SPEECH BY DR JANIL PUTHUCHEARY, SENIOR MINISTER OF STATE FOR HEALTH, AT THE HEALTHIER SG WHITE PAPER DEBATE 2022, ON WEDNESDAY, 5 OCTOBER 2022

Mr Deputy Speaker Sir, the Healthier SG strategy focuses on General Practitioners (GPs) and residents, as we encourage them to develop closer, longstanding relationships, to enable better preventive care. Family doctors, GPs will play an important role. The Ministry of Health (MOH) is supporting GPs to help them on-board to Healthier SG. We have consulted GPs extensively about this and I thank them for their time and valuable feedback.

2.             GPs are supportive of Healthier SG and I agree with the focus on health, not illness. They have raised some concerns and suggestions on how this will be implemented. Several members of this House have also raised similar concerns and provided suggestions.

3.             GPs require support for their enhanced role. We have worked with primary care teams to develop 12 care protocols. These will provide clarity and consistent processes for the GPs and the clusters who will support them. The protocols are on providing screening and vaccination, and managing common chronic conditions like diabetes, hypertension and lipid disorders. This will be a multi-year effort and we will continue to develop more care protocols such as for mental and dental health.

4.             Mr Xie Yao Quan suggested we strengthen the integration between GPs and the healthcare clusters. Our clusters will work closely with the Primary Care Networks to do this, developing clinical programmes for shared care. 

5.             Ms Janet Ang and Mr Ang Wei Neng asked about the enrolment process.

6.             Enrolment is tagged to the clinic, to enable service delivery even when a specific doctor is away or unavailable. After enrolment, residents can still visit other clinics if needed. Residents can also choose to change their enrolled clinic. For example, if your doctor leaves the clinic to join another group, you have the option to switch and enrol with your doctor’s new clinic. Others may prefer the convenience of staying with the same clinic in the same location. Ms Ang also asked if three generations could enrol to the same doctor as well. This is ideal. But for now, we must consider the capacity of the GPs for the enrolment process, especially the early in the rollout of Healthier SG. We will consider this approach that Ms Ang described as we open up to other age groups. 

7.             Ms Denise Phua and Mr Gerald Giam also asked about enrolment to polyclinics. They will assign enrolled patients to a regular care team, so that there is one team looking after the resident for continuity of care.

8.             Ms Joan Pereira asked if enrolled patients can use branded drugs at their own cost. They can. However, the enhanced Community Health Assist Scheme (CHAS) chronic drug subsidies will not apply. The enhanced subsidy tier applies to a targeted list of clinically effective and cost-effective chronic drugs, which will be reviewed regularly. For drugs outside of this list, the current CHAS subsidies will still apply. MOH will announce more details next year, including standard safeguards and reviews to guard against excessive purchases as raised by Mr Gan Thiam Poh.

9.             GPs have had questions about their remuneration, the design of the annual service fee, will they be penalised if patients refuse to adhere to their health plan, and would some GPs be incentivised to cherry-pick patients. They are also concerned about the impact on their business when drug prices are made more comparable with those at the polyclinics. These points were also raised by Dr Lim Wee Kiak and Mr Gan Thiam Poh.

10.          Let me first explain how the annual service fee will work. There will be a base rate that will differ for enrolled patients with and without chronic conditions. This is regardless of whether the enrolees, the residents, are compliant with the health plans.

11.          On top of this base rate, additional payouts will be provided upon the completion of critical care components recommended in the GPs’ care protocols and the residents’ Health Plan. For example, have patients with diabetes gone for their annual eye and foot screening? So at the start, doctors will be paid not on the basis of whether blood pressure or blood sugar levels have come down, but whether the patient has engaged with the interventions that will help bring down the blood pressure and the blood sugar.

12.          GPs have shared that educating and encouraging Singaporeans to turn up for screening requires dedicated time and effort, and the design of the service fee addresses this and minimises the impact of cherry-picking. This new annual service fee is on top of the existing government subsidies and the patient revenue that GPs already receive for services rendered.

