MOH Budget Speech (Part 3) - Care in the Community

06 Mar 2007

By Mr Heng Chee How, Minister of State for Health

Venue: Parliament

1 I thank members for their valuable comments and suggestions.

HEALTH PROMOTION

2 Dr Fatimah Lateef asked for the outcomes of our health promotion efforts.  Since its establishment 6 years ago, the Health Promotion Board (HPB) has focused on motivating Singaporeans to lead healthier lifestyles, so that they may live long and well, with peace of mind.  Its key initiatives include: (a) the annual National Healthy Lifestyle Campaign, (b) collaboration with hawkers to offer healthier choices at hawker centres, restaurants and school canteens, (c) working with food manufacturers to make healthier food products (such as fortifying food with nutrients like calcium), as well as (d) working with corporate and community partners to encourage chronic disease prevention and management, exercise, smoking reduction, stress management and mental and emotional health.

3 Surveys show Singaporeans have become more healthy.  The public's awareness of the importance of healthy living has risen and more are adopting healthier lifestyles compared to a few years ago.  The prevalence of hypertension, diabetes and smoking has decreased while the proportions of Singaporeans who exercise regularly, eat more fruits and vegetables have increased.  Smoking prevalence decreased from 15.2% in 1998 to 12.6% in 2004.

4 Students benefit from the efforts of the School Health Services.  Immunisation coverage is high at 95%.  The DMFT (Decayed, Missing and Filled Teeth) Index of 0.72 is among the best achieved by developed countries.  The CHERISH Award introduced in 2000 encourages schools to establish comprehensive school health promotion programmes.  Since its inception, the number of schools that achieved the award has increased from 84 in 2000 to 276 in 2006.

5 For the workplace, HPB facilitates the setting-up of workplace health programmes by employers.  To this end, HPB has provided grants of up to $5,000 to companies that implement and sustain workplace health programmes.  HPB also works closely with the Singapore National Employers Federation (SNEF) and NTUC to organise regular talks and dialogue sessions with business and union leaders, HR personnel and workplace health facilitators.  Surveys show that the number of private sector companies with a comprehensive WHP programme  increased from 32.6% in 1998 to 45.1% in 2003. Benefits from such programmes include improvements in the health profile of employees - more workers who exercise, fewer workers being overweight, reduction in medical costs per employee and reduction in medical leave taken. HPB will continue to pursue such initiatives with companies.

Workplace Health Programmes (WHP)

6 Mr. Yeo Guat Kwang reminded us not to forget older workers. I agree fully with him.  If employers think that older workers would inevitably incur more healthcare costs and thus be more costly to employ, they will be less willing to employ older workers.  In the light of an aging workforce, we must do more to help older workers maintain and improve their health, so as to enhance their employability. 

7 One key area is the management of chronic diseases.  As persons in middle-age stand a higher risk of getting these conditions, early detection, treatment and management will directly reduce damage, suffering and lifetime medical costs to both employee and employer.

8 Going forward, HPB will be stepping up its collaboration with NTUC through the new U-HEALTH (Union-Helping Employees Achieve Life-Time Health) initiative.  Under this initiative, HPB and NTUC will spearhead regular health chronic disease screening for workers.   Workers who suffer from diabetes, high blood pressure and high cholesterol will be helped with their follow-up treatment.  NTUC has already secured the commitment of 30 companies to pilot the programme. Once this pilot is proven effective, it will be ramped up.  As the health of workers improves, their employability and prospects for employment or re-employment will correspondingly strengthen.

MENTAL HEALTH

9 Mdm Halimah and Ms Josephine Teo asked about mental health initiatives.  I agree with them that good mental health is important to the well-being of individuals and their families, and to society at large, especially in an increasingly fast-paced environment.  To meet the challenges in this area, the Government has set up a national inter-ministry work group headed by PS(Health) with representation from employers and unions, to look comprehensively into inter-sectoral issues related to mental health.  The National Mental Health Blueprint, recently drawn up by MOH, describes the national strategy for the prevention and treatment of mental illnesses including dementia.  Under the Blueprint, MOH will train more mental health specialist doctors, nurses and healthcare professionals to meet expected demand.  This will be done through increasing specialist training places, offering training scholarships and including a mandatory posting in psychiatry for family medicine trainees.  Mental health care training will also become a regular part of GP partnership programmes to help strengthen such services at the primary care level.

10 MOH is also examining the possibility of assembling multi-disciplinary community teams to better serve the varied needs of different segments of society.  These teams can comprise psychiatrists, nurses, social workers and other mental healthcare professionals, and they will work alongside schools, community organisations and social services to help children, adults and the elderly achieve improved mental health outcomes.  MOH and HPB will continue to promote greater public awareness about mental health through partnership with VWOs.  HPB's "Mind Your Mind" education programme will also be expanded to give special attention to vulnerable groups, such as the elderly and those facing crisis events. To foster positive mental health in our young, HPB will engage teachers and counsellors, parents, as well as work through youth-centric media like the internet.

