パンデミック後の時代における医療保障の支持

Mdm Deputy Speaker : Dr Tan Yia Swam.

4.01 pm

Dr Tan Yia Swam (Nominated Member) : Madam, I beg to move*, "That this House commits to supporting healthcare beyond the COVID-19 pandemic and the whole-of-Government efforts for consistent and sustainable support".

[(proc text) * The Motion also stood in the name of Mr Abdul Samad and Dr Shahira Abdullah. (proc text)]

I declare my interest as a breast surgeon in private practice and my various medical leadership roles as an appointed member of the Singapore Medical Council and the Vice President of the Singapore Medical Association. More importantly, I speak as a daughter to elderly parents and parents-in-law and as a mother to children with medical conditions. Allow me to say a few words in Mandarin.

( In Mandarin ) : [ Please refer to Vernacular Speech .] As the saying goes "Doctors have the heart of a parent". Doctors should be caring and concerned towards their patients, just like parents to their children. Doctors should have this mentality throughout their life. However, patients are not necessarily willing to be treated like a child all their lives. When a child is young, he is ignorant and will obey the instructions of his parents. As he grows up, he will start to rebel against the instructions of his parents.

Thirty years ago, patients would generally listen to the doctor's words. But now, due to advanced technology and easy access to information, more and more patients will question doctors' diagnoses or instructions, or even challenge them.

( In English ): Why does anyone stand up to advocate for certain causes? We want to leave behind a better world than what we were born in.

I advocate for the doctor-patient relationship. As a patient, I want my doctor to look after my best interests and not be worried about being complained or sued unfairly. As a doctor, I want to focus on my patient's medical conditions, her needs and wants.

But life is more complicated than that. So many other factors influence this relationship – different kinds of health-seeking behaviours, different health beliefs, financing models, expectations of outcomes, customer service, social media marketing, business entities seeking to profit in the healthcare sector.

Why am I pushing for a whole-of-Government effort? Healthcare spending is the second highest in the national budget. The emphasis on building more hospitals, polyclinics, Healthier SG and recruiting staff – this cannot go on indefinitely.

While the current hot news is about the Cancer Drug List, I share a list of sobering health statistics: yearly, 26% of deaths are due to cancer; yearly, 20% of deaths are due to pneumonia; every day, 20 people die from heart attacks or strokes; every day, four people undergo leg amputations due to diabetes; Singapore ranks first in the world for diabetes-induced kidney failure; one in 10 people over 60 years old have dementia; one in 10 people have a mental illness; one-third of post-menopausal women have osteoporosis – and if they ever have a hip fracture, one in five will die within the year.

These are some well-known facts in our medical community. Health news magazines frequently report these, but people do not care until it happens to them. Most people have a healthcare encounter only when they are sick and that is too late.

Humans have short memories. That is why the institution has to remember and pass on the teaching.

It feels like the whole country, even the whole world, has moved on after COVID-19. But if you look back at the history of pandemics, the next one will be here – maybe in 10 years, maybe in five. We need to be ready for the next pandemic, for the silver tsunami, for the mental health crisis. Healthcare must be a global, national whole-of-Government effort and not only a Ministry of Health (MOH) effort.

I urge for all of you to adopt a mindset change. I urge every Ministry, every Government official, every public servant – in fact, anyone listening right now – to think in terms of how to better teach our people to look after their health and prevent illness.

Next, support for healthcare workers – what does it mean? It cannot be just a one-time snapshot, a once-off wellness event, a "thank you" campaign, a medal. Regular salary revisions to match inflation and the rising cost of living are essential. But beyond that, support for healthcare workers should be a deeply rooted respect and acknowledgement of the nature of our work.

Many of us see our work as a calling. We commit to looking after patients. It is more than just a job. Much like those in our armed forces who protect our nation, healthcare workers protect the health and well-being of our people. It is not just business transactions selling remedies.

What kind of support do healthcare workers want then? Back to my analogy about the parent-child relationship. I hope the doctor-patient relationship will be mutually loving and respectful. We cannot be just using that one day of Father's or Mother's Day to love our parents, right? It should be an ongoing process. Take into account what we say, listen and involve us in decision-making.

I have explained why we need to support healthcare beyond the pandemic and why we need a whole-of-Government effort. I will now share three broad strategies on how this can be done: one, identify and acknowledge problems; two, education at all levels; and three, cross-collaboration.

Let me tell a funny story. More than a decade ago, as a junior doctor, I remember there was one day when there was a mini commotion in the operating theatre. We were told to recall our chits so that the queue of patients waiting for surgery is cleared up. I demanded to know why and I was told, "Minister is visiting."

I remember being indignant and told the sister-in-charge, "Let him see. Let him see how swamped we are." Of course, I was chased away while the welcoming party walked him around. I was an angry young doctor, but I resolved to learn to be a better advocate for change.

Leaders need to walk the ground and healthcare workers need to learn to speak up better for ourselves. Maybe it is not in our nature to ever admit defeat or ask for help, because it implies weakness and we are determined to stay strong for our patients. Maybe that is why so many of us work until breaking point.

In the past two years, mainstream news and social media gave much attention to bed shortages, long working hours of junior doctors and nurses, bullying and harassment, but I tell you this is nothing new to us.

Corridor beds, lodgers in tentage, conversion of day surgery beds to acute care beds. Another story – once, when I was on call, I was called by my head of department in the middle of the night to urgently identify patients who may be fit for discharged in the morning, because there were 50-over patients waiting for a bed in the Emergency Department (ED).

There were patients fit for discharge but the common social request was to keep the patient until the weekend because the children cannot take leave to bring him home or the need to wait until the helper arrives in Singapore. So, instead of operating, I was there doing bed management and being scolded by family members for being heartless. Then, when I go down to finally attend to the new patients waiting, I get scolded for making them wait very long.

A call starts at 8.00 am and ends at 8.00 am the next day, followed by a full day's work until 6.00 pm the following day. We did six to eight calls a month. Eighty to 100 work hour weeks are not unusual. Doctors, nurses, lab technicians, couriers, healthcare attendants – everyone in the healthcare system is trying our best to meet demands; and sometimes, we cannot deliver.

How many of us have just gone to cry and hide in the toilet for a while? How many have walked away?

We have seen the ups and downs of problems in the past decades. The removal of the guideline of fees, coupled with as-charged plans, leading to escalating costs, due to multiple factors that we are still trying to address now in the Multilateral Healthcare Insurance Committee (MHIC). Changes to residency training, leading to the loss of mentorship, loss of a sense of belonging by the trainees. Shorter training periods with consequences in some specialties.

The privatisation and commercialisation of healthcare is a "necessary evil". Someone has to ensure there is money to run a sustainable business. But when healthcare workers are treated as a commodity by administrators, it is yet another bad influence on the doctor-patient relationship.

Currently, we face new concerns. In the private sector, business costs are increasing due to rental, manpower costs and pressure from business entities; perpetual problems with poor IT systems; a brain drain of experienced nurses, allied health and even doctors.

I have previously spoken on wellness and alternative health services, which are not regulated and which sometimes do more harm than good. Poor use of Google leading to badly written search engine optimisation articles that further increases the disconnect between doctors and patients.

