FOUNDATIONS FOR A HEALTHIER FUTURE
A) Introduction
1. Minister Gan has highlighted key shifts in our healthcare system to help build a sustainable healthcare system for Singaporeans in the future.
2. I will focus on how we are working to implement the “3 Beyonds” – beyond hospital to community, beyond quality to value, and beyond healthcare to health, in laying the foundation for a healthier future.
3. Madam Chair, let me begin by illustrating with a story of two villages that are situated along a river. This river is the source of life as it provides food and water to the people living along it. However, the inhabitants up-river are dumping waste into the river polluting the water downstream. Villagers staying down-river are falling ill as a result of bathing in and drinking the polluted water.
4. The affected village has several options. It can invest substantial resources researching the health effects of polluted water or put lots of money into expensive technological solutions to treat and purify the water. It can also look for alternative sources of drinking water. All these options would translate to long term commitment of time and resources in managing the consequences of a real problem. However, the underlying root cause has not gone away.
5. Alternatively, the affected village can work with the inhabitants up-stream to identify and remove the source of pollution into the river. This would definitely help address the real problem, without having to resort to expensive and complex solutions. Yes, this up-stream approach is one of the fundamental shifts that Minister Gan has alluded to in his speech – beyond healthcare to health.
6. Besides advocating health promotion in the general population, our focus now has shifted even more upstream to target Singaporeans as young as possible, from the preschool ages.
B) Better health starts young
7. The foundation of a healthier future is in our children and youth. There is strong evidence that good habits start from young, and these continue to reap benefits in healthier lifestyles and choices into adulthood.
8. MOS Dr Janil Puthucheary and I co-led an inter-agency NurtureSG Taskforce last year to jointly guide the development of a plan to enhance the health outcomes among our young.
9. Madam Chair, before I elaborate further, I would like to request to deliver a summary of the NurtureSG plan in Mandarin.
10. 良好的健康能为孩童及青少年的全面发展奠下良好的基础。然而，我们目前面临一些新趋势，如更频繁的电子仪器使用率、随手可得的高热量食物和饮料、人们的运动量不足。因此，我们必须探讨如何可持续性地培养下一代更健康的孩童和青少年。
11. 去年，我和教育部兼通讯及新闻部政务部长普杰立医生共同率领一个工作小组，携手规划改善年轻国人健康的健培计划（NurtureSG）。健培计划把重点放在孩童及青少年三方面的健康, 包括运动及饮食营养、心理健康，以及睡眠健康。我们将辅助年轻国人、父母、看护者及教师们，让我们的孩童及青少年过更健康的生活。
12. 健培计划将加强家长和孩童及青少年之间的沟通，给予家长相关的知识与育儿技能，以协助他们为孩子打造注重健康的家庭环境。除此之外，物质与社会环境对于孩童的健康，尤其是发展初期的孩童，有很深的影响。因此，健培计划也将着重于在学校及社区内促进活跃及健康的生活，把保健促进融入年轻人的日常生活中。
13. 为了延深及加强学校的保健教育，我们将提供孩童及青少年更多参与体育活动的机会，享有健康的膳食，让他们了解高素质睡眠的重要性， 并且加强他们的社会情绪能力以保持身心健康。
14. 只要大家齐心协力，我相信我们一定可以加强年轻国人的健康意识，并为下一代打造更健康的未来。
15. We announced the plans for NurtureSG two weeks ago. I thank Dr Chia Shi-Lu for his strong support for the NurtureSG Taskforce recommendations. NurtureSG seeks to foster healthier habits in our young in three key areas namely: (i) physical activity and nutrition, (ii) mental well-being and (iii) sleep health. And we will do so through two enablers: (i) through parents, who are role models in shaping attitudes and behaviours of our children, and (ii) through the school and community.
16. Dr Janil had elaborated during MOE COS the various initiatives the mainstream schools will be embarking on to address these three focus areas. I will now share with you what we will do in going further upstream to target children of preschool ages.