13.          GPs can also expect more revenue from these patients with the increased uptake of recommended preventive care services which will be fully subsidised. More comparable drug prices will help patients, who may have otherwise visited polyclinics, to see their GPs instead. Taken together, all of these mean that GPs will be fairly remunerated for the care they deliver under Healthier SG. Ms Denise Phua highlighted the plight of busy GPs and we hope this set of changes will also help them gradually evolve from a volume-driven model to one with more opportunities to connect with and empower their residents for health.

14.          To Ms Hazel Poa’s and Mr Gerald Giam’s comments on MediSave, we have limits on the use of MediSave to ensure Singaporeans have sufficient savings to meet their various healthcare needs throughout their lifetime. We will continue to review the adequacy of each MediSave limit. MOH also reviews the list of conditions on the Chronic Disease Management Programme (CDMP) regularly and has recently expanded the list to include three new conditions such as gout, allergic rhinitis and chronic hepatitis B, bringing the total to 23 conditions.

15.           To Mr Xie Yao Quan’s and Ms He Ting Ru’s questions on personnel and overseas Singaporeans who are healthcare workers, we are actively growing our pool of family physicians to meet our target of 3,500 by 2030. The annual intake for family medicine has been increasing and we will continue to review the training numbers. MOH has been working with the Family Medicine Training Advisory Committee and College of Family Physicians Singapore on expanding the number of training places. We are also increasing exposure to family medicine in the undergraduate curriculum, and have incorporated preventive care for all clinical modules.

16.          We conduct regular recruitment and retention efforts to reach out to overseas Singaporean medical students studying in medical schools recognised by us. We provide them with details on applying for jobs in Singapore and offer them Pre-Employment Grants to help with their school fees, in return for being bonded to work in our public sector healthcare institutions. We also offer, as appropriate, housemanship training positions or more senior jobs. Our aim is to facilitate as many of them as possible to return home. Overall, about 200 overseas trained Singaporean doctors come back every year.

17.          Mr Edward Chia asked about telehealth providers. Telehealth will be an important enabler. In line with this, we will also consider how remote providers without standard in-person clinic facilities can be included. We will share more on how GPs can leverage telemedicine to offer regular check-ins for their residents under Healthier SG in the future.

18.          But let me also address Mr Ang Wei Neng’s and Ms Denise Phua’s queries about doctors on company panels. We need to ensure as many GPs as possible who are on employer panels join Healthier SG. The Singapore National Employers Federation (SNEF) and NTUC, employers and union leaders agree that they will need to get more of their panel GPs to join the Healthier SG programme.

19.          What does this mean for an employee? If most panel clinics are on Healthier SG, the employee can benefit from Healthier SG benefits and employer medical benefits when they enrol with a Healthier SG provider that is already on their employer’s panel. If and when they change employers or retire, they can stay with the same clinic and continue to enjoy the Healthier SG benefits.

20.          These Healthier SG benefits will be on top of the employer medical benefits. Regardless of the coverage of the employer medical benefits, the employees on Healthier SG will receive a free consultation on their health plan and will be encouraged to complete the free nationally recommended screening and vaccinations. With effective preventive health, some employers may see savings in employer medical benefits. SNEF has been urged to plough back these savings into other health and wellness programmes to enhance the health of employees and SNEF is supportive.

21.          Mr Ang Wei Neng asked about the family physician requirements, and how it will impact the solo clinics. The intent is for all participating clinics to have at least one family physician per clinic. There is a seven-year runway to achieve this. The Primary Care Networks can support clinics in their network to achieve the requirements for Healthier SG and AIC can also provide support to clinics. We will find ways to facilitate the participation of solo GPs in Healthier SG.

22.          Dr Tan Wu Meng and Ms Joan Pereira raised concerns about the administrative burden of data submission and whether the IT systems would adequately support the work of GPs. Many GPs we engaged also highlighted the importance of IT and that the systems need to be improved.

