SPEECH BY DR JANIL PUTHUCHEARY, SENIOR MINISTER OF STATE FOR HEALTH, AT THE MINISTRY OF HEALTH COMMITTEE OF SUPPLY DEBATE 2023, ON FRIDAY 3 MARCH 2023

TRANSFORMING HEALTHCARE THROUGH DATA SHARING, STRENGTHENING CAPABILITIES AND CONTINUED INVESTMENTS IN MENTAL HEALTH

Health information as a key to transforming care

Mr. Chairman, Sir, as our healthcare system evolves, services such as home care and teleconsultations are becoming more commonplace. These changes drove our move towards a premises-neutral and services-based regulatory regime.

2. However, sharing of information remains limited. Patients need to remember and repeat their medical history, and there is an administrative burden on providers to avoid unnecessary investigations or tests. 

3. Some programmes are attempting to close this gap. Like the Primary Tech-Enhanced Care - Hypertension (PTEC-HT) Programme in polyclinics mentioned last year. This allows patients to submit their blood pressure data to their primary care team who views these readings through a dashboard. A patient can change polyclinics, and the new polyclinic can continue to monitor the patient’s blood pressure through the dashboard. The patient need not record and repeat their blood pressure readings from the original polyclinic. These are small steps in the right direction.

4. We need to build on these steps. It is critical that healthcare providers can collect, access, and share standardised health information across settings, to facilitate the provision of uninterrupted and holistic care. 

5. For example, we screen women at risk of gestational diabetes during pregnancy. We know that early detection and intervention for such women can improve both maternal and infant health outcomes. With Healthier SG and data sharing, GPs can identify women with pre-diabetes and support them on lifestyle changes to prevent the onset of diabetes. When the woman becomes pregnant, data sharing will enable her health information to be accessed by her obstetrician, who will then know about her higher risk to develop gestational diabetes. If she does develop the condition during pregnancy, she will have a higher risk of developing diabetes within the next five years after delivery, so her regular GP will need to know about what happened during the pregnancy and so work with her on preventive measures to keep diabetes at bay. Data sharing enables care and preventive care provision to take place seamlessly as she goes through different stages of her life, and this data sharing needs to happen from the community practitioners to the hospital specialists and back again.

6. I agree with Dr Lim Wee Kiak that data sharing is needed to enhance patient care, and on the need to expand the National Electronic Health Records (NEHR). And with Ms Mariam Jaafar, on building our capabilities to harness the power of digital tools. The NEHR was designed to facilitate data sharing for care coordination and give healthcare providers greater visibility of the patient’s medical history. This will enable practitioners to make better care decisions for their patients.

7. We have integrated the HealthHub application with the NEHR. In addition to viewing health information such as drug allergies and medications, patients and their authorised caregivers can also manage their medical appointments via the HealthHub app. With Healthy365, patients can check their health points, track their physical activities and diet, as well as access community activities. We intend to progressively make available more health information from the NEHR on the HealthHub app. 

8. To support these initiatives and many others, we will require our licensed healthcare providers and allow selected entities to contribute data to the NEHR. GPs participating in Healthier SG will be required to contribute to the NEHR within one year from the launch. We are also exploring how to better facilitate the sharing of health and administrative data between these partners. 

9. The sharing of data also enables public agencies, such as the Health Promotion Board and Agency for Integrated Care, to formulate national programmes, initiate new preventive healthcare programmes or reach out to residents who may be socially isolated and require support.

10. For example, through its Preventive Health Visits with seniors, AIC’s Silver Generation Office (SGO) shares relevant information it gathers with Active Ageing Centres and the Regional Health Systems so that they can follow up with relevant programmes.

11. To achieve all these, we will be introducing new legislation, the Health Information Bill. This was announced by Minister Ong Ye Kung during the COS debate last year. 

12. There are three things the legislation will seek to achieve: 1. to enable the collection of patients’ selected health data from healthcare providers, 2. to allow healthcare providers to share health and administrative data with one another for specific purposes, and 3. to govern the collection, use and disclosure of such data by setting out robust cyber and data security requirements.

13. Given the sensitive nature of health information, and the consequences of misuse, stringent requirements must be placed on the collection, use, and sharing of health information. There are measures already in place under the Personal Data Protection Act and the Cybersecurity Act, and these requirements apply to our healthcare providers today.

14. However, we will do more. We are engaging the Personal Data Protection Commission (PDPC) and the Cyber Security Agency of Singapore (CSA) to identify areas where requirements need to be strengthened, and where safeguards need to be fortified specifically for health information. 

