OPENING SPEECH BY MR ONG YE KUNG, MINISTER FOR HEALTH, AT THE HEALTHIER SG WHITE PAPER DEBATE 2022, “SHAPING A HEALTHIER SINGAPORE”, ON TUESDAY, 4 OCTOBER 2022

“Mr Speaker, I beg to move,

            ‘That this House endorses Paper Cmd. 19 of 2022 on “White Paper on Healthier SG” as the basis to transform our healthcare system by (a) focusing strongly on preventive care; (b) fostering lasting relationships between residents and family doctors; and (c) building strong partnerships within the community, so as to support individuals taking care of their own health and wellness and strive towards our vision of long and healthy lives for Singaporeans.’.”

The Case for Healthier SG

2.            COVID-19 has put all healthcare systems in the world under stress. It exposed the shortcomings and weaknesses of the systems. On the other hand, it made practices that used to be  impossible  possible now.

3.            It was a jolt to the core of all our systems.

4.            As the pandemic dust settles, many health authorities are in a reflective and soul-searching mode, re-thinking how to improve their healthcare systems.

5.            For example, Indonesia – I am constantly in touch with their Health Minister - is making a big effort to strengthen accessibility to healthcare services throughout the archipelago. New Zealand is strengthening central national healthcare planning to reduce the pressure on specialist and hospital care on the ground. The UK is making a renewed push in integrated care between social and health care organisations. Just yesterday, we heard that Hong Kong is doing a deep healthcare reform effort.

6.            As for Singapore, we are embarking on a long term and profound reform effort. There were two important considerations in driving this reform.      

7.            First, our society is ageing rapidly. To reduce the disease burden and preserve the quality of life for our people in the coming years, we have to become healthier.

8.            Second, our COVID-19 response showed that as a people, each of us are prepared to do their part, have each other’s backs and work together to fend off the pandemic.

9.            The things we do during the pandemic – vaccinations, tests, self-isolation – are all preventive care in action. We found ways to integrate preventive care with acute care in our hospitals, treatment facilities and with home recovery.

10.         If we can replicate that effort in our fight against debilitating chronic illnesses, especially those that come with ageing, then we would have made a big difference in the coming ten years

11.         That is why we developed the Healthier SG strategy, which I announced at the Committee of Supply debate earlier this year.

12.         It is a fundamental re-orientation and reform of our healthcare system, to focus on preventive care instead of curative care, emphasise health instead of  sickness, shift the centre of gravity of care away from hospitals into  the community. To rely less on doctors for health, but depend on communities, our families and ourselves. Live up to the name of Ministry of Health not Ministry of Sickness.

The Importance of Stakeholders’ Inputs

13.         During COS, I said that we would seek the input of stakeholders, as we flesh out our proposals, and then come back to Parliament again.

14.         Since then, the Ministry of Health (MOH) has engaged more than 6,000 members of the public, including 1,000 healthcare professionals. We did surveys, focus group discussions, and in-depth one-on-one interviews.

15.         We did not present our stakeholders with a blank canvas and ask them how to make the population healthier. Instead, we presented a broad plan of what we plan to do. 

16.         Then we asked: What is missing? What will make the plan work? What are your concerns? What are the details that matter? What are the potential pitfalls?

17.         It is an important process, to ensure that we design the system right. We received many useful inputs, which we have tried our best to incorporate into the White Paper.

18.         I want to thank our stakeholders for their contribution. They took the engagement very seriously. I think they realised that Healthier SG is a very major healthcare reform, possibly the most significant in decades.  

19.         I want to specially mention the about 50 family doctors from the College of Family Physicians Singapore, Singapore Medical Association, our Primary Care Networks, polyclinics, and the National GP Advisory Panel.

20.         They devoted a lot of time and energy into designing Healthier SG, some meeting almost every week and even weekends, on top of running their clinics.

21.         I would also like to extend my appreciation to the many healthcare practitioners and partners: they range from nurses, allied health professionals, pharmacists, people who work for community organisations, unions, grassroots leaders, employers – who shared your views and contributed your ideas.