Some family physicians have expressed their perceived difficulties to onboard Healthier SG. Many doctors are concerned over the capitation model, about the impact of the drug whitelist and actual payments to general practitioners (GPs), which may not cover their running costs.

I am not saying it is bad. I am saying doctors are worried about these changes. We have lived through changes with adverse outcomes and we feel really helpless when others dictate how we should practise medicine.

We should learn from the mistakes of the past so that we do not repeat it, but humans have short memories and few people have the time or commitment to dig into history.

Political office bearers come and go, but for most doctors and nurses, we are here for a lifetime. The longest serving Minister for Health is Mr Gan Kim Yong for 10 years and for that, I thank him for the warm and supportive relationship he had with our profession, which Mr Ong Ye Kung has kindly continued – hopefully, for the future, after my speech.

There is no one who is giving the healthcare system his full attention and thought. Doctors do clinical work. Clinician scientists do research. Nurses care for patients' daily needs. Many feel unease and unhappiness at "the system", but there is no one whose job is to really evaluate and improve the system.

Instead, experts from other service industries are imported to provide opinions, get paid consultancy fees – and they leave, while we care so hard and so badly, that it hurts. Even with all my lobbying for the private sector, for reviews into Shield plans, corporate insurance, concierge services, third-party administrators (TPAs), many have heard but might not be listening.

Sadly, even my own doctors do not pay close attention to my advocacy efforts and keep repeating the same old grouses. Some are aware but do not dare to take action. They might be afraid of losing their livelihoods if they do not play by the rules of TPAs who have come between doctors and patients. I have frequently said to my peers that it is common sense that a business should be profitable, but we should never profiteer here from people's suffering.

Healthcare providers are in a no-win situation – getting complaints for long waiting times in Government hospitals, getting accused of overcharging in private.

Patients have very high expectations now. We all want perfection – cheap, fast and good.

I have repeatedly vouched for our restructured hospitals. We have all trained and worked there at some point and they provide good quality care. Sometimes, the communications may not be as clear or personable, simply because it is a very large team-based practice.

I think restructured hospitals are cheap and good, and it is hard to be fast. I ask the public to be understanding. Restructured hospitals are teaching hospitals. We all start somewhere. We all learn through mentorship, by examining small lumps, do our first operations.

Patients are never used as an experiment. There is consultant lead practice and there is a specialist in charge of your medical journey. When you meet a young doctor with a heart, I hope you help the doctor to train and grow.

Some of you will choose to go private if you can afford it because you get personal service, it is generally faster, there is more privacy because it is a much smaller team attending to you. But then I ask for your understanding that every doctor runs a business and there are various models that are used with various business costs. If you find a doctor that you trust and there is clear communication and transparency, I hope you will also give him the support he needs.

I have listed a string of perennial problems, which are complex and systemic, and that I do not expect any one person to solve.

Stay with me as I share my views on education and cross-collaboration.

There are many ways how people learn. I think the commonest method is by frequent exposure and repetition. We eat frequently, right? Three times a day, maybe five times or even more. Singaporeans are passionate about our food. So, if I ask about chicken rice, there will be a very hot-blooded robust debate on which store is the best, comparing roast chicken versus steamed chicken, the ginger, the chilli. Enthusiasts will even know the exact cost breakdown from different stores: how much you charge for extra chilli, extra rice, an upgrade to thigh meat.

But how many of us need major surgery or admission for a major illness?

There are some patients with complex medical issues who have been in and out of hospitals. The healthcare team ends up knowing the patients and families very well over time. Such families will likely also be very aware of how treatment costs are like.

For most people though, the first major illness is the first time ever that we have to seek medical care in the hospital. That is not a good time to find out how expensive healthcare is. One is already worried about their cancer diagnosis and the impact on survival, side effects and potential complications of treatment, responsibilities of work versus family.

Not many people know the cost of treatments in Singapore and many are stunned when they first see the numbers. I know I was when I had to handle the bills for an open heart surgery.

Healthcare financing is very complex and there are actually many safety nets for Singaporeans – public sector versus private sector. Who pays? Taxpayers' monies, insurance pooling. Various combinations of co-payments and tiers of subsidies exist. The problem is most healthy people do not bother to check these until they encounter health issues.

If it is an elective surgery, there is time for financial counselling, pre-authorisation and so on. But in an emergency, the team would deliver the necessary life-threatening treatments first. The patient and their family may be saddled with a big debt. Or the hospital writes off bad debt – not often, I believe, but I know that this happens when we have a foreign worker with no health insurance, just an accident policy and there is no or inadequate cover. Same for locals who are not familiar with the product they bought, whether it is a plan for hospitalisation, critical illness or early cancer plan. Maybe they did not know about exclusion terms or coverage limits.

I picked up this lingo and knowledge only in these recent three years and I hate that I have to know it. It distracts from my real work in caring for patients. But it is necessary. This is what I talked about in March, for insurers to build closer working relationships with healthcare providers so that patients have more assurance of affordability.

People need to learn how to navigate our healthcare system. Some years ago, I started a blog specifically on how to enter the healthcare system, the different paths available and the pros and cons of each. But I could not maintain it. Other commitments took priority. Since then, I have seen several well-written articles. There is no need to keep re-inventing the wheel. Collect these, have a good library of such articles in the central repository and let it be the main reference for all Singaporeans.

People do not actively care until it happens to them. Look at global warming, does the average person worry about global warming, even when faced with evidence of changing microclimates? Does a person worry about fertility and starting a family young, until they are actually trying and come across difficulties? I know most of my patients never worried about breast cancer until they have a symptom or heard that a friend or colleague is recently diagnosed with breast cancer. Then, it triggers fear and worry. People care, only when things affect them.

I want my children to grow up and take responsibility for themselves. Likewise, I believe that everyone of us can take responsibility for our own health, but we need to be empowered on how to do this.

Humans are emotional creatures, but we have the capacity to think. Learning how to regulate emotions and using our brains to think is an invaluable skill that can be taught from childhood. I know some adults who still struggle with this. I cannot underestimate the importance of having a scientific and logical framework in approach to all problems. Fear, anger, worry, joy are all emotional responses that are normal but we must learn to regulate them. Too often, I see my patients so paralysed by anxiety that it interferes with the treatment process.

Some diseases are well-studied and the progression is clearly understood, for example, Hepatitis B leads to liver cancer and Hepatitis B vaccination is effective. Some others are multifactorial, such as most cancers and cardiovascular diseases. So, just because I smoke, it does not mean I will get lung cancer for sure. Likewise, just because I do not smoke, it does not mean that I will never get lung cancer. It is not so simple; there is no magic bullet or "免死金牌".

Obesity, strokes, heart attacks – we call these "lifestyle diseases" because every day, we make small decisions on food and activity level that will build up to or prevent these. Some illnesses are insidious. Do we recognise mental health issues or is it unseen until there is a sentinel event with self-harm?

Preventable trauma is another huge area we can improve on. Awareness on child safety seats, road safety awareness by all users including pedestrians and cyclists, stricter regulations for driving licenses, giving way to emergency vehicles, workplace safety.