15. Health information is personal, and it is something that Singaporeans expect to be carefully and sensitively handled. Thus, beyond engaging the PDPC and CSA, we have been extensively consulting stakeholders on issues surrounding data privacy and sharing. These include our licensees, healthcare professionals, IT vendors, members of the public, patients and caregivers.

16. The views gathered are helping us shape the Bill to address our policy intent, the needs of patients, and the administrative and operational costs for providers. The consultations continue and we will address the feedback. 

17. We subsequently intend to table the Bill in this House in the later part of the year. 

Cuts

18. If I may, Sir, turn to addressing some of the cuts that members have filed. Mr Alex Yam asked if the gestation limit for abortion could be lowered. 

19. Many countries have similar rules as us and allow for abortions for medical and socio-economic reasons after 20 weeks. Our current rules are not exceptional. 

20. At 23 weeks gestation, there are high risks that these extremely pre-term babies, if they survive, lead a very poor quality of life. Although it is improving, the chance of survival remains low.

21. We will continue to work with the professional community to monitor the neonatal survival and morbidity data, and continue to evaluate the appropriate gestational threshold.

22. In response to Ms Cheng Li Hui, the upper age limit of donors for elective egg freezing (which will be implemented in June 2023) is presently set at 35 years of age. Nonetheless, we are aware that the success rates of egg freezing remain relatively stable up to 37 years old at the point of donation. We are reviewing the evidence as part of the overall effort in developing the Assisted Reproduction Regulations under the Healthcare Services Act. 

23. We agree with Dr Tan that we need to sustain our efforts on the affordability of cancer treatment while keeping MediShield Life premiums affordable. Although cancer patients account for about 2% of all patients, cancer drugs make up 35% of public sector drug spending. Over the 5-year period from 2017 to 2021, this spending increased by over 90%, while overall national age-adjusted cancer mortality improved by 2.1%. 

24. The Cancer Drug List (CDL) has allowed MOH to negotiate for lower drug prices, thus making cancer treatments more cost effective and lowering financial burden on patients and families. Since its announcement in 2021, the CDL has helped MOH secure an average price reduction of 30% on the listed drugs. Expensive and novel treatments may not equate to better outcomes, and we strongly encourage patients and practitioners to choose the listed drugs where possible. 

25. From 1 September to 31 December 2022, an average of 90% of patients in private medical institutions and about 95% of patients in Public Healthcare Institutions were on CDL treatments.

26. A minority of patients are on non-CDL treatments, and they may need time to adjust to the changes. Multiple support measures are being provided to help them continue with their current treatment course with minimal impact to their out-of-pocket expenses. These include financial support for existing patients in our public institutions, and the preservation of Integrated Shield Plans coverage until 30 September this year. Thereafter, non-CDL treatments may remain covered by private insurance products such as IP riders. If affordability is an issue in private healthcare institutions, patients can opt for subsidised care at the public healthcare institutions where they may apply for additional support such as MediFund.

27. Patients who receive ancillary services such as consultations, scans and blood tests as part of their cancer drug treatment, and those requiring more intensive treatments are worried about future treatment costs. These can be claimed from MediShield Life under a separate cancer drug services limit. I would like to reassure patients that we are reviewing the data and intend to increase the claim limits. We will announce more details soon.

28. I would like to assure Dr Tan Yia Swam that complementary health and wellness service providers are not licensed under the Healthcare Services Act or the Private Hospitals and Medical Clinics Act, as such they are not allowed to provide any licensable healthcare services, or purport to treat, diagnose or manage any medical conditions or diseases. 

29. We do not allow unlicensed providers to advertise services or skills relating to a treatment of a medical condition. These measures will be ported over to the Healthcare Services (Amendment) Bill which will be debated in the House later this month. This allows unlicensed providers to be subject to the same penalties as licensed providers if they contravene the regulations on healthcare advertising under the Healthcare Services Act. We take a serious view of this and will not hesitate to take errant providers to task.

30. Members of the public are encouraged to remain wary of exaggerated claims when consuming healthcare services from unlicensed providers. 

31. I also agree with Dr Tan that the Clinical Claims Resolution Process (CCRP) could be used more widely. It was designed to be voluntary, where parties using the CCRP must mutually agree to participate and abide by the CCRP’s decision via a contract. MOH will continue to work with the relevant organisations to strengthen the CCRP process and its participation by all stakeholders.

32. To Dr Tan’s suggestion of a future collaboration with SMA in enhancing the education of payors, we agree that stronger collaboration between payers and the care team will contribute to a better patient experience, and this can be discussed further with the Multilateral Healthcare Insurance Committee.

33. MOH currently requires licensees using Third Party Administrator (TPA) services to reflect TPA administrative fees in the patient’s bill. However, as there is no direct patient care involved, we do not regulate the TPAs themselves.