22.         Last but not least, I also want to thank the officers of MOH, who did a lot of the coordination, staffing, drafting and preparatory work. I know they are very proud of being part of this co-creation effort with our stakeholders.

23.         Today, I will do three things:

• Go through very briefly the salient features of Healthier SG briefly as a recap,

• Explain what this means to the two most important sets of stakeholders– residents and GPs, and

• Speak more about its budget and financial implications, as this is covered only briefly in the White Paper.

Salient Features of Healthier SG

24.         To recap, there are five key components to Healthier SG:

25.         First, family doctors. They are the linchpin of Healthier SG. We want to mobilise them to build strong relationships with their patients and play a bigger role in preventive care.

26.         Second, health plans. These will be developed between family doctors and patients.  It comprises an overview of the health status of the resident, health goals to achieve, and an action plan, which can include going for essential health screenings and vaccinations, and changes to lifestyles. This is whole area is what we call ‘social prescription’. Doctors are saying ‘social prescriptions’ are often more important than drug prescriptions.

27.         This brings us to the third component, which is community partners. It may not be easy to follow diet or exercise advice and improve our lifestyles by ourselves. So we will draw on the effort of agencies such as Health Promotion Board (HPB), People’s Association (PA) and SportSG, which are organising many health-related activities on the ground, to create a supportive environment to help us change.

28.         Once the first three components are ready, we can embark on the fourth – a national enrolment exercise. This will commence in the second half of 2023, starting with residents aged 60 and above. Each resident chooses the family doctor or clinic where you wish to build a long-term preventive care relationship with. From there we begin our journeys towards better health.

29.         Fifth, enablers. We need the right IT systems, manpower, and financing structure to make Healthier SG work. These are invisible aspects which are critical and a lot of work has been done to build them up.

What it Means to Residents

30.         What will these mean to people? Let me start with the most important stakeholder group - residents.

31.         The greatest impact is that residents will receive much stronger support to stay healthy and prevent any existing illnesses from worsening further.

32.         We are making a big effort to support you, because it is almost human instinct to be tempted by instant gratification.

33.         Have a puff to destress now and worry about your health later, eat the cheese cake now and worry about the sugar later, eat the fried chicken now, laze around instead of exercising, binge watch a series instead of having a good night’s sleep.

34.         Nothing bad will happen immediately, but these habits accumulate to cause serious diseases, or can aggravate existing illnesses later. If you keep dropping every grain of sand, it becomes a bucket and by then it would cause us a big burden, which can cost us our organs, our limbs, our minds, our lives.

35.         I visited the National Kidney Foundation (NKF) recently. They told me that every day, six more patients in Singapore require kidney dialysis. To be on dialysis means you visit the NKF centre three times a week, needle in your arm, for four to five hours each time.

36.         The staff there told me that most patients regretted not correcting their diet and lifestyle while they could. But now it is too late to reverse course. They have to live with dialysis for the rest of their lives.

37.         So let us try to live without regrets. We can still enjoy many things in life – especially the good food, just in moderation and without over-indulging. We will find joy in exercising, especially with friends. We will be able to snub out smoking and Juuling and not miss them.

38.         We must support residents to do all these and it must come in several ways. The first and most significant form of support is your long-term relationship with your family doctor. Research has shown that people with a dedicated family doctor are much less likely to develop serious illnesses. Your enrolment with a dedicated family doctor is therefore a critical first step.

39.         However, since the release of the White Paper, there have been a few concerns on enrolment, which I wish to clarify in this opening speech.

40.         Some residents are worried that once you choose a doctor, it is a final and decision that you cannot reverse.

41.         Not to worry, we recognise that there are times when a resident needs to change their doctor, either because they move house, or found a more suitable doctor.

42.         So we have provided the flexibility for residents to change your enrolled doctor. Nevertheless, please make your choice carefully when the time comes and consciously.