There is so much to teach, so much to learn. Education cannot be assigned to just the Ministry of Education (MOE), just as health should not be the domain of the MOH only. I firmly believe that education starting from as young as infancy and carrying on throughout our schooling and working adult years will be the key to good sustainable health. I am glad that Minister Ong stated last month that MOH will partner MOE and the Ministry of Social and Family Development (MSF) to lay a strong foundation of health for our young.

I am alarmed at how often I notice infants being spoon-fed while they are looking at an iPad. Studies have shown that screen time adversely affects brain development. Babies are not able to read faces as well and develop social skills, leading to later problems in executive and higher order functioning, such as the ability to focus, impulse control and emotional regulation. I have seen increasing numbers of young adult patients in their 20s with such problems and I am deeply concerned for the future generations.

Teaching the appropriate use of technology is not just for the young, but for the adults as well. News abound of increasingly elaborate financial scams. In relation to health, there are trends of miracle cures to fight cancer or guarantee weight loss. I have seen patients trying the black garlic diet, aloe vera, alkaline water, negative ion clothing. The list is endless.

I call this pseudoscience because there is a hint of truth in it. There is one experiment to show that the item has one property that has killed a few cancer cells in a petri dish. To me, this is like an observation that, "Hey, the ant can use a leaf to float on water! Therefore, if I use a big leaf, I can use it to sail across the ocean!" I cannot professionally extrapolate such studies to claim that it can cure cancer, which is what some salespeople do and vulnerable patients will try it and sometimes even forgo proven treatments.

During the pandemic, vaccine hesitancy and big pharma conspiracies had direct negative impacts on public health. Internet connectivity has brought people closer together but has also allowed misinformation to flourish. People rely on word-of-mouth recommendations, some use Google reviews and some people do not know that these can be bought or faked, or that there are malicious marketing agencies who deliberately downvote rival companies.

Whose role is it then to teach people how to use Google and Artificial Intelligence (AI) as a tool? It does not feel like it should be the Government's job. It is up to individuals then.

Motivational speaker Jim Rohn said that, "You are the average of the five people you spend the most time with". I use this to take stock of my personal and professional growth periodically. Whenever I feel stagnant, time to review and change a bit, step out of the comfort zone, learn something new. Do not settle in too comfortably and be trapped in an echo chamber.

Lifelong learning is a challenge. How do we then cultivate this mindset in people? This leads me to my next point: cross-collaboration.

I think the COVID-19 Multi-Ministry Task Force was a good platform for leadership to discuss and share timely information on a rapidly evolving situation and align policy direction. Of course, there were problems as it filtered down, because humans being humans, we have a wide range of responses. We had people ranging from lawful good to chaotic evil, to use a Dungeons and Dragons reference. Some followed the exact letter of the law, some followed the spirit of what is intended. Some profiteered off other's desperations and some wilfully, selfishly lived by their own rules and not respect the society they are living in.

The Government of Singapore is complex: organised into 16 Ministries, further divided into departments, divisions and more than 50 Statutory Boards. Do people from different Ministries talk to one another, or is there a very strict protocol of how new ideas may be raised? I ask because previously when working within the confines of a restructured hospital as an employee, I know that there are clear hierarchical processes. And even now, I only have experience talking to certain folks within MOH.

I know there are incredibly smart and devoted people in the Civil Service at all levels of seniority. I know passionate and caring people who are active volunteers in various groups, charities and social enterprises. There is a flourishing ecosystem, but I wonder if perhaps there are too many small-to-medium groups. Can we pool these resources?

Every one of us may be a domain expert, but we do not know what we do not know.

From my participation in MHIC, I had the privilege of networking across different industries, to be acquainted with insurers, financial advisors, actuaries and to discuss healthcare problems from their point of view. It was humbling to realise how little of healthcare financing I knew before, as a clinician. I am yet again bringing up the story of blind men examining the elephant and everyone only touching the part they can touch and arguing about what the elephant looks like. Because it is true – we do not know what we do not know.

I now challenge you to think beyond your usual area and how you can apply your knowledge to better support healthcare, wherever you are in. You have heard the problems I brought up as a doctor, as a healthcare leader. Are you able to help me?

I respectfully share some of my ideas of how to align future policies, with the compass oriented towards healthcare. Formal workgroups seem very structured. I believe that when people with similar goals and ideas discuss casually, the mind-mapping and synergy may create something way better.

Starting from young, the Early Childhood Development Agency and MOE can work closely with MOH to identify key basic health messages for young Singaporeans to learn. And the challenge is not in rote learning but how to get updates on information, because some scientific breakthroughs develop rapidly.

The food pyramid that I learnt in primary school is now outdated, replaced by the healthy plate model and current nutrition and fitness research is leaning towards low-carb diet with resistance training. Who knows what will future research show?

Teach children how to eat right and cultivate the habit of regular exercise to maintain a healthy weight. A lot has been done for mental health education and safe, appropriate use of social media in primary schools. These can also be adopted for adults who did not grow up in the Internet age, so that they are also taught about online etiquette and safety.

Introduce and strengthen the idea of the family doctor and the importance of good primary care. Teach how to navigate the healthcare system, how to get into subsidised care and the role of different types of insurance.

MSF, in your mission to build strong families, could also collaborate with MOE and MOH to shape sex education, guide families on how to hold the tough conversations on morality, religious beliefs and identity. Ask the coaching industry, especially those who specialise in sexuality counselling.

Teach older teenagers and tertiary students about the parenthood journey, its many joys but also hardships so that in time, young couples can make an informed decision about marriage and the pros and cons of having children or not, and when to have children; in their 20s, 30s or 40s?

Once we enter the workforce, we often neglect our own health to pursue a career. In work with long hours or shifts, we develop unhealthy eating habits and irregular sleeping hours, and do not know how to make time to exercise. How many adults notice weight gain and lethargy over five or 10 years of working life? The weight creeps up on you.

Singaporean men have their yearly individual physical proficiency test to clear but women might not have a fitness benchmark. There is a phenomenon of being "skinny fat", where the person has a healthy weight range but has low muscle and bone mass.

I think this is where all the different Ministries can contribute to health, by continuing education on diet and exercise, screening and vaccinations as well as empowering adults.

For the Ministry of Manpower (MOM), look into how to develop healthy routines at the workplace; ask the fitness industry; make affordable healthy foods easily accessible; encourage 10 to 20 minutes of simple office or chair-based exercises; get the bosses to implement such health practices; teach workers screen time limits and the value of mental breaks; look into flexi-hours so that they may prioritise time for themselves, family and medical appointments; consider incentives for good health; work with MOH, Consumer Association of Singapore, Monetary Authority of Singapore to look into alleged complaints of poorly paying corporate insurances and panel limitations imposed by TPAs; help workers to access good quality care.

Ministries such as the Ministry of Culture, Community and Youth, MSF and Ministry of Communications and Information (MCI) might be ideal to be the facilitators of cross-collaborations between the different Ministries. Good ideas, content and projects can be supported by all, rather than every Ministry trying to come up with their own independent project.

I give one example. If you Google "Singapore how to lose weight", see what comes up. Articles on HealthXchange, HealthHub, Health Promotion Board (HPB) get buried amidst advertorials from aesthetics clinics, spas and gyms. One good quality article with a good video might be shared across different Ministries and across all the various social media platforms for wider reach. Repeat the same essential health messages in each of your various networks: eat right, exercise every day, protect your mental health, whichever division you are in, for social support, for youth or for sports.

