. Nursing homes have provided important support to many families with frail parents. It is highly subsidised and supports families who are no longer able to care for their loved ones at home.
59. However, building more nursing homes is not a sustainable long-term solution, and we are running the risk of becoming over-reliant on it. Why do I say that?
60. Because the worst enemy of the aged is often not diseases, but isolation and loneliness. Without the companionship and love of family members or friends, the loss of function will hasten, and they will become frail very quickly.
61. As I mentioned in this House before, research shows that the health impact of loneliness to an elderly is equivalent to smoking 15 cigarettes a day.
62. Our seniors need friends, relationships, love and activities around them. They need to feel active and purposeful, doing full-time, part-time or voluntary work, exercise, take walks in the park, squabble with their coffee shop kakis occasionally, hear the laughter of children.
63. These things keep our seniors healthy, or even reverse frailty in some instances. But they can happen only if the seniors can age actively in the community.
64. The Ministry of National Development has announced that they will be building more Community Care Apartments. It will help but will not cater to the majority of seniors. What is more important is for seniors to be able to age in their current homes, which hold unique memories. To do so, we can leverage two important assets.
65. First, our HDB estates. They are designed with many common spaces for interaction amongst residents – void decks, exercise corners, parks, coffee shops, hawker centres. They served a different imperative in our early years of nation building but the common spaces now offer opportunities for seniors to age healthily, in the community.
66. Second, our community partners, who have been providing social care and support in our housing estates and have built up precious personal relationships with residents. We have been working with some of them to implement pilot programmes for ageing in communities.
67. I visited Montfort Care’s Active Ageing Centre at Marine Parade recently. They told me there are about 5,000 seniors living in the area they are in charge of, and they have so far identified about 400 seniors living alone, who are their top priority for engagement.
68. Like MOH, they know from experience the pain and detriment of loneliness.
69. Montfort is hosting many activities for seniors. Like many Active Ageing Centre partners that I have visited, Montfort came to the same conclusion on what works best in attracting seniors, which is to ‘makan together’.
70. Once or twice a week, get volunteers to prepare the food, get donors to donate the food and serve it in a nice environment like a nicely done up void deck, and the seniors will come and gather.
71. From there, they make friends. They start to watch out for each other. The Centre staff can further engage them to ensure they are taking their medications, going for their health screenings and they can monitor their health.
72. The other attraction is the gym especially since we have many Gym Tonics on the ground now. Many seniors who don’t like to leave their homes, will go to the gym. I suspect seniors heard enough stories of how gym work actually strengthened them and people who were immobile are able to walk again, and even reverse frailty in certain circumstances.
73. We are putting these ground experiences together, into an effective and workable operating model for all Active Ageing Centres, as we expand the network.
74. To do this well, our community partners will need stronger support – in money and manpower. MOH is studying how best to strengthen our support to our AACs. This is potentially another major national healthcare programme, alongside Healthier SG.
75. This is urgent work. We are racing against time, because the pace of ageing in Singapore is relentless. If done well, this will be one of the best gifts to our seniors.
Premises-Neutral Support Systems
76. Mr Chairman, over the years, MOH has been explaining the need to shift healthcare from hospitals to community. With the three healthcare systems, we are making this into a concrete reality.
77. If care is shifting from hospitals to community, so must other aspects of healthcare. We need to be service-centric, not premises-centric.
78. Take regulation for example. We cannot just have standards and rules for hospitals and clinics. We need them for wherever healthcare services are delivered, including senior centres in the community, residential homes, mobile clinics or even remotely via telemedicine.
79. That is one of the key purposes of the Healthcare Services (Amendment) Bill, which we will present to the House at the end of the Committee of Supply debate.
80. Patient data is another good example. They need to flow across different healthcare providers and settings.
81. That is why we will be presenting the Health Information Bill to improve the current situation of data collection and sharing.
82. Likewise, the same argument can be made of healthcare financing for patients. Our healthcare financing framework S+3Ms, namely subsidies, MediShield Life, MediSave and MediFund must extend beyond hospitals, to wherever healthcare services are delivered.
83. We are therefore undertaking a review of our healthcare financing framework, to make it more premises-neutral.
84. This will take some time as it is a complicated issue. In the meantime, we will make three smaller, no regret moves.
85. First, MediSave claims for home care.
86. During the debate on the White Paper on Healthier SG, Dr Tan Wu Meng told the story of ‘Ah Ma’ twice once during White Paper on Healthier SG and once just a couple of hours ago. He has put out a compelling case – why financing schemes need to be premises-neutral, to support patients like Ah Ma who are immobile and homebound, and find it challenging to visit the polyclinics or hospitals and have to rely on home care.
87. Hence, in the second half of this year, we will extend the use of MediSave to homebound patients receiving home medical care. They will be able to tap on the MediSave500/700 and Flexi-MediSave schemes.