43.         Other residents are worried that once they enrol with a doctor, they cannot go to another doctor, including specialists they are now seeing because of their chronic illnesses.

44.         Please be assured that this will not happen. You are free to continue to visit all your current doctors, including our specialists. But please choose one to be your dedicated family doctor whom you trust, knows your conditions well and can work with you to practise preventive care..

45.         In the same vein, some residents are worried that their regular GP may be very popular, and they may get squeezed out by the demand.

46.         We will try our best to manage this. In the enrolment process, there will be a drop-down list. The doctor you regularly visit will be at the top for you. That will give you an edge.  We are working with the PCNs and polyclinics to let us know who their regular patients are in order to facilitate this. We are also doing enrolment  in stages so that enrolment demand will not be too overwhelming. You may want to enrol early when the time comes to ‘chope’ your regular GP!

47.         The second area of support is that once you are enrolled with a family doctor, the Government will fully fund the most important aspects of preventive care.

48.         Hence, annual preventive care check-ins with your family doctor, nationally recommended vaccinations such as Influenza and pneumococcal vaccinations and health screenings, will be free.

49.         The screening will include three very common chronic conditions – type 2 diabetes, hypertension, and hyperlipidaemia – and three cancers – breast, cervical, and colorectal. These are recommended for the general population and will be free.

50.         Those with specific risk factors may be referred for further tests. There are more complex screenings, like colonoscopy which is an invasive procedure and not appropriate to be made a standard screening for everyone. Although not free, it will continue to be heavily subsidised at our hospitals.

51.         Third, if you are using MediSave to pay for the treatment of your chronic illness, you are no longer required to co-pay 15% of the bill using cash. You can fully use your MediSave.

52.         These changes are somewhat of a departure from most Government subsidy schemes, where some co-payment from residents is often required, to reflect sharing of responsibility and uphold the concept of individual effort.

53.         Here, we decided that since preventive care is very fundamental to healthcare, further subsidy is justified. It does not contradict the principle of personal responsibility, because in the context of preventive care, personal responsibility and action are needed to make changes and  lead a healthier life.

54.         Fourth, we will enhance the subsidy for common chronic disease drugs at private GP clinics.

55.         Many residents gave feedback that there is a significant drug price differential between the GP clinic and the polyclinic. So even if they wanted to stick to one family doctor at a GP clinic, they will eventually go back to a Polyclinic to get cheaper medicines.

56.         To help residents anchor with a family doctor of their choice, we intend to level this price difference, by introducing an additional subsidy tier to CHAS for common chronic drugs and set drug price limits.

57.         This benefit will be available to all enrolled Singaporean CHAS card holders, including Pioneer Generation and Merdeka Generation card holders.

58.         I should add a small caveat, that the basis of calculating subsidies at Polyclinics and for CHAS are different. So due to this technical reason, we will not be able to equalise the price down to the last cent. But we will substantively remove the current difference in drug prices between Polyclinics and private GP clinics for individuals enrolled in Healthier SG.

59.         Fifth, we have roped in important community partners, such as PA, SportSG, HPB and others, to organise more health-related activities for residents, from ball games and brisk walking to Zumba classes and community gardening, and so on.

60.         So while you may see your enrolled doctor only once or twice a year, outside of the clinic, you will not be alone. We are enhancing public infrastructure like sports facilities, parks and park connectors, and community partners will ,  support your active lifestyle.

61.         Sixth, we will award health points to help encourage residents to adopt and sustain a healthy lifestyle.

62.         Regardless of whether a resident prefers to participate in community activities, or to do activities on their own, we offer you a useful virtual lifestyle companion, in the mobile app Healthy 365.

63.         Many residents who already participate in the National Steps Challenge and Eat Drink Shop Healthy Challenge are familiar with this app. It is your virtual companion to nudge you to be healthy.

64.         The app awards Healthpoints for living an active lifestyle and making healthier food purchases. It does not just clock steps but also tracks physical activities  through your heart rate.