I thank the Ministry of National Development for the new SkatePark at Lakeside Garden. I hope you continue to integrate sports into the community. Are you aware that Singapore's cityscape is acknowledged as a parkour paradise internationally? But practitioners frequently get chased away by residents who think they are vandalising and that the Police are called to chase them away. I hope for stronger support for the parkour community in Singapore.

The Ministry of Sustainability and the Environment (MSE)'s mission to supply water and safe food may also extend to more affordable fresh produce, as eating whole foods has more health benefits than processed foods. Food safety labels are regulated by the Singapore Food Agency (SFA), under MSE, but nutrition labelling is by HPB, under MOH. I found the 64-page handbook online. I think that people still buy a lot of bubble tea even when graded "C" or "D"!

What is commendable is the rise of urban farming, supported by state agencies such as the Singapore Land Authority, Urban Redevelopment Authority (URA), Agri-Food and Veterinary Authority, SFA and Animal and Veterinary Service and Housing and Development Board (HDB). I hope I did not miss anyone out. This has benefits such as a start towards food security and the health benefits of working with nature, learning to grow and eat our own organic foods will be lasting.

Information technology (IT) continues to be a huge challenge in so many aspects. I said in a previous speech; electronic health records are sometimes nothing better than Microsoft Word documents or PDF documents scanned and stored online. Systems are unwieldy and not instinctive. Vital signs are still keyed in manually. My patient tried to find her operation histology from HealthHub, Healthy 365 and Health Buddy; we could not find it.

I do not know how this can be achieved, but can MCI, GovTech, Integrated Health Information Systems (iHIS) and other IT Statutory Boards please coordinate and get a good national system up? I envision using Singpass and Healthhub, with trigger questions to remind the individual of major health checkpoints: height and weight; health screening; vaccinations; appointments.

Medical tourism is a complex international issue. Will the Ministry of Trade and Industry (MTI) look into how this could contribute to increasing healthcare costs locally but still help Singapore maintain a leading-edge reputation as one of the best places to get good quality care? I am still deeply bothered by the businesses of medical concierges who collect fees from healthcare providers in exchange for bringing in foreigners for healthcare.

Will MTI help MOH to attract Singaporeans to take up essential jobs in healthcare? Look into the development of healthcare workers to recruit, train and retain experienced workers. Human resource management will be essential, not to manage people as commodities, but to truly build a good working relationship for them, so that they feel appreciated and will stay for the long haul.

Complex medical conditions are managed by a multidisciplinary care team. I apply a similar concept to our healthcare system problem. Cross-collaborate; engage with healthcare providers; step outside of your comfort zones across the different Ministries and industries.

Appropriate remuneration for consultancy work may be something to consider and, in time, build up a network. I am very mindful of costs and ideally, if we can call upon volunteers, that would be great, but I also realise that runs the risk of the same few big-hearted people being called upon again and again.

Set up a think tank whom all the Ministries can have access to and call up on for brief consultations on global issues, not ad hoc requests to organisations.

As I end, let me recap. I have explained why healthcare should be a whole-of-Government concern and not just MOH. I have listed chronic problems in healthcare. I emphasised the need for education at multiple levels of engagement and I asked for everyone to cross-collaborate.

My old friend told me, "Don't pretend you want people to be healthy. You doctors want more patients, right? Got business!"

No! Ideally, I want to look after patients who become sick despite their best efforts, not those who have neglected themselves through the lack of knowledge, a lack of resources or lack of self-care. Let us work together to bring down the number of preventable illnesses. That is the real cost savings. It is our individual responsibility to keep as fit and healthy as we can. Be educated and keep up to date.

As a society, to be kind and civic-minded. For those who hoarded medical supplies and tried to profiteer during COVID-19, shame on you! As a doctor, I look after all patients equally. But when intensive care unit beds are full, who deserves it?

The pandemic has made everyone acutely aware of limited resources – masks, antigen rapid test kits, oxygen. That is the real fact of life. There are limited resources and who will be the gatekeeper as to who needs it most?

Healthcare workers need the Government to help shape these policies. We need everyone to prioritise health. Do not force us to have to have to triage and decide who to save. I look forward to a robust debate. [ Applause. ]

[(proc text) Question proposed. (proc text)]

Mdm Deputy Speaker : Dr Shahira Abdullah.

4.31 pm

Dr Shahira Abdullah (Nominated Member) : Before I begin, I would like to declare that I am an orthodontist working at Khoo Teck Puat Hospital.

Mdm Deputy Speaker, we are now in Disease Outbreak Response System Condition Green, the lowest health alert level since the COVID-19 pandemic began. The COVID-19 pandemic has had a profound impact on the world, with healthcare workers playing a vital role in providing critical care to those who need it. As we begin to move beyond the pandemic, it is clear that we need to continue to prioritise and support healthcare.

This Motion acknowledges the importance of healthcare in our society and seeks to ensure that healthcare workers and patients alike receive the support and resources they need to thrive. It recommends a whole-of-Government approach to build a healthier and more resilient society for all.

Beyond the pandemic and towards the future, I would like to touch on three areas that require our continued attention and support: firstly, the manpower shortage of healthcare workers which is related to burnout and the mental well-being of healthcare workers; secondly, the provision of dental care to our migrant workers; and thirdly, supporting the special care and geriatric dentistry scene.

Firstly, the manpower shortage of healthcare workers. Healthcare workers have always faced intense stress, emotional situations and challenging working conditions, with long and unpredictable work hours, risk of injury and exposure to diseases. These factors can contribute to burnout and mental health issues, even before the pandemic.

Although short-term measures such as counselling and mental health programmes are crucial, it is imperative to address the underlying root causes of burnout and mental health issues.

This requires addressing systemic issues such as workload, work-life balance, support, training and the workplace culture. At the core of this is actually manpower shortage, which MOH is already trying to address.

However, even globally, there is competition for a scarce healthcare workforce. Singapore experienced a significant attrition rate for foreign nurses, which increased from 9.5% to 14.5% between 2019 and 2022.

In her Committee of Supply (COS) speech this year, Senior Parliamentary Secretary Ms Rahayu Mahzam mentioned that "The loss of both local and foreign nurses to our competitor countries is a key reason for the stress and high workload for our nurses. We need to replace the manpower lost to other countries, safeguard the welfare of nurses, and meet increasing needs." If we were to go one step further, we need to ensure that our healthcare workers are supported and have the resources they need to provide the best care possible, we need to build "fat", or buffer, into the system.

I have a few suggestions on how we can retain and attract healthcare manpower.

Number one: granting permanent residency to the immediate family members of healthcare workers who are good performers. MOH is supportive of fellow Nominated Member of Parliament (NMP) Dr Tan Yia Swam's suggestion of granting permanent resident status to foreign healthcare workers who are good performers. For these good performers, can we go one step further and automatically grant their immediate family, namely spouse and children, permanent residency as well?

I know of several dental nurses at my workplace who have left due to this reason. After repeated applications, they have in the end given up, choosing instead to uproot their whole family to places such as Canada, New Zealand and Australia. If we grant permanent residency to their family, they will sink their roots in Singapore and the likelihood of losing them will reduce. When we lose good performers, especially senior ones, we do not just lose a worker, we lose their years of experience in our healthcare system.