23.          We will work closely with GPs and their IT vendors. This work has already started with GPs and their IT vendors, to support the enhancement of IT systems to simplify administrative processes, improve data flows and sharing, all while ensuring data security.

24.          The indicators that will need to be submitted for outcome tracking and remuneration have been streamlined, taking reference from existing clinical indicators that doctors would routinely document and track in their own record to deliver good care.

25.           We want GPs to use a Clinic Management System (CMS) that supports their daily operations well and connects to all the key public health IT systems. This will save them time on administration so that they can focus on the patients. We are working closely with the commercial CMS vendors to improve their products and strengthen their backend services. Some GPs continue to use pen and paper services, and we will provide them an interim web-portal for them or their staff to enter the essential information while they adopt a CMS. We have given them some time to do so.

26.          We know that it is not easy for GPs to upgrade to an IT system that is Healthier SG compatible and they will have one year from the launch of Healthier SG to adjust. We will also provide a one-off IT support grant to support this transition and MOH and AIC will continue to support GPs in this process. We want them to come on board Healthier SG.

27.          Our plans will require close collaboration among family doctors and healthcare clusters and a wide range of service providers. However, the use of IT and record-sharing differs widely, hindering coordination and communication across partners today.

28.          Going forward, to deliver Healthier SG, we must transform how we communicate and share data for more holistic and integrated and coordinated care. Ms Mariam Jaafar and Dr Tan Yia Swam spoke about this.

29.          One key tool will be the National Electronic Health Record (NEHR). NEHR will capture summaries of patient medical records on one platform and healthcare workers who need it to support clinical care they are delivering, such as family doctors, will be able to draw from, and contribute to, this common platform.

30.          We put in place controls to restrict the access to sensitive health information to selected user groups only. There are also additional authentication processes for this sensitive health information, and we audit the access to this set of information. We will continue to implement safeguards to balance the patients’ need for privacy, and to ensure that the correct healthcare providers are able to access critical information necessary to provide care to patients.

 
31.          We will introduce new legislation, the Health Information Bill, in 2023. This Bill will facilitate the proper collection, use and sharing of health data among healthcare providers in a safe and secure manner. This includes our healthcare clusters who will serve our residents as regional health managers. Only authorised personnel will be allowed to access the data, which will be limited to what is necessary for their work.  MOH will be seeking feedback on the Bill later this year. We look forward to hearing your views.

32.          Ms Mariam Jaafar also highlighted the importance of data analytics. Data-driven intervention is indeed our intent; we will continue to work with clusters and partners to share data and deploy such capabilities to help our residents. It is important therefore that we set up NEHR with the safeguards and obligations spelled out in the proposed Health Information Bill.

33.          We are strengthening the IT platforms, services and connections across all the partners: family doctors and healthcare clusters. I thank the many IT teams, public and private, who are collaborating on this. It is with their help that we will improve the flow of data, impact health outcomes and optimise the user experience for residents and our healthcare providers.

34.          I am glad that Mr Xie Yao Quan also highlighted the importance of having sufficient IT and cybersecurity talent. While we have built up expertise, a key challenge remains to attract and retain skilled IT professionals in a competitive market. We will continue to remunerate competitively. We also hope that healthcare IT colleagues see the contribution they make and the fulfilling career they can have in transforming our system, caring for our society.

35.          Ms Ng Ling Ling suggested that more comprehensive health screening is needed as we move towards preventive health, and Mr Abdul Samad further suggested more MediSave utilisation for this. We take guidance from the recommendations of the Screening Test Review Committee. This guidance is based on scientific evidence to ensure that screening tests are safe, effective, and suitable for population level screening - means applied to everyone across the population. We need to strike a balance, to balance the practice of good preventive care, but consider what the test involves, without going overboard.