17. With regard to the nutrition of our pre-schoolers, let me share an example of how the Health Promotion Board’s Healthy Meals in Child Care Centres Programme – or HMCCP for short – contributes to our vision of “Healthy Meals for Every Child”.
18. This is Raenelle. Since 2015, she has been attending Agape Little Uni @ Sengkang, which participates in HMCCP. Raenelle has grown to love healthier food, and is a health ambassador in her home. As a result, her mother, Regina, has adopted healthier cooking methods, such as steaming and stir-frying at home, and also taking right meal portions. And when they shop for groceries, they look for healthier food options contributing to a balanced diet. Although certain healthy food options can be slightly more expensive, there are also a wide variety of affordable alternatives labelled with the Healthier Choice Symbol. By making the right choices, Raenelle and Regina are on track towards a healthier future.
19. To complement the efforts of improving nutrition in the meals served in pre-schools, the Early Childhood Development Agency – or ECDA for short – will double the minimum daily time for physical activities for full-day pre-school programmes to an hour a day, of which 30 minutes will be conducted outdoors to cultivate young children’s interests in physical activities.
20. We also have plans to teach our young to manage themselves well, by equipping pre-school educators with the knowledge and understanding of socio-emotional development in young children.
21. Last but not least, we want to raise awareness on the importance and benefits of adequate and quality sleep. A lack of sleep is associated with impaired cognition, obesity and an increased risk of mental health issues[1]. The Health Promotion Board will be launching a campaign in mid-2017 to share tips about good sleep habits. For example, parents who establish regular sleep patterns for children, and reduce the amount of screen time for computers, televisions or mobile phones before sleep, will go a long way towards ensuring quality sleep and better physical and mental health for their children.
22. To Dr Chia’s queries on NurtureSG, the initiatives would benefit our children and young from pre-school to the Institutes of Higher Learning. The respective agencies will be supporting the respective recommendations. However, as this is a multi-year, ongoing effort, and builds on top of existing efforts on child health, it is more meaningful to focus on the programmes than on an overall budget. As reported in the Health Promotion Board’s Students Health Survey in 2015, one in six of our secondary 1 to 5, junior colleges and centralised institute students do not eat breakfast at all. This is a concern and we hope that NurtureSG plans would better guide our youths to live a healthier life.
C) War on Diabetes – Disease Management
23. Minister Gan has spoken about the War on Diabetes. I will now focus on the clinical management of diabetes, and the development and implementation of evidence-based clinical and lifestyle management of the disease. This work is led by a Disease Management Workgroup under the National Diabetes Prevention & Care Taskforce set up in July last year.
24. Good clinical management of diabetes is important as poorly controlled blood sugars can lead to multiple complications in the long term, such as diabetic retinopathy, limb amputations and chronic kidney disease. In 2014, two in three new kidney failure cases were due to diabetes. Early detection and treatment can prevent or slow down the progression of diabetes-related kidney disease[2].
25. In 2011, the National University Hospital and the National Healthcare Group Polyclinics developed the Nephrology Evaluation, Management and Optimisation programme – NEMO for short. The pilot programme initiates and optimises kidney protective medication for suitable patients showing early signs of kidney disease. As of September 2016, about one-third enrolled on the programme demonstrated improvements, while over 60% maintained stable kidney function. These positive outcomes give us confidence to scale this initiative nationwide.
26. So from April this year, we plan to extend an enhanced version of the NEMO programme. We will call it “HALT-CKD” which stands for Holistic Approach in Lowering and Tracking Chronic Kidney Disease. The new national programme will benefit more patients nationwide, and will be implemented progressively at all polyclinics.
27. Minister Gan also spoke about the setting up of the Agency for Care Effectiveness, or ACE. This will help clinicians and patients alike achieve value, beyond quality, in the areas of drugs and healthcare technology, which will support our War on Diabetes. To better equip our primary care doctors to care for diabetic patients, we will roll out two Appropriate Care Guides (ACGs) in July this year. The first care guide will provide recommendations on medications for type 2 diabetes, and the second, a systematic way to manage pre-diabetes.