65.         You may be dancing, lifting weights or doing community gardening. Healthy 365 will not know exactly which activity you are doing, but it knows you are being physically active because of your higher heart rate, and grants Healthpoints accordingly.

66.         Healthpoints can be exchanged for a range of rewards for public transport and many participating merchants. The reward may not be large but it gives us a certain psychological satisfaction. It can be a very effective nudge, especially when gamified. 

67.         We will be enhancing Healthy 365.  For example, it will be able to help you track your calorie intake. So you take a picture of your char kway teow and it will match against your database of different food and their calorie intake and it will monitor your intake.

68.         We have also made Healthy 365 compatible with more popular digital health apps like Apple Health Kit, Fitbit and Samsung Health, so that your lifestyle data captured by popular commercial apps can be ingested into Healthy 365, and help you claim Healthpoints. 

69.         A dedicated doctor, a health plan with social prescriptions, full subsidy for nationally recommended vaccinations and health screening, full use of MediSave for chronic disease management, enhanced subsidy for common chronic drugs at GP clinics, more community lifestyle activities, more Healthpoints for leading a healthy life – they all come together, complement each other, to support residents to take personal responsibility and action to embark on their healthy life journeys.

The Impact on Private GPs

70.         The second important group of stakeholders are our family doctors, from both Polyclinics and private GP clinics, who will find themselves at the centre of a strategic long term public healthcare transformation plan.

71.         GPs need to earn a living by running their clinics. We must make sure that Healthier SG works for them. Hence, from the time we conceived Healthier SG, we were very mindful that Healthier SG should not take business away from GPs.

72.         GPs will continue to attend to their existing patients and prescribe medication to them. What Healthier SG does is to enlarge their client pool, through enrolment for preventive and chronic care consultations.

73.         In line with this, GPs should be fairly compensated by MOH for their effort and advice in delivering preventive care. MOH will therefore extend an annual service fee payment for each resident who enrol with them.

74.         The service fee is what we will describe loosely as a ‘capitated payment’. That means we do not pay the GP for every consultation, every test, every prescription and every service they provide.

75.         Instead, we pay the GP a base standard fee per enrolled patient for maintaining a long-term relationship with the patient. . This fee will cover the regular check-ins, ensuring residents adhere to their health plans, associated administrative work, and also reviewing the health plan annually.

76.         This is over and above subsidies for health screening and medication, which are separately funded.

77.         For the Government, this method of payment and subsidy is not new. It is largely how we fund education, where polytechnics and universities receive a standard amount of budget per student, even though some students take more modules or participate in more subsidised activities than others. We pay an average standard rate.

78.         For GPs, it is also not a new concept. GPs who assist our healthcare clusters to manage complex chronic patients get a ‘Care Plus’ service fee payment of $100 per patient.

79.         Healthier SG will broaden such schemes to cover preventive care for large segments of the population. The fee will be similar or higher than the current Care Plus fee, depending on the health conditions of the enrolled residents.

80.         We estimate that in the coming few years, Healthier SG service fees and revenue from subsidised services can grow as more residents enrol and become a significant component  of a GP’s annual revenue – maybe a quarter or a third.

81.         Hand on heart, I think MOH has always been a very fair and prompt service buyer, and I assure GPs that we will continue to be so.

82.         What MOH may not be very good at, is to minimise your administrative workload. It is unfortunately inevitable, as we need medical data of patients to be captured in our national health record system, and paperwork is needed for payment claims. We will try our best to minimise and streamline this administrative workload.

83.         Some GPs also do not have IT systems to support Healthier SG. Some are still largely using pen and paper. MOH will also provide a grant to each GP clinic to help them be IT-ready for Healthier SG.

Finance and Budget Implications

84.         Mr Speaker Sir, let me now move on to elaborate more about the finance and budget implications of Healthier SG.

85.         Healthier SG requires a lot of effort and resources to set up. We need new IT systems, ground support capabilities, and to give GPs one-time support for the necessary IT enhancements and capability building to bring them on board. We estimate a set up cost of over $1 billion over the next three to four years.