36.          In some cases, some of the screening tools are better applied to targeted population. It may be better for some cases to take a calculated, risk-based approach, to offer tests that are effective, and easy to administer to high-risk groups. One example is what we are doing for those 50 and above, such as with the 2-day Faecal Immunochemical Test (FIT), which is for colorectal cancer. There are some tests which the science suggests that we should apply to the entire population and there are some tests which the science suggests you should apply to targeted population.

37.          And we will continue to review emerging scientific evidence on these screening tests as well as the effectiveness of our financing models. Fundamentally, access will not be denied to those who need it.

38.          Ms Janet Ang asked about regular eye and dental screening. These are important. We must look after our teeth and have our eyes checked, and most of us do so. The screening processes and tools are less appropriate as a mass exercise for all under the population approach for Healthier SG and again, as also as a more suitable as a targeted effort for certain groups of Singaporeans. Healthier SG is a multi-year effort, and we will continue to review and include other necessary care protocols in future. Meanwhile, to reassure Members of the House, regular oral health and eye screening programmes are already easily and readily available as a routine service in many settings, and we will continue to offer these. One example, Project Silver Screen conducts check-ups for seniors at community locations for age-related decline in vision, oral health and hearing, so that they don’t have to visit a clinic or a hospital, and timely interventions can be provided. So likewise, we would also like to assure Mr Dennis Tan that there are already similar preventive dental health programmes in place.

39.           To Mr Abdul Samad’s comment, there are nationally recommended health screening tests widely available at CHAS GP clinics, polyclinics and participating community providers. In future, Singaporeans should go to their enrolled clinic to enjoy free screening.

40.          Finally let me address mental health and well-being, a topic important to many we engaged during our public consultation. Several members such as Ms Tin Pei Ling, Ms He Ting Ru, Mr Wan Rizal, Mr Melvin Yong, and Mr Dennis Tan have also raised this. Good health is also about good mental health. The current planned interventions under the first phase of Healthier SG will support mental well-being. People have asked when we will start to look at mental well-being. Yesterday, actually years ago. The interventions we already planned under Healthier SG, starting with our initial emphasis on eating well and regular exercise, will have a positive effect on mental health. But allow me to also highlight what we have put in place over the last few years to promote mental health and well-being, even before Healthier SG.

41.          To raise mental health awareness, we have developed MindSG, a trusted online resource portal providing comprehensive and current information on mental health. To improve access to community mental health services, we developed the Community Outreach Teams (CREST).

42.          We have the redeveloped Alexandra Hospital, coming up, which will provide psychiatric services. The National Addictions Management Service at the Institute of Mental Health (IMH) will be extended to other hospitals, including Changi General Hospital and National University Hospital, to make the services more accessible.

43.          We have been working closely with AIC and GP partners to have more GPs provide mental health support. As of March this year, there were over 390 GP partners trained to care for persons with mental health conditions in the community.

44.          We have convened the Interagency Taskforce on Mental Health & Well-being with members from over 30 organisations. The Taskforce has reviewed our mental health needs and identified four focus areas:

i. First, to strengthen services and family support for parents and youths;

ii. Second, to provide and improve access to quality and affordable mental health care by integrating health and social services;

iii. Third, to provide employment support for persons with mental health conditions; and

iv. Fourth, to improve mental health literacy among the citizens and create an inclusive society for persons with mental health conditions.

45.          We have completed our public consultation on the issue of mental health strategy in August.  Members of the public and key stakeholders have shared their feedback, and we are now refining the recommendations. The Taskforce will share its findings soon.

46.          Mr Deputy Speaker Sir, a Healthier Singapore requires a whole-of-society approach. We need the support of all healthcare professionals, the healthcare clusters, community partners and many, many more. We need to, and will, put in place systemic enablers for this challenging set of reforms to succeed. Ultimately all of us need to also play our part in taking responsibility for own health and changing our behaviours. By working together, we can improve health for all of us. Thank you.