Number two: ensuring remunerations are competitive locally and internationally. Singapore's public healthcare sector has increased the base salaries of nurses by 5% to 14% by 2022 with retention payments as well. I am aware that MOH monitors our pay competitiveness locally and internationally regularly. Salary may not be the sole determining factor for healthcare workers, but it is still an important consideration for many individuals when choosing their career paths, especially with the tremendous demands of care work. It can also incentivise foreign healthcare workers to continue working in Singapore. Honestly, higher pay packages will always help.

Number three: flexible work arrangements (FWAs). This is something Member Dr Tan Wu Meng has spoken about at length during the COS debates and it is something I cannot overstate the importance of. Healthcare workers are also mothers, fathers, daughters and sons. They may have an elderly parent, or young children at home. Yes, there are already FWAs available for healthcare workers. However, MOH and MOM can work together to come up with more creative permutations of flexible and family‐friendly human resources (HR) work practices suited for healthcare workers in different stages of their lives as well as the unique needs of each healthcare setting. For example, other than staggered shift times, we can consider having flexible shift lengths that split shifts into shorter scheduled times or offering healthcare workers even more paid leave.

Number four: increasing the public's respect for healthcare workers. The public should understand that healthcare workers are not just transactional service providers who need to kowtow to the patient's demands. There should be zero tolerance for abuse or threats. Therefore, I am encouraged by the great strides that we have taken in this area and with the recommendations of the Tripartite Workgroup to Prevent Abuse and Harassment of Healthcare Workers. My fellow NMP Mr Raj Joshua Thomas will speak further on this topic.

Number five: improving the home caregiving landscape by providing broader support and help. To relieve the healthcare sector, caregivers are the foundation of ageing-in-place. However, I have witnessed, from my relatives, how difficult the journey can be.

One low-lying fruit that we could consider is having more caregiver-inclusive HR work practices and granting more eldercare leave, a suggestion that has been raised before. Another is how we can work between Ministries to ensure that families who are already overwhelmed, can navigate the different caregiving options and available subsidies, ensuring that every family about to start this journey is attached to a medical social worker who can do a needs assessment and guide them along the way. This is so that while they look after the needs of the elderly, we should also look at needs assessment for the caregiver itself so that they are not ignored, whether in self-care for their mental well-being or financial security when they themselves grow old.

Secondly, let me turn my attention to the importance and provision of dental care to vulnerable cohorts, particularly the migrant workers, the geriatric and the special needs population. Dental health is a very important health aspect that can be easily overlooked, but modern research has shown links between oral health, systemic health and quality of life. For example, gum disease can increase the risk of diabetes, infective endocarditis and other vascular diseases. Dental pain due to neglect can also be debilitating. We cannot ignore the importance of oral health and its impact on overall health and quality of life.

However, for the migrant workers, even if the dental treatment is deemed necessary, employers will have to bear the cost of dental treatment and dental treatment can be costly.

Currently, the Primary Care Plan ensures accessible and affordable healthcare for eligible migrant workers. May I suggest extending this dental care for migrant workers as well? The care may not need to encompass all dental care, like routine scaling and polishing but really to address the urgent needs, which means dental cases which can be very painful as well as cases with infection and swellings which, if untreated, can actually be life threatening.

I would now like to speak about supporting the geriatric and special needs scene. As we work towards the goal of Healthier SG, we want to ensure oral health is addressed in successful ageing and inclusive healthcare.

Before I start, I would like to talk about the case of my colleague. A woman with a severe intellectual disability presented at the Geriatric and Special Care Dentistry Clinic for treatment. Her challenging behaviour meant that treatment under local anaesthesia – that means when she is awake – was not viable. However, dental treatment under general anaesthesia, which is going to sleep, came with its own set of problems. Risks outweighed the benefit, especially for a single tooth extraction.

Furthermore, hospital policy requires legal representation for consent involving mentally incapacitated adults, and obtaining Court-appointed deputyship could take months and can be costly. To make matters worse, the woman had previously had a traumatic experience in the hospital environment. Her family therefore chose chair-side management after weighing the options.

After attempting to prepare her with three acclimatisation visits, the dentist attempted the extraction with physical restraints. However, due to profound difficulties faced, they just could not do it. The treatment was aborted.

This experience highlighted the struggles faced not only by the patient's family in navigating the system, but also by the dentist and the medical team in treating individuals with complex needs.

I would like to touch on a few areas.

Number one: engaging elderly and special care needs patients and their communities. The lack of oral health knowledge and health goals in these groups underscores the need for advocacy and mindset change. Patients and caregivers often struggle to navigate the various services available and may not know who to approach for financial help and other supportive services.

To address this, there may be a need for closer cross-collaboration between those involved in their care; professionals such as dentists, ward nurses and caregivers need to know basic oral health literacy as well as where to get reliable treatment information. We can consider looking at Nursing Practice Guidelines to ensure that oral care offered to residents is also up-to-date and practical.

Number two: reserving capacity for those with complex needs. Dentists are doing their best to help out, but there is a lack of guidance on standards of care. A clinical practice guideline as well as care pathways are needed to help ensure quality and appropriate care is offered. Complex cases with multiple health and behavioural problems can be seen in the hospital settings and milder cases can be referred to a network of dentists in GP clinics. Complex cases can also be sent to GPs once they are stabilised.

Number three: the lack of access to dental care in elderly and special needs facilities. Some of our communities and organisations serving vulnerable persons have taken the lead to develop their own dental capacities. Out of all nursing homes in Singapore, only some have access to onsite dental services through Unity Denticare buses or mobile teams provided by volunteer groups or institutions. Even fewer homes have a fixed brick-and-mortar clinic run by a volunteer dentist when manpower is available.

An example is the Hospice Care Association where a dental clinic was built in their newest day hospice Oasis@Outram.

On the special needs front, Movement for the Intellectually Disabled of Singapore (MINDS) Developmental and Disabilities Medical Clinic was launched last year and is already working towards providing dental screening and referral services for patients. This has the potential to scale as MINDS open their cross-disciplinary Health Hubs.

However, the lack of coordination between volunteer groups is also a major issue. The Agency for Integrated Care (AIC) coordinates care for the caregivers and seniors but dental services are not included. This results in inefficient allocation of resources, such as manpower, and unmet needs in homes yet to be served.

While we must commend the spirit of volunteerism as well, almost all these services do not have any cost-recovery component, making this model unsustainable. The cost of consumables, materials and manpower needs to be considered if services rendered are intended for the long term.

Therefore, to address these issues, I would like to call for more support from MOH and the MSF in helping different social service organisations develop their personalised dental capacities. Having onsite dental services has various advantages. For someone with an autism spectrum disorder, going to an unfamiliar place for dental care can be a difficult experience. Injections can be scary. Removing a tooth is also scary.

Without onsite services, patients have to be ferried to primary care services, which may sometimes require costly private ambulances. Treatment in clinics outside is limited by cross-institutional restrictions of data sharing, higher costs in specialised services and long waiting times to be treated, plus many more. Therefore, it is beneficial that dental needs of the seniors and special needs persons to be managed "in place". Such clinics will also divert the efforts away from elective treatment such as dental aesthetics, and instead focus on primary needs – increasing their efficiency and cost-savings.

