Speech by Minister of State for Health Dr Lam Pin Min at the MOH Committee of Supply Debate, 12 Mar 2015

SPEECH BY MINISTER OF STATE FOR HEALTH DR LAM PIN MIN AT THE MOH COMMITTEE OF SUPPLY DEBATE, 12 MAR 2015

(A) Enhancing Primary Care

1               Since 2012, we have taken significant steps to make primary care more accessible and affordable to Singaporeans through our network of primary care facilities.

Innovative Care Models

2               Under the Healthcare 2020 Masterplan, MOH’s key thrust for primary care was to better tap on GPs in the private sector to improve the access, quality and affordability of primary care.  Part of the plans was to introduce new innovative care models such as our Family Medicine Clinics (FMCs) and Community Health Centres (CHCs). 

3               Since then, we have developed six FMCs and six CHCs. Patients, especially those requiring care for chronic conditions, now have more options for their medical follow-up. One example is Ang Mo Kio FMC, which has been serving patients in the Ang Mo Kio and Central areas since 2013. Care managers identify suitable patients who can be referred to the FMC, and share with them the services and benefits available there. Because patient volumes at the FMC are lower, waiting times are shorter. Moreover, patients visiting Ang Mo Kio FMC will get to see the same family doctor across visits, and are also assured of the same level of care as experienced at the polyclinic.

4               One patient who has benefited from visiting Ang Mo Kio FMC is Mdm Betty Lee Oi Neay, aged 67 years old, who has both diabetes and hypertension. At the age of 38, Mdm Lee was referred by a heart specialist to Ang Mo Kio polyclinic. In 2014, she moved to the FMC. She is happy to visit the FMC as she only waits 20 to 30 minutes to see the doctor. With her Pioneer CHAS benefits, she does not need to pay much for each visit.

5               The FMCs have also encouraged shared care programmes between hospitals and GPs, and reinforced the role of GPs as ‘first-line’ doctors. For example, the National University Hospital (NUH) has been referring selected patients from its Specialist Outpatient Clinics (SOCs) to Frontier FMC. Linked up through a common Electronic Medical Record system, family physicians from Frontier FMC share the care of these patients with their hospital colleagues, and meet regularly to jointly review their patients’ care plans. Patients have benefited from this collaboration. One example is Mdm Ang Hwea Kee, an 86-year old lady with multiple chronic conditions. Before her first visit at Frontier FMC in July 2013, she had been admitted four times in one year to NUH. The FMC primary care team has worked together with NUH specialists to care for her, including adjusting her medication doses when needed. Since her first visit to the FMC, she has not been re-admitted to NUH nor visited its emergency department.

6               Mr Zainal Sapari and Mr Ang Wei Neng asked about our plans to enhance primary care services and work closely with the GP sector. We will continue to try out new care innovations to benefit patients. The FMC model is relatively new and we will continue to test it out.  By the end of this year, we will open a seventh FMC at the upcoming Ci Yuan Community Club (CC) at Hougang Avenue 9.

7               In addition, we have planned for a new primary care development at Sembawang. The Sembawang Primary Care Centre will be developed by a team from Alexandra Health System (AHS). It will be a test-bed for the introduction of new care models, innovative ideas and care processes.

8               Among the CHCs, one of our CHCs adopts an innovative model of running on wheels and providing mobile services to residents living in Bishan-Toa Payoh, Hougang and Whampoa. With its pit stops at various Community Clubs and HDB car parks, patients are able to access services, such as diabetic foot screening nearer to their homes. Patients who have benefited include Mdm Sarasvathy d/o Rama Panickar, who has diabetes. With the Mobile CHC at Hougang Community Club, she can walk a short distance on her own to the CHC for her screening, and feel more independent.

9               As Minister Gan Kim Yong mentioned, besides building a new polyclinic in Bukit Panjang, we are also redeveloping Yishun and Marine Parade polyclinics. These expansions will allow us to meet expected demand even as the population in the estate grows and ages. Yishun Polyclinic will be redeveloped at a permanent site at the junction of Yishun Central and Yishun Avenue 9 by 2018, and expanded. Marine Parade Polyclinic at Marine Parade Central will be expanded from its current single storey to two storeys by 2016. Construction of Jurong West and Punggol polyclinics will begin later this year.  

10          Whilst polyclinics remain an important part of our primary care system, our private GPs still provide the majority of primary care in Singapore. We have regularly enhanced CHAS since 2012, enabling us to leverage on the capabilities of GPs to expand our primary care network. Most recently in 2014, we opened CHAS to all ages and further raised the monthly household income per person to $1,800. With the Pioneer Generation Package, all Pioneers will benefit from CHAS. This means that there are now 1.2 million Singaporeans eligible for CHAS, more than double from a year ago. Similarly, the number of CHAS GP and dental clinics has also increased, from about 800 to over 1,300 over the last year.

11          I would like to reassure Mr Ang that measures have been put in place to prevent overcharging of CHAS and PG patients. Prices charged by private GPs differ from clinic to clinic and from patient to patient, depending on the patient’s condition, treatment provided, medications prescribed and length of consult. It also depends on the pricing structure of the GPs. But we expect CHAS GPs to price reasonably, bearing in mind CHAS patients are expected to be lower- to middle-income. MOH closely monitors CHAS claims submitted by clinics, and clinics will be called upon to account for any exceptional claims. CHAS GPs should make their charges transparent. We encourage patients to clarify charges and ask for itemized receipts if they are unclear.

12          Together, the polyclinics, FMCs and CHAS clinics provide good quality, subsidised care to Singaporeans – close to their home. Today, over 9 in 10 HDB dwellers live within 15 minutes, by public transport, of a polyclinic or CHAS clinic.