88. As a start, this will apply to 25 home medical and home nursing providers that are receiving subvention and support from MOH. Collectively, they serve close to 10,000 patients. When the scheme stabilises, we will consider extending to the rest of the service providers.
89. Dr Tan Wu Meng also suggested allowing patients to take their blood tests at polyclinics before their surgery and to standardise their forms. We will look into that. But we are mindful not to add further workload to polyclinics, especially with Healthier SG coming on stream. So let us study the proposal carefully.
90. Second, normalise telehealth for care delivery.
91. During the COVID-19 pandemic, we wanted healthy individuals to recover from COVID-19 infections at home and minimise visits to clinics.
92. Telehealth made this possible. Infected persons isolated at home could seek consultation with a doctor online, and have medicines delivered to them. It benefits doctors too, as they can leverage technology to attend and care for more patients.
93. To support and encourage the use of telehealth during the pandemic, we extended usage of MediSave and CHAS Chronic subsidies for teleconsultations for chronic disease management. The policy was meant to be time-bound, effective only during the period of the pandemic.
94. Now that we are in Dorscon Green, we will not lapse it because telehealth has become widely accepted and demonstrated to be effective. Hence, we have decided to continue the pandemic arrangement, normalise the use of appropriate telehealth and make it part of routine chronic disease management.
95. Third, stronger support for palliative care. Mr Yip Hon Weng and Mr Xie Yao Quan have asked about this.
96. Survey findings consistently show that the great majority of Singaporeans prefer to pass on at home, in familiar surroundings, in the presence of loved ones, instead of an unfamiliar hospital surrounding
97. However, currently three in five deaths still happen in hospitals. We have a long way to go in fulfilling the wishes of Singaporeans.
98. Hence, we are improving the clinical protocols in the hospitals. We are upskilling providers to develop general palliative care capabilities. We are engaging in early conversations with patients and their loved ones on their wishes.
99. Later this year, MOH will be embarking on an outreach effort, to encourage more Singaporeans to plan ahead with a Lasting Power of Attorney and Advance Care Plan.
100. We also need to work on expanding the capacity of the palliative care sector.
101. Community palliative care providers, such as HCA, Assisi Hospice and Dover Park Hospice, have been doing a tremendous job all these years. They provide three modes of palliative care – at home, in a day hospice, or in an inpatient hospice.
102. They have also been raising significant amount of charity dollars every year to complement Government funding to support their operations.
103. However, their capacity are heavily utilised. To unlock their capacity constraints, the hospices will need additional resources.
104. At the same time, instead of having three different public funding formulas for different hospice settings – inpatient, home and day hospice – we can bundle them into one per patient funding rate, set it at an adequate level, and empower the hospice to decide which settings are most suitable, based on the patients’ care needs and their family circumstances.
105. We will pilot this new approach with Dover Park Hospice, which is working closely with Tan Tock Seng Hospital. We will grant them more resources, through a new bundled per patient funding rate. We will learn from the pilot and review the arrangements, with a view to mainstream the scheme next year.
106. Let me end this section with some comments on questions concerning healthcare costs, posed by Dr Lim Wee Kiak and Mr Xie Yao Quan.
107. Healthcare inflation in 2022 is 2.2%, up from 1.1% in 2021. It is calculated post subsidies, and significantly lower than general inflation in both years.
108. We will continue to keep healthcare costs affordable through our S+3Ms framework. Low-income Singaporeans in particular can be assured that additional financial assistance will be available to you if you need them.
109. We will also extend financial assistance. This is a question raised by Mr Xie Yao Quan. We will extend financial assistance on a case-by-case basis, to needy Permanent Residents, especially those with a strong nexus to Singaporeans.
110. However, for the great majority of Singaporeans who are healthy, the best way to keep healthcare cost low is to stay healthy. That is another reason why Healthier SG and ageing in communities are our top priorities now.
111. Mr Chairman, let me now say a few words in Mandarin.
112. 我相信大家都注意到新加坡人口正在迅速地老龄化 – 邻里的年长者，越来越多了。
114. 人口老龄化是大势所趋，但不等于说我们毫无对策，不等于说要举手投降。人口结构的变化，我们不能改变。但是对年龄的看法, 我们可以改变。
117. 我回答“Auntie，我其实才五十三岁啊！” Auntie毫不不尴尬地说：“哎呀，现在的人，五十几，六十几，通通看起来都很年轻！”
121. 第一，就是卫生部正在积极筹备、即将出炉的“健康SG”计划。从今年七月开始，我们将邀请六十岁以上的国人前来报名。每人可以选择一名家庭医生，做为您长远的 “健康伙伴”。
127. 我最近到马林百列的一家咖啡厅，名字很特别，叫“独一52”。因为咖啡厅就在大牌52的组屋楼下。这是蒙福关爱（Montfort Care）活跃乐龄中心的设施之一。
128. 在那里协助乐龄朋友的义工，他们自己也是乐龄人士。他们每周会有一两天到中心去，准备一些美食， 招待住在附近的年长者。有的切肉、有的Dia Dao Gay、有的煮菜、有的摆设餐具，大家一起忙。