Funding is an important aspect of support as dental services have a high capital cost. Other aspects of support could be flexibility in administration and licensing. For example, we have tried to get the handheld portable dental X-ray as the standard of care for extractions done in home-based settings. However, until now it is still not approved here.

Number four: tapping on dental officers. We, however, still do have a shortage of dentists who volunteer and treat this population. To ingrain the spirit of volunteerism and service, we could have dental officers serve short postings while serving out their bond, to treat these elderly and special needs patients. This could also be extended to other vulnerable groups such as the migrant workers. This would hopefully encourage them to do the same when their bond has completed.

In conclusion, as we commit to supporting healthcare beyond the COVID-19 pandemic and ensuring consistent and sustainable support, we must not forget that dental health is a crucial component of healthcare to achieve an overall well-being and quality of life. The dental healthcare of vulnerable groups such as the migrant workers and the unique needs of the elderly and special needs populations should not be overlooked. Mdm Deputy Speaker, I support the Motion.

Mdm Deputy Speaker : Mr Abdul Samad.

4.45 pm

Mr Abdul Samad (Nominated Member) : Mdm Deputy Speaker, it is difficult to speak after two doctors who are experts in their fields. Nevertheless, I thank fellow NMP Dr Tan Yia Swam for allowing me to take part in the team rising this Motion.

As I represent the voices of the working people, there are two main areas that my speech will focus on, namely, the welfare of healthcare workers and the challenges of enticing young Singaporeans to embark on a career in the healthcare sector – they are the future of our healthcare workforce.

For a start, I would like to share with this House that the Healthcare Services Employees Union (HSEU) and the Singapore Manual and Mercantile Workers' Union (SMMWU), which represent nurses, allied health professionals and support staff, collectively have a membership strength of more than 35,000 members.

We call on those who are not members yet to quickly join the unions. The reason is simple. Unions will not just represent your voice at the workplace, but will also be your voice for a reason.

While the healthcare industry is not within my purview, I have nonetheless reached out to the leaders of both HSEU and SMMWU to get their feedback on their members' concerns challenges and aspirations, both in the near- and the long-term future.

With the recent pandemic, we realise how much our healthcare workers are doing for Singapore behind the scenes. Indeed, the hours are long and from time to time, they are on the receiving end of abuse by families of the patients. The question is, why should it take a pandemic only for us to realise the importance of healthcare workers? Why do we need a pandemic to learn how to appreciate them?

Sadly, this is a reality of life. It is only in periods of crises that we know the importance of these frontline workers.

Just like myself in the power industry, it is only when there are tariff hikes or power failures that we start to realise the importance of a stable and reliable power supply which we have taken for granted in our daily lives. Do not be ashamed to deny this reality in this real world.

Madam, this House debated quite at length last year on the topic of Healthier SG. Many good suggestions and ideas were proposed by all in this Chamber for us to remind ourselves on leading a healthier lifestyle. While the focus was on developing healthy lifestyle, we should not forget the efforts of those who help us to develop healthier lifestyles, namely, our healthcare workers.

Let us be aware of the challenges faced by the healthcare workers, including those by our administrative and support staff, not just doctors and nurses who are facing patients directly. Let us not forget the equally critical roles of those supporting at various other departments like radiology, pathology and more.

This, then, brings me to focus on the welfare of healthcare workers now and preparing the future generation to serve in this industry.

Prior to this Sitting, I reached out to not just the two unions, but also current friends in my network, as well as fellow Singaporeans, who observed first-hand the hard work of our healthcare workers. We acknowledge that while the Ministry has done their part to better support this group of workers via the hospitals' management, there are still areas that can be further improved like shift work, wages and more.

I would like to touch on shift rosters and, in fact, note that the Ministry has repeatedly stated that it does not regulate such rosters and leaves the same to the hospitals' management teams. Accordingly, I appeal to the Ministry to clearly have a team to independently observe the shift rosters that the healthcare workers are assigned. Let us not wait until an unforeseen incident happens before we start to investigate.

We need to ensure that shift rosters pay close attention to rest time in between, as we need physically alert workers at all times to attend to patients and support doctors.

I feel strongly for this because my daughter is one of the thousands of healthcare workers. I have witnessed first-hand the long working hours that she has had to go through during her past 10 years at Sengkang Hospital. Sometimes, I feel that it is not about the corporate shift policy, but the line managers who plan the rosters who may be biased toward their preferred choice of workers. She left recently and also shared with me that about half of her colleagues in the same team had also left much earlier. She is now embarking on the new journey at a new workplace.

Ironically, prior to that, she was an intern in that same hospital in 2020 during her final year of studies in Republic Polytechnic. I was shocked then to hear that she received zero allowance during her internship. I did not raise this flag earlier as I was still doing my checks with my close friends within the sector. While doing my checks, I then recall this same issue was raised many years earlier at some dialogue sessions, and incidentally, my daughter also suffered the same fate.

I would like to ask if MOH is aware of such situations where interns are not compensated for their labour. Let us not paint internships like another day at school. It is not and will never be the same between academic and work experiences. I do not think you will cripple the hospitals' or MOH's finances to grant an allowance to these students as they are working in the real world, not in school.

I call on the Ministry or hospitals to review this immediately and not make subject our students to free labour. Let us not make our children, the workforce of the future, a source of free labour for today. We should not be perpetuating such practices.

Madam, as Singapore builds more restructured hospitals across the island, that means there will be more job opportunities. This will mean healthcare workers may be able to relocate to their preferred hospitals near their homes, or get better pay, or even both.

Are we prepared for the pipeline of Singaporeans wanting to work in this healthcare sector, especially the young ones?

While we remain open to foreign healthcare workers to help supplement our resident workforce, what are the steps in place to ensure that there will be sufficient Singaporeans to be the core of our healthcare workers? The above concern also represents a few of the many concerns that were shared with me by my fellow brothers and sisters in the unions.

While much have been said for those at hospitals, let us not forget the healthcare workers at our neighbourhood polyclinics. The stress that they face at work is equivalent to those working in hospitals. Based on my interaction, some have highlighted that they hoped polyclinics operate strictly on appointments as they still see many walk-ins even when appointments are already full. This really stretches them and even the doctors there. Separately, there are those that hope that polyclinic operations can soon be reduced to a five-day work week upon review of operating hours.

On the lighter note, I do understand the ongoing tripartite efforts around the protection and prevention of abuse and harassment of our fellow healthcare workers. More severe action must be taken against any such abuse towards our healthcare workers, regardless of the magnitude. Please allow me to speak in Malay.

( In Malay ) : [ Please refer to Vernacular Speech .] In our journey towards preparing for an ageing population, we ramped up our healthcare plans inclusive of fellow healthcare workers. Equipping the current ones with new knowledge and skillsets is vital in view of job demands and labour shortage. We need trained and caring healthcare workers to look out and take care of our ageing Singaporeans, both in hospitals and community homes. This job requires not just physical strength but also demands mental toughness when faced with difficult patients and challenging caregivers.