Elderly Depression and Suicide

11 Ms Irene Ng asked about depression amongst the elderly.  Depression and past history of attempted suicide are risk factors for suicide among the elderly. When such indications are picked up, health professionals refer the patients to the psychological medicine services and hospital medical social workers for assessment, treatment, counselling, and support.  We will explore additional ways to equip medical teams with the ability to help such patients with early identification of symptoms and intervention.

12 Sometimes, medical problems cause a certain degree of disability in elderly patients, which then becomes a source of stress and depression.  In severe cases, it may lead to suicidal tendencies.  To minimise this likelihood, restructured hospitals have set up geriatrics units to teach elderly patients and their caregivers how to take proper care in the light of the disabilities.  Hospitals also work closely with community-based services and family physicians, so that after an elderly patient is discharged from an acute hospital, active rehabilitation continues in a step-down care facility if needed.

Dementia

13 Dr Fatimah Lateef spoke on dementia in Singapore.  Today, its prevalence in Singapore is 6.2 per 1,000 population .  This is low compared to other developed countries in the Asia Pacific region, such as Japan and Hong Kong, with prevalence rates of 14.6 and 8.6 respectively.  The prevalence of dementia in Singapore is expected to reach 12.3 per 1,000 population by 2020 as our population ages further.  We do not currently track detailed cost data associated with dementia, but can look into facilitating appropriate studies.  We recognise that well-formulated policies that tap collaboration with private and community organisations can reduce the cost impact of the projected prevalence growth through effective interventions for people with dementia and their families. We will consider ways of doing so.

IMH

14 Mr Low Thia Khiang asked about support for the IMH.  Since the restructuring of IMH in October 2000, the budget given to IMH to pay for subsidised services has doubled from $41 million in FY2000 to $80 million in FY2005.  MOH has also supported new mental health initiatives introduced by IMH over the years.  Examples include the Early Psychosis Intervention Programme (EPIP), inpatient psychiatric rehabilitation service, mobile crisis team and hotline service.  Pioneered by IMH, the EPIP has successfully shortened the time taken to detect, manage and treat patients with psychosis, and this has helped more such patients to continue working.  Our work in this area has been validated when IMH's programme received the inaugural State of Kuwait Prize for research in health promotion awarded by the World Health Organisation (WHO) in May 2006.

15 MOH also provides proportionately more Medifund to IMH compared to other public hospitals, as most of its patients are long-staying patients who do not have financial support from their families.

16 Mr Low asked about night clinic service at IMH.  IMH had piloted such a clinic which had low volume and demand, hence it made more sense to focus resources towards normal day clinics.  We will continue to monitor patients' feedback when determining the feasibility of services. At the same time, there is a national network of GP clinics capable of providing treatment and care to these patients. 

STEP-DOWN AND COMMUNITY CARE

17 Assoc Prof Kalyani Mehta spoke on ways of assessing healthcare needs.  MOH and MCYS presently use the Resident Assessment Form (RAF) to assess the nursing care needs of persons who require residential care in nursing homes or sheltered homes. The RAF is a concise 9-item assessment tool which can be applied easily and quickly by eldercare professionals to determine care needs.  It was introduced in 1993 and was adapted from the Australian System of Resident Classification. In 1999, the RAF's use was extended beyond assessing the physical needs of residents, to also assessing patients with dementia and psychiatric needs.

18 InterRAI, where RAI stands for "Resident Assessment Instrument", is an international scientific consortium of researchers, clinicians and policy-makers.  They have developed a series of uniform assessment tools to assess and plan the long term care needs of elderly and disabled persons. Some countries have adapted the RAI for their use, e.g. the US and Japan. Compared to the RAF, the RAI is more complicated. 

19 That said, we are continually studying ways of strengthening our assessment system. We are presently in discussions with InterRAI to assess the feasibility of adapting the RAI for use in Singapore.

20 Mr. Ang Mong Seng asked about the community health screening programme.  The "Check Your Health" (CYH) community health screening programme screens for high blood pressure, diabetes and high blood cholesterol. Early detection and treatment is definitely better and cheaper than late detection.  Hence, residents detected with such problems are advised to see their family doctors and be treated as soon as possible. 

21 Recently, the conditions screened for under the CYH have been included in the Chronic Disease Management programme. Patients may use their Medisave to pay part of the cost of such treatment.  Their children may also use their Medisave to help pay for the treatment.  This significantly reduces out-of-pocket treatment cost.

Disabled

22 Ms. Denise Phua asked about support for the disabled.    Currently, the same rules apply to all under the 3Ms system.  In respect of Medisave, the disabled and non-disabled are treated alike, and are subjected to the same withdrawal limits.  My Ministry has just announced increases to some of these withdrawal limits, and the relief will extend equally to the disabled.

23  While Medishield does not cover pre-existing illnesses or disabilities, disabled persons have been able to secure Medishield coverage for health risks unrelated to the disabilities themselves.