132. 今年下半年，我们将调整政策，让这类病人也能动用保健储蓄，从而减低这些 行动不方便年长者的医疗费用负担。
A Frontier, Biological and Social Science
139. Mr Chairman, let me conclude by addressing Mr Henry Kwek’s question on longevity science.
140. The Geriatric Education and Research Institute and Centre for Healthy Longevity as well as other similar centres are doing good work. But in the transformation of healthcare, we are dealing with much broader and more fundamental questions.
141. They are: What is medical science? How does it translate into public policy? I think the definition of medical science lies on a spectrum.
142. At one end, medicine is a frontier science.
143. As a matter of life and death, it attracts a lot of research and development, including very exciting work on human longevity.
144. Some of the advances sound like science fiction. We can now 3D print body replacement parts, teach our human cells to treat diseases, edit genes to fight cancer.
145. Many medical moon shots have been fired.
146. But we need to exercise caution when translating medicine as a frontier science, no matter how promising and exciting, to public health policy.
147. Emerging treatments usually work for exceptional cases. While these get reported in the media, they usually are not suitable for the majority of patients. Furthermore, they are by nature very expensive.
148. So if we are not wise or careful in the deployment of frontier medical science, the country can end up paying a lot – including wiping out the savings of many people – for very little good outcomes.
149. We have to ensure that standard clinical practices and healthcare policies do not run ahead of the evidence of clinical benefit and cost-effectiveness.
150. In the broad middle, medicine is a biological science.
151. This is where medicine finds wide applications in treatment of diseases. It is the heartbeat of our acute care system. It has improved lives all over the world.
152. When people unfortunately fall sick, hospitals do their best to treat them. Safety nets are set up to make healthcare costs affordable.
153. But make no mistake – we don’t like sickness, and all countries hope that demand for medical care is as low as possible. Therefore, the system must be designed with an emphasis on personal responsibility to ensure prudence and discipline in spending on sickness.
154. That is why co-payment of medical bills and insurance payouts remain an important principle of our system.
155. At the other end of the spectrum, medicine comprises relatively simple and general interventions that apply to entire populations – adequate sleep, eat healthily, exercise regularly, don’t smoke, don’t doctor hop, go for periodic screenings and vaccinations.
156. Unlike medicine in hospitals where we wish for less, we want more of such socially good medicine that enhances health, well-being, and productivity of people.
157. As Rudolf Virchow, the father of modern pathology and social medicine, famously said in 1848 – ‘… medicine is a social science, and politics is (nothing but) medicine at a larger scale.’
158. However, while the benefits are significant, many people are unable to bring themselves to do the simple things that make us healthy. Because eating well, exercise etc takes effort, sacrifice and perseverance, the rewards happen gradually and much later, they deny the all-too-human need for instant gratification.
159. Hence, our public policies need to recognise the positive externalities of this spectrum, overcome and compensate for this hesitancy, in order to maximise the social good.
160. This is the driving force behind the healthcare transformation that we are witnessing.
161. So through Healthier SG, we have decided to make preventive care like nationally-recommended health screenings and vaccinations – just like public parks and libraries – all over and free.
162. We need to invest in infrastructure and systems that keep people healthy – just as we do for public transport and clean water.
163. We cannot sweat the minority of abuse cases and let them dictate the overall design of our preventive care system – just like how we designed the vaccination system during the COVID-19 pandemic.
164. We need to mobilise the support of communities and partners to deliver preventive care well – similar to how we say it takes a village to raise our children.
165. We need every individual to play a part in health and assume personal responsibility – just like national defence.
166. It is a new realm of thinking in healthcare policy, but the considerations are not at all unfamiliar in public policy making.
167. Mr Chairman, our healthcare system has always reflected the face of Singapore. In the 1960s, we had a lean, cost-efficient system suited to a mainly young and vigorous people.
168. Today, we need a more mature and multi-faceted healthcare system – three systems – spanning frontier, biological and social sciences – so as to provide for the more complex needs and opportunities of an ageing population.
169. Today, we have, through the crisis of COVID-19, and all that we as a nation have learnt in overcoming it, a powerful impetus to act – decisively, with resolve and extraordinary will, to see through this necessary transformation.
170. If it is true that politics is medicine on a larger scale, we in this House have the duty to ensure that we, our families and fellow Singaporeans, will enjoy good health for generations to come.
I ask for your support. Thank you.