86.         Beyond that, there will be recurrent costs. These include all the support measures for residents I talked about earlier, and the annual service fee for GPs. This is estimated to be another $400 million per year.

87.         We spend about 6% of our healthcare budget on preventive care annually, such as to fund HPB. With Healthier SG, we will and we want to grow this – perhaps to double the share of total healthcare expenditure.  

88.         In making these investments, our main and primary motivation is to reduce disease burden and the suffering of our people and their loved ones.

89.         Will there also be a financial payback, in terms of reducing healthcare spending in future? It will be good if this comes about, but it is too early to give a realistic estimate.

90.         Because any impact in health of people will not happen immediately. The impact will perhaps be discernible eight or ten years down the road.

91.         Even so, let us be clear. We cannot reverse the rise in healthcare spending. That is not possible with an ageing population. What we can hope for is to slow down the rate of increase of healthcare spending.

92.         Today, our national healthcare expenditure is expected to be about $22 billion a year. This is the annual medical bill for the whole nation. We are expecting it to almost multiply threefold in the coming ten years, to $60 billion in 2030.

93.         If this national medical bill doubles instead of triples in ten years – we would have saved much more than what we are planning to spend on preventive care.

94.       At the heart of Healthier SG is a philosophy of how we choose to live our lives. If we put in a bit of effort every day, a bit of discipline and restraint every week, we can avoid big life-changing suffering later.  

95.   We can illustrate this logic from a personal perspective. Earlier on, I talked about the kidney dialysis patients who regretted not taking preventive action.

96.    If they had practiced preventive care, it would have cost them very little, in effort and money. They may have to see their GPs periodically for advice, moderate their food and sugar intake (which actually saves money), take some medication as needed.

97.         But when the disease is allowed to go out of control, and dialysis is required, it costs about $25,000 a year. Taxpayers and donors have to help them foot the bill. The bigger cost, which is what we are most concerned about, is their personal suffering.

98.         Some residents say they prefer not to do preventive care or health screening; they would rather not know and have to go through expensive treatment.

99.         I really hope we do not have that mentality because even if you don’t know now, the disease will make sure you know later. And when the disease makes you know even later, the treatment will be even more expensive, not just in monetary terms, but in suffering, for you and your loved ones.

100.      Let’s take action now, systematically, and also individually.   

101.      Mr Speaker Sir, let me now say a few words in Mandarin.

102.      议长先生

103.      卫生部从今年3月起，通过各个管道，聆听了超过6000人对于 “健康SG” 的想法和建议，成就了这份白皮书。

104.      我们向公众 征求意见的时候，并不是从零开始，而是呈现了 卫生部在“健康SG”战略上 的想法和执行概念，然后 征求公众的意见，看大家 有什么顾虑、疑问和建议。

105.      在这个 过程中，我们也认识 了自己的盲点。 而通过公众的反馈，我们能够 使这个计划 变得更完美，更有效，更实际。

106.      在这里我要 由衷感谢 大家的意见和支持。

107.      白皮书 叙述 我们要如何 通过各种方式 帮人民过得更健康。重点如下：

108.      第一、也是最重要的，是确保 每个国人 专一地看一个 家庭医生或到一家诊所。至于哪一个 医生、哪一间诊所，人民是有选择的，也有换医生的伸缩性。

109.      我也要澄清，“健康SG”的家庭医生，不仅限于私人诊所的医生，也包括 综合诊疗所的医生。所以一些年长者，如果现在固定去 综合诊疗所看医生，可以继续下去，不需要转去私人诊所。

110.      第二、政府将提高 预防性医疗的 津贴。这包括了 卫生部推荐的身体检查、接种疫苗，和 定期 预防性医疗的 看诊费用。

111.      这些医疗服务，政府会 提供全额津贴，就是你不用付钱，政府帮你付完。

112.      第三、许多国人已经有了 慢性疾病，而动用 保健储蓄来支付 医疗费用。以现在的条例，大家需要用 现金来共付 一部分的费用。在“健康SG”的制度下，我们将 取消 用现金共付 慢性病医疗费用 的这个条例。