24 The reason why insurers do not insure against pre-existing illnesses or pre-existing disabilities is that it undermines the viability of the insurance product and causes it to fail.  Insurance is to pool risks.  In other words, it is to bet against something which may or may not happen.  If something has already happened, then there is no question of betting.  If an insurance cover includes things that already happened, there would be every incentive for people to wait till the condition develops before joining, and no incentive for the healthy to join or stay on, otherwise known as "adverse selection".

25 It is for this reason that my Ministry's approach is to persuade Singaporeans that it is critical for them to get themselves on basic MediShield insurance as early as possible, and to help them do so.  In this way, they will have more protection against big medical bills before the onset of illnesses and disabilities.

26 As for Medifund, it helps Singaporeans who, owing to financial difficulties, are assessed to be unable to afford their already subsidised treatment.  This help extends to both disabled and non-disabled Singaporeans, and is calibrated to the circumstances of each case.

27 Having said all these, my Ministry fully understands the additional difficulties faced by the disabled, and wants to do more for them.  We currently have a scheme called the Primary Care Partnership Scheme (PCPS).  This scheme enables the elderly poor to seek treatment at participating private GPs for acute conditions like coughs and colds and pay polyclinic rates. We have decided to extend the convenience and benefit of the Primary Care Partnership Scheme to the eligible disabled by the end of this year.  Details will be announced in due course.

28 On research into intervention methods for common special needs, the Child Development Units (CDU) currently monitor the incidence of child development problems in Singapore.  They also conduct some amount of research on diagnostic and intervention methods.  They have plans to research into the areas of skills training and mediated learning for persons with special needs in time to come.

29 As for Disability Medicine, rehabilitation services are currently available in various settings, including acute and community hospitals and day rehabilitation centres.  The 4 Community Hospitals provide inpatient convalescent and rehabilitation care for patients after they have been discharged from the acute hospitals, while the day rehabilitation centres provide day programmes for persons with disabilities.  There are about 30 such day rehabilitation centres spread across the island.

TCM

30 I agree with Dr. Ong Seh Hong that developing TCM would enhance our position as an international medical hub and help with the SingaporeMedicine initiative. Singapore is well-placed to do this because of our recognised strengths in Western medicine and our proximity and close links to countries like China and India which have strong roots in traditional medicine.

31 Demand for complementary medicine is strong and growing. I recently accompanied my Minister to visit the TCM clinic at Raffles Hospital.   We were told that demand has tripled over 2 years and the facilities to support the use of TCM in inpatient settings have also expanded.    We saw both Singaporeans and foreign patients at the clinic. I believe that successfully developing TCM in Singapore will give patients, both local and foreign, additional good options to choose from. 

32 Of course, in doing so, we must make sure that quality and safety are always maintained.  The systematic training and qualifying of TCM practitioners will boost their credibility and give confidence to patients.    Having foreign TCM practitioners of high standing come to practise in Singapore will also contribute positively to this capability building.

33 In this regard, the two main local TCM schools, the Singapore College of TCM and the Institute of Chinese Medical Studies, started TCM degree courses in 2006 with my Ministry's encouragement. These courses are carried out in collaboration with respected TCM universities in China.  The TCM Practitioners Board, the industry regulator, currently allows TCM practitioners with bachelor's degrees from six approved TCM universities in China to be registered here. The TCM Practitioners Act also gives the TCM Board the means to allow practitioners with qualifications outside the approved list, but who are assessed to have outstanding skills and expertise, to register and practise in Singapore. Foreign practitioners currently form about 5% of the registered TCM practitioner pool of around 2,000 here.

INFLUENZA PANDEMIC PLAN

34 Dr Lam Pin Min asked for an update on our pandemic plans.  Effective surveillance is important in detecting disease outbreaks early. MOH does this through (a) continuous monitoring of news reports of disease outbreaks overseas and assessing the risks of these occurrences to Singapore; (b) keeping hospitals and doctors informed of developments and providing guidelines for detecting and reporting of suspect cases; and (c) enhancing laboratory capabilities and capacities for disease detection.

35 Beyond surveillance and detection, prompt and correct response is equally important to retard and limit the spread of the outbreaks.  In the latest review of the Pandemic Plan, focus was placed on bringing in the participation of private GPs and private hospitals to expand the healthcare resources available nationally to cope with demand during a pandemic. 

36 MOH conducted exercises with public and private hospitals in April and May 2006 to test their preparedness for avian and pandemic influenza.   These were followed by a system-wide exercise in July 2006 that involved MOH, hospitals, polyclinics, GP clinics, nursing homes and relevant government agencies.  The lessons learnt from these exercises served to improve the design of the plans.  Exercises will be conducted from time to time to ensure continued preparedness.

37 On our anti-viral stockpile, we have now stocked 1.05 million courses of Tamiflu. They will be used to treat infected persons during an avian flu pandemic. The stockpile of Tamiflu was delivered in batches and the first batch will expire in 2008.   While there is limited scope of rotating Tamiflu with clinics and hospitals because of very low usage of the drug, my Ministry will nonetheless do our utmost to minimise the stocking cost of this anti-viral stockpile without compromising Singapore's pandemic preparedness.