SPEECH BY DR JANIL PUTHUCHEARY, SENIOR MINISTER OF STATE, MINISTRY OF HEALTH, AT THE PARLIAMENTARY MOTION DEBATE ON ADVANCING MENTAL HEALTH, 7 FEBRUARY 2024

        Mr Speaker, I rise in support of the Motion. I want to thank Dr Wan Rizal, Mr Edward Chia, Ms Mariam Jaafar, Dr Tan Wu Meng, and Mr Yip Hon Weng for putting forward this motion on advancing mental health, and highlighting the need for a Whole-of-Singapore effort to implement a national strategy to enhance mental health and well-being. 

2.     I would also like to thank my colleagues who had shared on efforts in the health, social, education, workplace, and community sectors, and many Members of Parliament who have supported the various mental health initiatives and provided suggestions for improvements. I would also like to record my thanks to all members of the Taskforce, Political Office Holders, people whom we consulted, community representatives, civil service officers, as well as professionals who have contributed to not just the development of the strategy, but so much of what we have done since we launched the strategy to implement these programmes into action.

Shifting Mental Health Care Delivery into Community Settings 

3.     What is it that we are trying to achieve? As many colleagues have emphasised, mental health exists on a spectrum, and requires a comprehensive approach involving the entire government and society. Instead of managing mental disorders largely in hospital-based settings, the aim is to bring mental health support closer to individuals’ everyday environment, such as their homes, workplaces, and social circles. By integrating care within the community, mental health support can be seamlessly delivered within natural social settings such as schools and workplaces, while leveraging existing social and support networks, such as families, friends and coworkers. The National Population Health Survey conducted in 2022 reported that our residents were more willing to seek help informally from their social circle than formally from healthcare professionals¹. By shifting the focus of our efforts, the centre of gravity to the community, by broadening the number of professionals and processes involved in mental health, and by engaging larger circles of the community, we are hoping to do a number of things in terms of changing what we do for mental health in Singapore. 

4.     The first is increasing access to our mental health services ecosystem. We want to make it easy for people to find the help they need, and access the touchpoints that will provide them the interventions that they would find useful. The second is to make sure that we make these interventions effective, and certainly for persons with mild mental health conditions, care in the community where they are able to continue interacting with their social circles, friends, family, workplaces, and have a normal routine of life. Interventions in those settings may be more effective than removing the person from the natural rhythm of their life, institutionalising them, and providing a very clinical response. The third reason is that by involving a much wider variety of partners and more members of the community, we hope to be able to drive that shift in attitude that so many Members in this House have spoken about, as being key to changing our approach towards mental health here in Singapore. That is what we are trying to achieve and why we are trying to do this. How we are doing so, I will go on to explain some of the details. 

Tailoring Care Based on the Tiered Care Model 

5.     In particular, the Tiered Care Model, as brought up by SPS Rahayu Mahzam, which has been a central part of the Strategy. I would highlight, that this tiered care model is not something that we need members of the public to internalise or use as a guide to how they seek services. Someone with mental health concerns does not need to look at the Strategy and ask which Tier they belong to. It is an internal way of organising our services, and thinking about how we will invest in the development of our services, to shift the development of our professional capacity and capability, and integrate the various parts of our system with each other. We are serious about re-organising how we deliver our services and how we develop our capacity and capabilities. In explaining the breadth and depth of what we are doing, I will need to explain a bit about how the Tiered Care Model will be developed and implemented. It will guide the delivery of mental health services according to the severity of mental health needs and apply across various settings. It serves as a foundation for strategic enhancements to our mental health ecosystem, and our overall goal is to improve access to care, mitigate unwarranted medicalisation and reduce stigma. 

6.     Not every mental health issue needs to be addressed by a psychiatrist, just as not every medical condition needs to be treated as an in-patient by a specialist. There will be four levels of mental health support, from mental health promotion, self-help and peer support at Tier 1, to the most intensive level of care in hospitals and specialist clinics at Tier 4. 