Raising Quality of Doctors

13          To plan for future healthcare needs, quality manpower is also needed. We will do more to retain and train doctors within the primary care sector.

14          We have been training more GPs with post-grad qualifications, such as the Graduate Diploma of Family Medicine and Master of Medicine in Family Medicine. We need to better harness existing talents in the private sector. As part of our Family Physician (FP) development plan, we will offer funding support for selected candidates, to encourage more doctors to undergo post-graduate training in family medicine (FM). This will allow us to raise the standards of family medicine training, and ensure a consistent supply pipeline of capable family doctors.

What Next for Primary Care

15          So what is next for the primary care landscape? We have made progress in strengthening primary care and will continue to plan ahead and do more.  We will continue to foster stronger public-private partnerships and further integrate GPs into the national healthcare system, so that together, polyclinic doctors and private GPs play an important role in providing primary care to meet our population’s changing health needs.

16          Ideas and initiatives will not be developed by MOH alone. Over the next few months, we will consult our stakeholders, including primary care doctors and patients on what they envision as the desired primary care landscape for Singapore. We can then move on to our next phase of primary care development.

(B) Strengthening Residential Intermediate and Long-Term Care (ILTC) services

Expanding Capacity

17          Chairman, I will now touch on how MOH will strengthen residential intermediate and long-term care services. Minister Gan touched on improvements in rehabilitative care. One of the ways we are doing this is by expanding capacity for community hospitals. By 2020, we will more than double our community hospital beds through the building of four new community hospitals in Jurong, Yishun, Sengkang and Outram. Last December, we opened the new Changi General Hospital’s (CGH) and St Andrew’s Community Hospital’s (SACH) Integrated Building (IB). The integrated building not only provides additional capacity but also enables both hospitals to collaborate and develop new ways to treat and rehabilitate patients. The new model of care at the integrated building will focus on optimizing patients’ recovery to prepare them to transit back to the home. Our hospitals are also working with their community partners to better integrate inpatient rehabilitation services with those in the community.

18          MOH is also looking into addressing nursing home availability. We are on track to increase our nursing home capacity by 70%, to 17,000 beds by 2020. We have just opened a new nursing home in Bukit Batok run by Renci, and will open another one in Yishun run by All Saints Home in April. By the end of the year, we hope to open three more nursing homes in Jurong West, Jurong East and Bishan.

Raising Standards of Care

19          As our healthcare sector expands, along with an increase in Singaporeans’ expectations, I agree with Ms Tin Pei Ling that we will need to ensure that the standards of care provision whether in the hospitals or in primary care, or in the ILTC sector, continue to rise. 

20          One area that we have worked on is to establish appropriate standards of care in nursing homes.  In 2013, we announced the development of a set of Enhanced Nursing Home Standards (ENHS) by an industry-led workgroup. The standards were finalized last year. To help nursing homes attain these standards, MOH has worked closely with the Agency for Integrated Care (AIC) to provide support, for example, a guide on the details of the standards.  AIC has also developed new courses in Advanced Care Planning and falls prevention for nursing care staff and supervisors in nursing homes. The standards will take effect this year. Providers will be given a one-year grace period before the standards are enforced from 2016. With these standards in place, patients and their families can be more assured that their well-being will be taken care of.

21          To maintain high standards of care across different settings, MOH has also developed evidence-based guidelines to improve clinical practice. These guidelines aim to support good care outcomes and recommend the use of clinically effective treatments and were developed by professionals.

(C) Affordability of Long Term Care Services

22          In addition to raising standards of care at nursing homes, we have taken steps to ensure affordability of long-term care services for the elderly. Ms Lee Li Lian has asked if ElderShield and IDAPE will be reviewed. MOH is carefully studying options to enhance the current ElderShield product. We are mindful that we will be introducing MediShield Life at the end of 2015, and that it would not be best to introduce a new ElderShield insurance plan at the same time. We have taken other steps to ensure affordability of long-term care services for the elderly. For example, in 2012, we enhanced ILTC subsidies to raise subsidy levels and cover more middle-income households. We implemented the Pioneer Disability Assistance Scheme, or Pioneer DAS last year, where Pioneers with severe disability can receive $1,200 cash payouts a year.

(D) Ensuring Adequate Medical Manpower

23          As SMS Dr Amy Khor mentioned, we are growing our healthcare professional workforce to ensure that we can adequately support expansions in healthcare services.

24          Ms Kuik Shiao-Yin was concerned about the potential impact of these changes in medical indemnity coverage for obstetricians on obstetrics services and has suggested that MOH provide post-retirement protection for these doctors as an assurance for them to continue their practice. There is also concern from the ground on whether this change will affect the supply of obstetricians.

25          The insurer Medical Protection Society (MPS) is continuing to provide post-retirement protection for obstetricians by providing tail cover, which covers practitioners against any claims that may occur after the practitioner is no longer covered or has retired. This tail cover is available in five year blocks for purchase. Also, the new premiums per year after the change in insurance cover will be lower. Currently, there are adequate numbers of obstetricians, including those in training, to ensure availability of obstetric services to the general public. 

26          There will be 60-70 new obstetricians graduating over the next 5 years to ensure a continuing supply of obstetric services. Notably, we have sufficient trained and experienced midwives with the capacity to deliver more babies in our restructured hospitals.

27          MOH is discussing with professional leaders and other stakeholders how best to address this issue. MOH will also consider ways to work with relevant parties to minimise impact on services and expectant mothers.

(E) Conclusion

28          In closing, MOH is committed to strengthening our primary care and residential ILTC services, deepening our infrastructural capacity, while raising our healthcare standards and ensuring affordability of care.