28. ACE also recently evaluated two classes of patented diabetic drugs. One of them was found to be significantly more cost-effective. Arising from this, MOH will be listing the drug from the more cost-effective group under the Medication Assistance Fund (MAF), and eligible patients can apply for financial support for this drug.
29. Patients themselves also have a vital role to play to achieve optimal control of diabetes. The key to managing diabetes starts with taking active steps to lead a healthier lifestyle and to comply with treatment. To better support patients, we are developing a framework to empower them to initiate and sustain lifestyle changes, and enhance treatment adherence. Diabetic patients are also best managed when anchored in meaningful doctor-patient relationships in the community.
D) Primary care as the first and continuous line of care
30. This brings me to primary care. Primary care is the bedrock of our healthcare system, and the key to enabling the shift to bring healthcare beyond hospitals into the community. It is an integral component in our transformative efforts to bring patient-focussed care closer to home.
31. Currently, only 20% of our primary care attendances are in polyclinics, the remainder are with private GPs. This is also reflective of where our primary care doctors practice today. 80% of our primary care doctors are private GPs and a small number of them provide medical care in nursing homes and home medical services. Within primary care, we are also seeing an increase in attendances with chronic medical conditions, like diabetes, hypertension and hypercholesterolemia, rising from 18% in 2010 to about 27% today.
32. Our GPs are therefore very much part of our healthcare eco-system in delivering care in our communities, and providing better chronic disease management for our patients. We have introduced the CHAS scheme in 2012 to provide means-tested patient subsidies at participating CHAS GPs. We have also piloted the Primary Care Networks or PCNs in 2012 which have shown promising results, in terms of the outcome of chronic diseases management. This year, we will be scaling up our PCNs, to better support GPs.
33. PCNs are made up of GPs who are organised into virtual networks and deliver care through a multi-disciplinary team of doctors and nurses, to manage patients’ needs more holistically and effectively. Patients will benefit from nurse counsellors who will provide individualised advice to better manage their conditions. In addition, diabetic patients will be able to access diabetic foot and eye screening services more conveniently at the PCN GP clinics, allowing for early detection and treatment.
34. Through PCNs, GPs also have greater scale to link up with community providers. Dr Tan Wu Meng and Dr Fatimah Lateef suggested strengthening primary care to manage patients in the community, and better streamlining of care coordination across care settings. I agree with both of them. The regional health systems and public healthcare institutions have care coordination programmes and care coordinators for patients with multiple needs and frequent hospitalisations. PCN care coordinators would be able to spend more time evaluating care needs holistically and refer these patients to the appropriate channels of social assistance, including VWOs and MSF’s Social Service Offices. The team-based arrangement will also facilitate like-minded GPs in cross-sharing and peer learning of best practices across PCNs.
35. MOH will provide GPs participating in PCNs with funding and administrative support to implement team-based care to better track the care outcomes and monitor patients more closely. MOH will be launching the PCN application call on 1 April this year for a period of two months and interested GPs are encouraged to participate in the application. Funding support will also be available to enable GPs to better care for patients with complex chronic conditions, such as diabetes.
36. I would like to share a story about Mr Mohd Bin Sahat who has been seeing his regular family physician, Dr Chong Chin Kwang, for about eight years to manage his chronic medical conditions. Since 2012, he has been utilising the PCN services at Dr Chong’s clinic, which gives him access to ancillary services such as diabetic foot and eye screenings. I would like to quote Mr Mohd and he said, “I have received timely reminders on my appointments and follow-ups from the (PCN) staff… the (PCN) nurses also gave advice and recommended tips on diet and exercise. I really appreciate them.”
37. I am happy to note that Mr Mohd’s efforts in leading a healthy lifestyle, coupled with holistic chronic disease management by the PCN team, have helped him to manage his chronic conditions optimally.
38. Beyond PCNs, MOH will also continue to renew our Primary Care infrastructure. As announced last year, two new Family Medicine Clinics (FMCs), in Keat Hong and Tampines, will be operational early this year. In particular, Tampines FMC will be located at the integrated complex, Our Tampines Hub, together with a Community Health Centre (CHC) and a Senior Care Centre (SCC), providing our patients with a range of comprehensive community care options.