As mentioned in my English speech earlier, there were, are and will be challenges for all of us. Please note that there are two unions, HSEU and SMMWU, that are your voices to hear and speak for you about your workplace challenges. Join them if you had not!

Your unions are aware of your workplace challenges and will try their very best to advocate for your interest ranging from workplace matters to the provision of other welfare benefits. Do not be shy to provide feedback because I know that my union brothers and sisters will always to be there for you.

Amongst the challenges are long working hours for those on shift, fatigue from extended hours, demanding patients and caregivers, and a salary that should be reflective of the workload, not just during crisis.

I am appealing to MOH to seriously look into shift working hours at hospitals and not wait for an unwanted incident to take place. This call has been made repeatedly by Members of the House and I hope that it will not be taken lightly.

Another worrying area is students doing internships at hospitals who are not getting any allowances but are doing work similar to the staff, which can be classified as free labour. I used to doubt such practices in the past when I heard about it, but reality hit me when my own daughter experienced it when she was did an internship at Sengkang Hospital in 2020. Hence, I call on the Institutes of Higher Learning (IHLs) and MOH to review this practice and disallow this sort of free labour to be practiced in Singapore.

If the above practice is not stopped, it could hinder young Singaporeans from joining this meaningful sector. We need more young Singaporeans to join this sector as we prepare for an ageing population. New hospitals are being built and they appreciate the efforts of my fellow union brothers and sisters from HSEU and SMMWU who are working with management partners to upskill their members and workers for the advanced mode of today's work and preparing for the future.

Please also ensure that our workers who have gone through such training will have better wages and better work prospects than before.

( In English ): Once again, I call on the relevant parties to remind ourselves about the importance of this group of healthcare workers and doctors, and never be shy to appreciate and say thank you to them whenever you visit hospitals, both restructured and private, polyclinics and even neighbour clinics. On behalf of all my fellow leaders from the Labour Movement, we would like to thank you for your efforts to look out for our families, friends and fellow Singaporeans.

Once again, do not forget to join the union because for the union – members first, workers always. Mdm Deputy Speaker, I support the Motion. [ Applause. ]

Mdm Deputy Speaker : Ms Ng Ling Ling.

4.58 pm

Ms Ng Ling Ling (Ang Mo Kio) : Mdm Deputy Speaker, I stand support of the Motion raised by the three Nominated Members. In fact, I have no doubts that the Government is committed to supporting healthcare beyond the COVID-19 pandemic. Looking at the 2023 national Budget that this House supported recently at the COS Sitting, health, with a projected total expenditure of S$12.59 billion is only second to defence, with a total projected expenditure of S$13.41 billion.

Where I think the Government needs to continue to be vigilant is how this Budget is being spent and, more importantly, if it is translating to better health outcomes for our ageing population. In addition, I cannot agree more with the NMPs that health for Singaporeans must be a whole-of-Government effort. I will push further to say that it must be a whole-of-society effort.

Let me elaborate through three points: one, supporting our family doctors through the Healthier SG implementation; two, looking after our frontline workers, especially those in the emergency wards; and three, empowering Singaporeans with more knowledge and support to manage our own health better.

Firstly, on supporting our family doctors in GP clinics. I am a firm proponent of the Healthier SG initiative, having visited various parts of Netherlands, the United Kingdom and the United States a few years back on their healthcare systems to manage increasing chronic disease burdens in ageing populations of advanced countries like ours.

GPs in Singapore, who are in the heart of the Healthier SG movement have, however, not been the centre of gravity in how our Government ensures delivery of good healthcare until recent years.

I cite an example of a very hardworking GP in my Jalan Kayu constituency. He has a GP clinic situated at the basement of a HDB block, a bomb shelter built by HDB and leased out to this clinic for many years. During the COVID-19 pandemic, as a Public Health Preparedness Clinic, he was given a temporary booth at the vacant void deck as his clinic stepped up to help in the administering of COVID-19 tests and vaccinations. It was proven then that senior residents could access this clinic more readily with the void deck space, instead of the basement bomb shelter space which can only be accessed through a stairway.

The Singapore Civil Defence Force (SCDF) could not approve the clinic to install a wheelchair lifter down the flight of stairs. Extending a lift to this basement clinic will need to wait for HDB's Lift Upgrading Programme, with no definite plan or timeline in sight.

With the GP, I appealed to HDB to provide the vacant void deck space permanently to this GP Clinic. While the in-principal approval came, we were told the process from concept drawing to Temporary Occupation Permit will take another six to 12 months. This GP is struggling with the capital renovation quotes of about $200,000 he has just received from potential contractors and he is thinking of giving up. Even if he manages to raise the amount, we were informed that the approval is further subject to agreement by the URA, Building and Construction Authority and SCDF.

Help doctors to help patients more and to do administration less. This example I cited is just one of several that I have experienced while rallying GP clinics in my constituency to support Healthier SG, so that our residents can start their preventive health journey early with a trusted family doctor as exhorted by the Government. More handshakes across agencies under different Ministries for a less onerous and time-consuming workflow must be made with a whole-of-Government mindset if we want to see GPs embracing Healthier SG to help this multinational strategy succeed.

Secondly, looking after our frontline healthcare workers, especially those in the emergency wards. Last week, some of us were informed of a message that some community groups in a western part of Singapore have received from a good public hospital. It was a cry for help. The message shared that the hospital had been facing a very high emergency load, with 100% occupancy in the past two weeks. ED doctors were operating as fast as they could with admission waiting time increasing and about 100 patients waiting for beds. Their plea is for grassroots volunteers to help spread the message of not going to emergency wards unless necessary and to consult the GP clinics first if their conditions are stable.

I thank the Government for the various interim strategies announced in this House to provide a valve to the high demands of beds faced by our hospitals and the long-term strategies through Healthier SG to build capabilities and capacities among our GP clinics. In the meantime, it will be important to step up bolder HR actions to support the frontline healthcare workers. I repeat my suggestion for consideration of employing above establishment with the appropriate HR mechanism in public hospitals to allow buffer for surges and more importantly, essential rest for the physical and psychosocial wellness of our doctors, nurses and frontline healthcare workers.

Lastly, my point on not only the need for whole-of-Government commitment, but also whole-of-society actions for maintaining health in our ageing population.

I would like to make a specific suggestion to exploit faster the telehealth capabilities of not just video consultations, but end-to-end full-loop remote vital sign monitoring systems for management of common chronic diseases like hypertension, diabetes and hyperlipidemia.

Government funded clinical trials must speed up and extend to private GP space. Chronic diseases are silent diseases, and complications in the form of heart attacks and strokes are too late for Singaporeans to know that their health is not in a good shape.

Many of the remote vital sign monitoring technology has been clinically proven to have better health outcomes for specific segments of chronic disease patients, but I see two constraints slowing its proliferation in Singapore. One, operational trials to smoothen end-to-end data transmission between patients and primary healthcare teams, and care team workflows for responses to anomalies in the vital signs; and two, consent procedures for individuals to decide on the extent of releasing their personal vital signs data to their trusted doctors, public or private, and supporting teams, including community organisations like Active Ageing Centres.

Both constraints require the trust and protocols or even legislation to be established by the Government, with the trust and facilitation from the private and public healthcare providers, including GP clinics as well as the not-for-profit charities providing community healthcare services, to empower more Singaporeans to receive the right knowledge of their health and take charge in managing our own health in an informed way with our care teams.