7.     Based on the severity of their symptoms, individuals can tailor care according to their needs. Individuals with severe symptoms of mental health conditions will benefit from hospital-based psychiatric and medical treatment. Those with mild to moderate symptoms are best supported by mental health practitioners in primary care and community settings. The majority of individuals, who may experience mental distress periodically without a mental illness, could be best supported by peer supporters in schools or workplaces, as well as using self-help resources including those online.  Overall, we aim to ensure that individuals with mental health needs receive the right support at the right time. This reflects a more nuanced and responsive approach to mental health.

8.     SPS Eric Chua shared about the Practice Guide that is being developed by the Interagency Taskforce on Mental Health and Well-Being, together with key stakeholders from the health, social, and education sectors. This will translate the core concepts into practical steps to help practitioners effectively apply this tiered approach, make the framework work for their clients and patients, and enhance the integration and coordination of our mental health support system. We have already put in place implementation teams, working groups and committees to execute our various plans and strategies. The processes in this Practice Guide will be piloted with some of the service providers and fine-tuned before being disseminated to mental health practitioners across our ecosystem by the end of this year. 

Expanding Mental Health Services in Primary and Community Care Settings

9.     General Practitioner (GP) clinics and polyclinics are important touchpoints for all of us, especially for individuals with mental health needs. They are community-based and easily accessible. We know that there is a strong association between physical and mental health conditions. Therefore, primary care doctors are ideally-placed to treat patients’ physical and mental health conditions simultaneously and holistically. 

10.     Today, 19 out of the existing 25 polyclinics provide mental health services. These services at polyclinics are helmed by multi-disciplinary teams with family physicians, psychologists, medical social workers and nurses. In addition, over 450 GPs in GP clinics are trained to support persons with mental health needs under the Mental Health General Practitioner Partnership (MHGPP). 

11.     To ensure that more patients with common mental health conditions, such as anxiety and depression, have access to mental health services in a primary care setting, we aim to make these services available in all polyclinics and 1,350 Healthier SG GP clinics by 2030. 

12.     Expanding mental health support in the community beyond healthcare settings is essential. Today, 73 Community Outreach Teams (CREST) work tirelessly to raise awareness, to detect, and to refer individuals with mental health needs to appropriate services. Eight of these teams cater to youths. By 2030, we will expand the number of outreach teams to 90, with 15 teams catering to youths. 

13.     Community Intervention Teams (COMIT) provide mental health assessments and psychosocial interventions. Today, we have 29 COMIT teams, with four catering to youths. By 2030, we will expand the number of teams to 50, with 15 catering to youths. MOH is working with the Agency for Integrated Care (AIC) to publicise these services so that more people can benefit from access to these community-based mental health services. 

Building Capabilities for Early Identification and Intervention

14.     Other than expanding mental health services in primary and community care settings, we must also continue to ensure the safety and quality of services. I thank Dr Syed Harun, Ms He Ting Ru, Ms Rachel Ong, and Ms Razwana Begum for their suggestion to introduce regulatory frameworks for psychologists and other professionals. I will point out that this space is not entirely a vacuum today. There are indeed some regulatory processes and frameworks in place. Today, services provided by clinical psychologists in healthcare institutions are subjected to the clinical governance framework of these healthcare institutions, and existing healthcare legislations such as the Healthcare Services Act. In non-healthcare settings such as MSF-funded early intervention programmes, operators do indeed employ mental health professionals, including clinical psychologists, to provide therapy services. The funding agreements for these services specify the minimum qualifications and training required, before staff can be deployed to provide such services. There is some regulatory framework in place, but Members have made the point that perhaps it is insufficient for our situation today, and potentially insufficient for the outcome of the shift that our national mental health strategy will engender. Psychology practice is evolving and already encompasses diverse fields with their own unique safety concerns. MOH has been working with agencies, service providers and professional associations to update the risk assessment taking into account developments that occur in the field in the near future, review the findings, and study the possible need to regulate clinical psychologists. I thank Members for their suggestions. There is consensus among suggestions within the House, as to which professions need what type of regulations. We will study the suggestions made and look at these possibilities.