39. Residents in Jurong West and Punggol can also look forward to the opening of Pioneer and Punggol polyclinics this year. We are on track to operationalise new polyclinics in Bukit Panjang, Eunos and Sembawang by 2020. I am also pleased to announce that we will build a new polyclinic in the Kallang/Balestier area which is expected to be operational by 2020.
40. We are also working with the polyclinic groups to refresh the existing polyclinics, to evolve the polyclinics according to changing care needs. Polyclinics have progressively been renovated and expanded over the years.
41. Dr Tan Wu Meng had asked if Clementi Polyclinic can be expanded. I have good news for Dr Tan. - Expansion plans are already being planned for at Clementi Polyclinic, and are expected to be completed by next year. My Ministry is also looking into partner arrangements to better care for patients. Since June 2014, Clementi Polyclinic has worked with NUHS-Frontier Family Medicine Clinic (FMC) to transfer over 6,700 patients from Clementi Polyclinic to Frontier FMC for primary care needs.
E) Future-ready healthcare
42. Finally, to future-ready our healthcare system, we will also be revising the Private Hospitals and Medical Clinics Act (PHMCA) which was enacted in the 1980s. Dr Chia Shi-Lu asked for the progress of the review of the PHMCA. While the PHMCA has served us well in ensuring the delivery of safe and quality care, more IT-enabled interventions and mobile services have emerged in recent years. We need to ensure adequate standards for these services. It is important that our healthcare laws stay current and flexible to allow for these shifts in models of care.
43. I announced the revision of the PHMCA in Oct 2016. Since then, we have actively engaged stakeholders, including hospitals and clinics, in focus group discussions. We have also engaged patient groups and members of the public to see how we can better ensure patient safety, welfare and continuity of care through the new Healthcare Services Act.
44. To date, we have held 11 Advisory Panel Discussion sessions and 34 Focus Group Discussion sessions.
45. The feedback has been constructive and helpful.
46. Both providers and the public have welcomed changes to license healthcare providers by services rather than by premises. They have also been supportive of changes aimed at making healthcare costs more transparent through the display of fees, more targeted financial counselling, and bill itemisation.
47. Requirements to increase the accountability of healthcare providers and clinical oversight over more complex services has been generally positive. Various providers and members of the public gave useful suggestions on how we can enhance continuity of care for patients through an integrated national electronic health record system, in short, the NEHR.
48. One of our focus group discussion participants, Dr Theresa Yap commended the NEHR as she felt that it not only enabled her to make better treatment decisions, but also provided patients with greater continuity of care when they visited multiple healthcare checkpoints. Members of the public who were consulted were also supportive of the NEHR as they felt that it would make healthcare less costly by preventing duplication of diagnostic tests and chances of erroneous prescription or drug interactions.
49. However, we are also aware of the concerns raised with regards to ensuring security of patient records, confidentiality of patient information and costs to providers. There are currently security measures in place and my Ministry will continue to strengthen the measures to address these concerns.
50. The draft Bill will be put up for public consultation this year. We welcome all healthcare service providers and members of the public to review the Bill and provide us with more feedback and suggestions.
F) Conclusion
51. Madam Chair, our country’s journey for better care and better health starts from a commitment and understanding of how to stay healthy in every individual. Healthy lifestyle habits keep chronic diseases at bay. Staying connected to a regular doctor with improved access to healthcare services within the community will allow for better care management. MOH will continue to review our system and ensure that it evolves to ensure a safe delivery of appropriate care to patients. I urge all Singaporeans and healthcare providers to partner us in our initiatives to build a healthier future for Singapore.
52. Thank you.
[1] Cognitive Performance, Sleepiness, and Mood in Partially Sleep Deprived Adolescents: The Need for Sleep Study: June C. Lo, PhD; Ju Lynn Ong, PhD; Ruth L.F. Leong, BSSc; Joshua J. Gooley, PhD; Michael W.L. Chee, MBBS
[2] United States Renal Data System. 2014 Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Bethesda, MD, 2014.