Mental health, special needs and TCM

04 Mar 2011

By Health Minister Khaw Boon Wan

Mental Health

1. We launched the National Mental Health Blueprint in 2007.  MOF gave us strong support, with $178 million invested so far.  The key thrust is to strengthen and develop mental health services in the community.  The two key words are: deinstitutionalisation and destigmatisation.

2. We are half way through the implementation, but some impact is already being felt on the ground.  I met a group of psychiatrists last month and asked them about the state of mental health programme in Singapore, as compared with 5 years ago.  They told me that the progress was significant as a result of the Blueprint.  But they added that we still have much to do.  The situation as described by Ms Ellen Lee confirms the psychiatrists’ assessment that the cup is half-full.  We will press on to top up the cup.   

3. Mdm Cynthia Phua, Ms Ellen Lee, Mr Sin Boon Ann and Mr Chiam See Tong asked for more help and support for these patients.  I agree with them.  We are doing more and a lot more will happen in the next few years. We need to detect patients early, so that there is timely intervention.  We need to reduce the stigma surrounding mental illness, so that the patients can be more confident to come forward for treatment and after receiving treatment, to integrate back into the community.

4. Under the Blueprint, we have set up a series of multi-disciplinary community mental health teams to bring about early detection and initiate treatment.  They are organised under 4 different programmes, separately targeting children, youths, adults and the elderly.  Each programme caters to a specific age group.  These programmes are at different stages of implementation.  By then I mean we have tried it out in small areas of Singapore and now we want to bring it up nationwide. But the results are promising, improving quality of life for the patients and reducing their re-admissions to hospitals.  We are scaling up the programmes nation-wide.

5. We certainly need to involve the community more intimately.  First, we are building up a community network to support the patients through neighbourhood social services, GPs, polyclinics and other care centres. 

Today, we have a GP Partnership network where stable patients are put on a shared-care programme with GP partners managing and providing follow-up in the community.  This way, patients do not have to go back to IMH and it’s much more convenient for them. There are nearly 50 GPs and more than 600 patients on the programme.  We are also putting multidisciplinary mental health intervention teams in the community.  These teams will support the GPs to manage simpler cases, as well as provide basic psychotherapy, counselling or case management. This is an area where we will always be short of physiatrists and the more we train up allied health professionals the better it will be.

6. Second, we are strengthening the capabilities amongst the community organisations and social service providers to better manage the patients in the community.  Training will be rolled out to equip staff with the right skill-sets.  So far, we have trained over 2,000 grassroots leaders and frontline staff in eldercare agencies.  We have also put in place community support mechanisms, such as help lines, to link up patients with the appropriate services or resources they need. Cynthia Phua spoke about the hotline in IMH currently serving their discharged patients. The intention is definitely for such national help lines to look after all patients in Singapore and not necessary just ex-IMH patients.

7. Third, we will help our patients pick up skills needed to return to the workforce and achieve independence in the community.  This is key. We need to allow them to properly reintegrate into the community and give them the best chances for recovery.  But to do so I need the support of many more enlightened employers to provide job opportunities for these ex-patients. The Institute of Mental Health (IMH) has a “Job Club”, which helps to support patients’ reintegration into the workforce. Since its launch in 2009, more than 550 patients have been successfully placed within the Job Club scheme.  We will continue to encourage more employers to step forward to help.

8. Fourth, we will continue to provide the service providers with adequate funding.  Recently, the Tote Board Community Healthcare Fund has pumped in an additional $15 million for us to push this programme.  It is an important boost and I will always try my best to seek more funds to support this cause. But my sense is this - money is not the real bottleneck. We need more enlightened people, whether it’s employers, family members or neighbours who are prepared to keep their mind open and give these patients a hand. If IMH has decided that these patients can return to community, they are safe. There’s a wide spectrum of mental illness and there may only a small number who may cause danger to themselves or others. Those who are discharged to community have already stabilised and they need our support.