113.      第四，我们将 通过 Healthy 365 的 应用程序，扩大 健康生活的奖励范围。许多国人 已经 积极地参加 “全国健步大挑战”（National Steps Challenge）的活动。

114.      除了步行以外，其他的活动，例如打球、跳舞，园艺，健身 等等活动，都能获得奖励。有了 数码科技， 吃得健康，也有奖励。福建话说的 “wu jia go wu gia”

115.      有些人可能觉得做体检、打疫苗，固定看医生等等，都是没有必要的。我们常常会听到 这类故事 -- 我的朋友、某某人每天抽一包烟，每周吃肥肉，但是活到90岁。

116.      我觉得，这是一种“中马票”的心态。不健康但是没病痛的“赢家”，绝对是极少数的，就是那些“中马票”的。

117.      但我们都知道每个星期买马票的人，没有中的是大多数的，只有非常少数的会中奖。大致上，生活不健康的，往往都是 “输家”，病痛找上门的可能性很高。不要把自己的 健康和生命 拿来做赌注。

118.      之前在《联合早报》，我读到了唐代名医 孙思邈 的名句 ，觉得非常有意义，值得在国会重复。

119.      名句说“上医医国，中医医人，下医医病”。

120.      意思是，次一等的医生 只会医一个人身上的疾病，中等的医生可以处理好一个人的整体健康，而高明的医生可以提高一个国家人口健康。

121.      “健康SG” 所要做到的 就是“上医医国” 的宗旨。保健不单靠药物，也靠生活习惯；保健不单靠医院，也要靠社区；不依赖医生，也借重 个人和家庭。

122.      西方医学其实也有 同样的概念，把保健体制 划分为 医疗体制 （healthcare system – 也就是 医病和医人的 体制）和 人口保健 体制（population health -- 也就是 医国的 体制。） 中西都有这样的概念。

123.      “健康SG”是一个横跨很多年的长期策略。这份 白皮书 是我们国家保健政策的 重要 转捩点，对卫生部来说是一件任重道远的工作。它的成功，要靠人民和国家的配合以及努力。

Conclusion

124.      Mr Speaker Sir, Healthier SG involves a mindset change in the way we look at healthcare. I would like to quote a passage in the White Paper:

“…we need to do things differently

…clinicians will need to constantly think of ways to prevent residents from falling sick, against instincts trained to treat as many suffering patients as possible.

When conducting…health screening, we will have to deploy less precise but more scalable solutions, to identify residents…who have higher risks of falling ill.

Policy planners need to…develop and evaluate programmes and initiatives across a multi-year budget cycle, consciously investing in preventive care now to avoid years of pain and suffering later.

Every player needs to work closely, increasing the extent and depth of integration of their services.”

125.      Only by doing things differently, and collectively, can we achieve results beyond what traditional healthcare can deliver. In western medicine, there is a distinction between different levels of health system.

126.      The traditional understanding of healthcare system comprises primary and acute care - clinics, hospitals, ICUs etc.

127.      But there is also the concept of population health, where healthcare, social support systems, societal habits and personal responsibility come together to make a population healthy.

128.      It is a higher level of health outcomes, going beyond what medical personnel alone can do, but a whole of society achievement.

129.      There is a similar concept in Chinese medicine. It is well summarised by Tang Dynasty doctor Sun Si Miao, who said ‘上医医国, 中医医人, 下医医病。’ The saying essentially differentiates between the outcomes of curative care, preventive care, and population health.

130.      If all of us come together to make Healthier SG work, we will progress towards the holy grail of healthcare - healthy longevity. That is when the number of years we can live healthily, approximates the number of years we can live biologically.

131.      Mr Speaker Sir, I look forward to the views and suggestions of Members of the House. Thank you.