34. We understand that there are concerns about the potential impact on healthcare affordability and access when using TPAs, and we remain committed to minimising the risks by working closely with stakeholders such as the College of Family Physicians. 

35. In response to Dr Shahira Abdullah, our two National Specialty Dental Centres (NSCs), namely the National University Centre for Oral Health, Singapore and the National Dental Centre, Singapore were set up to provide subsidised dental services for patients requiring more complex or specialist dental treatment. Although the NSCs also receive subsidised patient referrals directly from other government hospitals, these numbers are very small. There is adequate capacity at the two NSCs to manage referrals for specialist treatment. 

36. On special care and geriatric dentistry, the Bachelor of Dental Surgery programme at the National University of Singapore includes training in geriatric dentistry. Today, the majority of dental needs of geriatric or special needs patients are met by general dentists. 

37. We are reviewing and monitoring dental specialities that are not formally recognised by the Dental Specialist Accreditation Board in Singapore, including the need for clinical practice guidelines for geriatric and special needs dentistry. Beyond these measures, healthcare institutions are provided funding to enable better accessibility and care transition for elderly and special needs patients, and we encourage dentists to tap on institutional scholarships or the Health Manpower Development Plan to pursue further clinical training in these areas.

38. Mr Pritam Singh wishes to understand more about the Vaccine Injury Financial Assistance Programme for COVID-19 Vaccination (VIFAP). As of 31 January 2023, MOH has received 2,405 applications, with 414 pay-outs made. 

39. VIFAP applications are reviewed and assessed by an independent VIFAP clinical panel, which includes senior specialists in the relevant fields of neurology, immunology and allergy, and infectious diseases. 

40. To determine eligibility for VIFAP, the panel reviews the medical details of the application objectively alongside available scientific evidence, to assess if it was likely caused by the COVID-19 vaccine received and its severity. It is not necessary to prove absolute causality for a pay-out to be awarded. This is in line with the standards applied internationally and by the World Health Organization. 

41. Pay-outs for events assessed to be related to the vaccine are based on the panel's assessment of severity, including if activities of daily living are affected. Persons will also continue to receive support through applicable healthcare financing schemes, such as CareShield Life, MediShield Life and subsidies at our public healthcare institutions. 

42. Unsuccessful applicants can file an application for re-assessment if new evidence becomes available. The VIFAP panel will assess the application and consider the new evidence. There have been 24 applications that were successfully re-assessed. 

43. We have informed healthcare professionals to be facilitative and support their patient's applications in a timely manner. That said, I would like to assure the House that patients have three years to apply for the VIFAP.

44. With time, if new evidence emerges showing potential links between vaccination and a severe adverse event, the VIFAP panel may reassess related applications.

Continued Investments in Mental Health and Well-Being

45. Mr Chairman, Sir, if I may now shift our focus to Mental Health. We recognise the multi-faceted nature of mental health issues, and the need for better coordination between the health and social sectors. For this reason, the Interagency Taskforce on Mental Health and Well-being was established in July 2021 to oversee and coordinate mental health efforts across different sectors, focusing on cross-cutting issues that require interagency collaborations. The Taskforce is co-led by MOH and the Ministry of Social and Family Development (MSF), and comprises public sector agencies such as the Ministry of Culture, Community and Youth (MCCY), Ministry of Education (MOE), and Ministry of Manpower (MOM), as well as private and people sector agencies. 

46. Dr Wan Rizal and Mr Xie Yao Quan have asked for an update on the work done and plans under the Taskforce. In the past year, members of the Taskforce played an important role in reviewing the population’s mental health needs, identifying gaps and challenges, and developing plans for improvements. 

47. The Taskforce has preliminarily identified 12 recommendations focused on three areas: (i) improving the accessibility, coordination and quality of mental health services; (ii) strengthening services and support for youth mental well-being; and (iii) improving workplace well-being measures and employment support. 

48. To gather views and feedback on the preliminary recommendations, the Taskforce conducted public consultations between May and August 2022. 

49. Over 950 responses were received, with feedback from groups such as youths, parents, persons with mental health conditions, service providers, employers, and community agencies. In general, respondents agreed with and were supportive of the preliminary recommendations, and most of the feedback were suggestions to refine the implementation details. 

50. Let me now elaborate on some of the plans under the Taskforce. We have recommended to implement a tiered care model for mental healthcare delivery. This is a framework that matches the level of care to the severity of the mental health need. The model is based on the idea that different individuals have different levels of mental health needs at different times, and interventions can be tailored to meet each person’s specific needs. The tiers differ in their levels of care intensity. For instance, the first tier typically involves self-help resources, peer support networks, and hotlines offering basic emotional support for individuals. Individuals with more severe mental health symptoms would access higher level of care, such as ones involving psychotherapy or more intensive medical treatment.  