Children With Special Needs

9. Mr Laurence Wee spoke about a different subject of helping the parents of children with special needs.  Children with developmental difficulties are prone to displaying difficult behaviour such as aggression, disobedience, or engaging in dangerous activities.  It can be a major source of stress for the parents, and can even impact their mental health.  All these can take a toll on family relationships.  Often, parents are at a loss on what to do. 

10. KKH and NUH have been conducting “Parents Forums” for a long time for such parents.  More recently, KKH and the Parenting Research Centre of Australia launched a training programme to equip parents to understand their child’s difficult behaviour, develop their own ways to manage them effectively, and prevent the further development of behavioural concerns.  This is a parenting support course, delivered through a network of qualified facilitators.  The original programme started in Victoria, Australia and was very effective.  We are adapting it to suit local conditions. We hope we can achieve the same results as it did in Victoria. With the support of Temasek Cares, the course is heavily subsidised and the fees kept affordable. 

Traditional Chinese Medicine

11 Ms Ellen Lee and Mr Chan Soo Sen spoke on TCM.  We have had 10 years of TCM regulation and have made some progress in raising its standard of practice and training.  Of course there is scope to do more.  The key question for us is this: do we simply emulate the practice in China?  Or do we forge a niche role for ourselves in Singapore, given our different history and greater exposure to western medicine? 

12 I believe both approaches are sensible.  The second approach is much more challenging but it may open up new opportunities.  For example, for western drugs, the reporting of adverse events is routinely done to HSA so we can analyse the information and give proper advisory to the public. .  What about adverse events as a result of taking a Chinese herb?  What about adverse events as a result of the interaction between Chinese herbs and western medicine?

13 I’ve been discussing with HSA that if we set up a resource centre to collect such information objectively, it may become a useful resource centre not just for Singapore, but perhaps even for the region.  Could Singapore play such a niche role in TCM?

14 Some of our Western trained doctors with interest in TCM have begun joint studies and clinical trials with TCM physicians.  A small group in SGH have been doing similar studies in diabetes for a few months now. The Chinese have their own way of treating diabetes too and if we can subject TCM practices to scientific scrutiny and publish the findings in western medical journals, it would be of benefit to the world.  Perhaps this could be another niche role for Singapore?

15 Over the next few years, I hope the TCM leadership can think through these questions and help us determine the way forward.  If the TCM legislations need to be amended to facilitate the next stage of TCM development, I would be happy to do so.

16 But we must acknowledge the vast difference between TCM and western medicine, both in philosophy and in approach. They are two different things, almost like two different religions. The different regulatory regimes reflect these differences.  Our healthcare system is based on western medicine.  TCM is considered an complementary medicine, regulated to different benchmarks.  A TCM physician is not regulated to the same extent as a western-trained doctor.  A Chinese herb is not regulated to the same degree as a western drug.  That is why Medisave does not cover TCM and many employers do not accept MCs issued by TCM physicians.  Whether this will change in the future will depend on how TCM intends to reform its practice and approach.  It is also not obvious if TCM needs to, or even if it wishes to, can reform and emulate the western medicine approach.  China has tried to integrate TCM and western medicine for many years and has not found it easy.  One professor in Nanjing TCM University told me they tried and the result was “两败俱伤”. That is, both sides suffered when they tried to integrate east and west. There are many times more western-trained doctors in China than TCM physicians.

17 Meanwhile, we will continue to raise their level of professional standards, within the traditional TCM framework.  TCM practitioners wishing to upgrade themselves with a degree have several options.  The two local TCM colleges have partnered PRC TCM universities.  Their Diploma graduates can go on to acquire a recognised PRC degree.  The NTU also runs a double degree programme in Biomedical Science and Chinese Medicine course.

18 Ms Ellen Lee noted the setting up of TCM clinics in many hospitals and asked if we should allow them to be set up in polyclinics.  There are more than 1,000 TCM clinics in Singapore, mostly in HDB towns.  I believe access to TCM clinics is not a major issue.