15.     Beyond the regulation of clinical psychologists, building the competencies of other mental health practitioners and the community to effectively support individuals with mental health needs is another critical component of our Strategy. We introduced the National Mental Health Competency Training Framework to enhance the capabilities of practitioners across the various tiers of care. This framework will complement existing professional standards for mental health professionals such as psychologists and counsellors. It provides guidance to service providers in acquiring the necessary competencies which will be aligned with the Tiered Care Model. Importantly, this national mental health competency training framework is designed to be inclusive, encompassing all practitioners and individuals involved in mental health support, from lay responders like peer supporters, to mental health professionals such as psychologists and counsellors. 

16.     As we step up our capability building efforts, a substantial pool of peer supporters and service providers across Tiers 1, 2 and 3 will have the necessary baseline competencies to support individuals with mental health needs over the next two years. We will equip a wide spectrum of practitioners, enhance the overall capability of the community to provide effective support for individuals with mental health needs.

17.     We will also engage peer supporters and frontline personnel that are not within the healthcare and social space. They will be trained to identify mental health needs and provide Psychological First Aid if needed. Just as you don’t need to be a healthcare worker to provide first aid, we want to train people to provide Psychological First Aid even if they are not a care professional. Today, over 48,000 frontline personnel, including school teachers and officers from various agencies such as the Singapore Police Force (SPF), Housing and Development Board (HDB), Central Narcotics Bureau (CNB), Social Service Offices (SSOs), and Family Service Centres (FSCs), as well as 54,000 volunteers, have already been trained to recognise and provide basic emotional support to individuals in need, and to refer these individuals for further support as needed. The eventual goal is to extend this training approach to over 130,000 frontline personnel and volunteers by 2030, to have a broad network of support for individuals with mental health needs. AIC has created e-learning modules aimed at enhancing awareness of the signs and symptoms of mental health conditions, and providing guidance on supporting individuals with mental health needs. These modules are accessible and open to the public. There are courses that you can go for, such as Psychological First Aid. Caregivers of individuals with mental health needs may also find it beneficial to participate in these courses to enhance their ability to care for their loved ones and care recipients.

18.     This issue here is supporting individuals with mild symptoms of mental health conditions, how to identify these individuals, prevent escalation of their symptoms, de-escalate mental health crisis, and formulate a safety plan for individuals with suicide risk. 

19.     Next to this, we have plans around what to do to support individuals with moderate symptoms of mental health conditions. For that, service providers are trained to conduct mental health assessments and provide psychotherapy. We distinguish the 130,000 frontline personnel and volunteers focused on people with mild conditions, and a separate tier of interventions for individuals who can support people with mental health needs that are moderate in nature, to reduce the severity of their symptoms. To raise the capabilities of these practitioners, MOH and the Ministry of Social and Family Development (MSF) are collaborating with National University of Singapore (NUS), Nanyang Technological University (NTU), and Singapore University of Social Sciences (SUSS) to develop an onboarding course for practitioners providing Tier 3 support. These courses will equip participants with skills to provide Cognitive Behavioural Therapy (CBT) for a range of common mental health conditions, including depressive and anxiety disorders, schizophrenia, obsessive compulsive disorders, and insomnia. We aim to upskill 80 practitioners a year through these courses starting from this year. This is part of our commitment to proactively upskill practitioners in the community to effectively support individuals with diverse mental health needs.

20.     Mr Keith Chua, Ms Mariam Jaafar, Mr Yip Hon Weng and Mr Vikram Nair highlighted concerns about persons with suicide risk. The causes of suicide are multi-faceted and require a holistic, multi-agency approach to address them. For example, in schools and Institutes of Higher Learning (IHLs), students at risk of suicide are supported by school counsellors, and referred to Response, Early Intervention and Assessment in Community Mental Health (REACH), CHAT, or emergency services in hospitals. CareLine, a 24/7 social support hotline, provides tele-befriending as well as emergency response services to seniors in distress, and is operated by staff who can speak various dialects. Those in crisis can access crisis helplines such as the Samaritans of Singapore (SOS)’s Hotline and Care Text, and the Institute of Mental Health (IMH)’s Mental Health Helpline. Under the National Mental Health Competency Training Framework, service providers in the community would be equipped with suicide risk assessment and intervention skills, so that individuals with suicide risk can be detected early and be provided with the relevant interventions. We will continue to work on this, find ways to do what we do better, and to make sure that every individual that needs help can find it.