51. What are the benefits of this model, and how is it different from the existing model of service delivery? The tiered care model will map both health and social services involved in mental healthcare delivery into the same framework, using the same language and model. This will facilitate clearer referrals, coordination, and care planning for individuals whose needs are managed by different service providers who may be operating from the social, education and clinical care settings. 

52. Let me give some examples. Last year, KKH embarked on the Temasek Foundation Youth Connect pilot programme to support adolescents facing difficulties with life challenges or mental health issues. The multidisciplinary KKH team came together with counsellors and social workers from schools and social service agencies to develop a set of intervention resources. KKH is also working closely with schools and community providers to facilitate referrals of adolescent patients between social service and healthcare settings. Such collaborations ensure that adolescents’ needs are holistically met through the respective touchpoints. 

53. Another example from social and education stakeholders - Recognising the need for deeper collaboration to meet the mental health and well-being needs of students, AMKFSC Community Services has been working closely with counsellors from Nanyang Polytechnic (NYP) to ensure timely and coordinated mental health support for students facing academic stress, as well as family and peer relationship issues.

54. In another example, the Institute of Mental Health (IMH) has partnered with the Samaritans of Singapore (SOS), and are in the midst of developing a set of guidelines for youth suicide prevention programmes as a resource for service providers.

55. Other benefits of the tiered care model include ensuring better access to care, and encouraging early help-seeking and intervention. The mapping of services and professionals across the tiers in the care model serves as a signpost to the public on the mental health resources and touchpoints available in the community, primary and tertiary care settings. This supports individuals in identifying the services that best meets their needs, and gives them the know-how to access care as early as possible. 

56. Ultimately, the goal of the model is to ensure individuals receive the care most appropriate for their needs in a timely manner. In doing so, it also avoids an over-reliance on centralised specialist care, and optimises the use of resources.

57. For the tiered care model to be implemented effectively, there is a need to ensure adequate competencies and standards among all mental health practitioners. Taskforce representatives from the social, health, and education sectors have come together to develop a national mental health competency training framework. 

58. The framework will establish a structured approach to guide mental health practitioners in developing the knowledge, skills, and competencies necessary to deliver high quality and effective care. The framework will spell out the training needs of the practitioners, and through this, mental health training courses can be aligned towards a common set of training standards as described by the framework. 

59. The framework will apply to practitioners involved in supporting individuals with mental health needs, ranging from lay responders such as peer supporters, to mental health professionals including nurses, social workers, and counsellors, among others. Practitioners can benefit by receiving more consistent and evidence-based instruction and training. This uplifts mental health care capabilities for all providers, which will result in higher quality care, and improved outcomes for clients. 

60. Finally, to complement these efforts, there needs to be a proper understanding and perception of mental health issues, as well as a willingness to seek help when needed. That is why HPB launched the “It’s OKAY to Reach Out” campaign to emphasise that help-seeking is appropriate, and to encourage individuals to seek help for their mental health needs. 

61. Normalising conversations on mental health will take time, and may require different approaches for different citizen segments. At the broad level, we continue to encourage such conversations through the SG Mental Well-being Network. To better support parents, HPB rolled out a public education campaign for parents to better understand their children’s emotional health and identify behaviours of concern, so that parents can be better equipped to support their children, and know where to seek help from, as early as possible. 

62. The Interagency Taskforce fulfils the critical role of bringing together diverse partners and stakeholders to shape mental health policies and strategies, spearhead initiatives, proliferate resources, and create a conducive environment for ground-up initiatives to thrive. The Taskforce will continue to carry out its mandate, and work towards the development of a national strategy for mental health and well-being aimed to be released by the end of the year. We will also continue to explore other options to coordinate national efforts on mental health and well-being, such as considering the value of establishing a central coordination office.

63. With these efforts, we can expect a cohesive system of diverse mental health service providers coordinating care within a common frame of reference and tiered model of care delivery. A more well-defined competency training framework will enhance the quality of care provided to Singaporeans. And I hope we will develop a more inclusive and supportive culture as a nation, with improved awareness and knowledge on mental health and well-being. 

Closing

64. I have outlined MOH’s plans on health information, capacity, and mental health, and we will focus our efforts to provide our healthcare workers with the necessary information, technology, and infrastructure so that they continue to do what they do best - deliver quality care to our patients, and keep our nation healthy.

65. As we emerge from the pandemic, I would like to express my deepest gratitude once again to the healthcare workers who have held the fort and led us through the pandemic. 

66. With that, Sir, I wish you and all Singaporeans good health. Thank you.