Expanding Hospital-Based Acute Care and Long-Term Care Capacity as a Safety Net

21.     As a safety net to meet the care needs of individuals with severe and chronic mental health conditions, MOH will be expanding our hospital-based and long-term care capacity. This will be supported by plans to expand the pool of psychiatrists and psychologists in Public Healthcare Institutions (PHIs) as shared earlier. The balance of the capacity increase will be different, depending on whether we are talking about inpatient psychiatric beds in places like IMH and the redeveloped Alexandra Hospital, compared to long-term psychiatric care capacity. While we will increase inpatient acute psychiatric capacity, the need for that will not be so significant because of the things we are doing upstream in the population and the community. But we will continue to need some increase in facilities for long-term psychiatric care capacity. 

22.     Today, we have almost 1,000 acute psychiatric beds. By 2030, this will be 1,070. 

23.     Today, we have 3,000 step-down residential care beds, and there will be about 3,500 of such beds by 2030. The balance is on the long-term residential psychiatric care.

24.     Even though we are expanding our capacity to provide mental health support for persons with severe mental health needs, it does not mean that we are adopting a purely medicalised approach towards mental health. There is room for non-medical interventions, such as art-based interventions, to play a bigger part in promoting mental well-being. To cultivate mental wellness, we need to live healthily. That means having friends, adequate sleep, a healthy diet, taking part in sports, arts, and volunteer work. While these are not medical interventions, they make a huge difference to an individual’s life and health. 

Closing

25.     The National Mental Health and Well-Being Strategy puts forth a comprehensive and holistic approach to addressing mental health issues across many different facets of society. It encompasses preventive components as well as curative perspectives. We want to tackle the whole continuum of mental health issues coherently, with emphasis on the community, schools and workplace settings. We want to foster a whole-of-society approach, uniting efforts across different sectors to build a mentally healthy and resilient population. 

26.     After we launched the strategy last year in 2023, we continued to engage with professionals and stakeholders in this space, and sought their feedback on the Strategy and how the implementation was going. All of them had supported the Strategy and its recommendations, but all of them raised concerns over persistent stigma and the need for stronger partnerships between clients and providers, and across different service providers. We must not forget these fundamentals even as we talk about the other things we are doing around the implementation of this Strategy. We will continue to address these issues as we go forward.
   
27.     There are many initiatives rolled out by the various ministries and agencies to support individuals with mental health needs. Ms Carrie Tan asked about the need to transition the current inter-agency taskforce to a permanent national well-being committee. We have a plan for whole-of-government coordination, which is the National Mental Health Office, which we will establish by 2025, with officers from the health, social, and education sectors to oversee the implementation of the Strategy, to ensure cohesive alignment of policies and programmes at the national level, and to track the progress and impact of our Strategy. These teams and officers have already begun work in supporting the work of the inter-Ministry Taskforce, putting the Strategy in place, and implementing our various programmes and recommendations. But the work is not done and will continue. Members have highlighted issues that we have to continue to study, whether it is about the regulation of professionals, issues to do with how insurance is made available, stigma, and access. There is a need for continued work in this space. 

28.     I would like to thank all ministries and agencies who have come together to better support and advance the mental health and well-being of our population. The collective dedication and commitment of government agencies and whole of our society are instrumental in driving positive change and fostering better mental health for all. Thank you very much.

¹ In the NPHS 2022, it was found that 79.7% of the respondents were willing to seek help from informal social networks, as compared to 56.6% of respondents who were willing to seek help from healthcare professionals.