Mdm Deputy Speaker, in conclusion, I have quoted the phrase "Health is Wealth" several times in my speeches in this House. Lest it becomes a motherhood statement, where we talk about but see people around us constantly losing their health with a heart attack or a sudden stroke, complications for chronic diseases as our population continues to age, let us have all hands on deck, in a clinically informed, administratively efficient and coordinated way, to ensure that this phrase is truth for most Singaporeans in the many years to come. Mdm Deputy Speaker, I support the Motion.

Mdm Deputy Speaker : Mr Gerald Giam.

5.06 pm

Mr Gerald Giam Yean Song (Aljunied) : Mdm Deputy Speaker, the world is facing a severe manpower crunch in health and social care. The chief executive officer of the International Council of Nurses (ICN) said last year that, "The scale of the worldwide nursing shortage is one of the greatest threats to health globally." The ICN estimates that due to existing nursing shortages, the ageing of the nursing workforce and the effect of COVID-19, up to 13 million nurses will be needed to fill the global nurse shortage gap in the future. The Southeast Asia region alone is facing a shortfall of 1.9 million nurses, according to the World Health Organization (WHO).

Singapore needs another 24,000 nurses, allied health professionals and support care staff to operate hospitals, clinics and eldercare centres by 2030. Our rapidly ageing population is causing demand for health and social care to increase dramatically. Yet, Singapore is facing a high attrition rate of nurses. One of the reasons why nurses in Singapore have reported to be resigning is because of their heavy workload and stress, which is caused, in large part, by the manpower shortage.

Urgent measures are needed to address this manpower shortage. There are no quick fix solutions. We need to encourage more Singaporeans to choose health and social care as a career, so as to boost the pipeline of future professionals in this field.

I highlighted in my speech on Singapore's COVID-19 response in March that nurses in Singapore are often still seen as the assistants to doctors instead of being professionals in their own right. We need to boost the image of the profession and enhance societal esteem for nurses and allied healthcare workers. Nurses should be granted more autonomy and entrusted with higher level responsibilities.

Schools should highlight careers in health and social care early to students. Professional associations should come up with materials and videos highlighting the careers in this field and share them with schools to disseminate to their students. I agree with Member Dr Tan Yia Swam's call just now for a repository of articles on navigating the healthcare system – and I hope she starts her blog again so that we can continue to tap on her knowledge. Career guidance should start in Secondary 1. This is so that students' interest in health and social care careers can be sparked early, and they can start working towards choosing suitable subjects as they move up to Secondary 3.

As I mentioned in my speech on the education system in April, schools should move away from sorting students according to their grades and towards allowing students to take subject combinations based on their interests. This is how we can continue to raise up a generation of future healthcare professionals who love what they do and are passionate about their work.

IHLs could develop guidebooks to help local students prepare themselves for their eventual applications to these institutions. These guidebooks could include information on the subjects they need to take in school, the grades they need to obtain and the co-curricular and extracurricular activities they need to get involved in to best prepare themselves to get admitted to the institution and major of their choice. For example, this guide could recommend that students take certain subject combinations, join the science club, find opportunities to conduct scientific research, write and publish research papers, or work as an intern in a health or social care institution during their school holidays.

It should provide guidance on how to search out these opportunities and work with professional health and social care associations to create these opportunities for students. These could all help our students focus early on pursuing their area of interest in health and social care and better prepare them for their eventual careers in this exciting field. It is too late to attempt to put together a portfolio just before applying for university or polytechnic. Yet, this is often what many students do, because they go through secondary school with little idea of what they are interested in and do not participate in activities that prepare them for their future careers.

Students from more well-resourced families, on the other hand, often obtain this guidance from their parents and are provided with opportunities for hands-on experience through their parents' professional connections. In order to level up our society and capture a wider pool of talent in our population, we need to make this information available to every student.

However, changing public perceptions and increasing public awareness about health and social care careers takes time and requires a concerted effort from various stakeholders, including the Government, the media, schools and parents. We must continue to develop targeted initiatives to address the concerns of healthcare workers, such as work-life balance, remuneration and career progression.

Having said all this, it is simply not sustainable to rely on increasing manpower supply alone to meet the health and social care needs of our nation. Considering our own ageing population in Singapore, which will require greater care needs, if we are to staff all our health and social care institutions with the doctors, nurses, allied health professionals and care workers to meet the ideal healthcare worker-to-patient ratios, the health and social care sector will likely take up a disproportionate share of Singapore's manpower and will starve other sectors of the economy of skills and talent.

Technology can play an important role in boosting productivity and augmenting manpower. In my Adjournment Motion in this House in 2013 on easing the cost of healthcare, I said that technology should be used as a force multiplier in the face of limited manpower in our healthcare system. This is even more so now than it was a decade ago.

Healthcare technology, or HealthTech, is a fast-growing and promising field which must be developed further in Singapore. Transformational technologies are being developed now which will revolutionise the way healthcare is delivered in the future. These include AI-driven diagnostics that can detect diseases early and make more accurate diagnoses more quickly than conventional means. For example, researchers at Massachusetts Institute of Technology have developed an AI model called Sybil that can predict a patient's risk of lung cancer within six years using low-dose computed tomography scans.

The emerging field of precision medicine has the potential to transform healthcare and is being used in the treatment of diseases like cancer, cardiovascular diseases and genetic disorders. It can potentially improve patient outcomes by providing more targeted and effective treatments, reducing adverse reactions to medications and optimising disease prevention strategies. I note that there is now a Singapore Precision Medicine initiative aiming to generate precision medicine data of up to one million individuals, integrating genomic, lifestyle, health, social and environmental data. This is a very positive development.

There are also other healthcare technologies that are not as "deep tech" as what I mentioned earlier but are already in the market and can provide a boost to the productivity of healthcare workers, enhance the patient experience and improve health outcomes.

The National Electronic Health Records (NEHR) system is a major, multi-year HealthTech initiative. According to the MOH website, there are 2,231 healthcare institutions participating in the NEHR as of 5 May 2023. This list appears to be growing every day and I note there has been a marked increase in the number of participating healthcare providers since the start of this year.

The Straits Times reported on 2 May that, "The private sector has been slow to participate in the NEHR since it was launched in 2011". According to a Parliamentary Question reply by Minister Ong Ye Kung to Mr Leon Perera in March 2023, only about 30% of licensed private ambulatory care institutions have view-access to the NEHR and less than 4% are contributing data.

A 2020 survey and paper by Clinical Asst Prof See Qing Yong of Changi General Hospital entitled "Attitudes and Perceptions of General Practitioners Towards the NEHR in Singapore" found that solo practising GPs who are more than 40 years old and who had practised for more than 15 years were less likely to view and contribute data onto the NEHR. Doctors who regarded themselves as less computer savvy and those who perceived that an inadequate level of technical or financial support was available were also less likely to use the NEHR.

The Health Information Bill was supposed to be tabled in Parliament in 2018 to make contribution of data to the NEHR mandatory for licensed healthcare groups after a grace period. However, this was deferred in the wake of the cyberattack and data breach of SingHealth's system in July that year, in order for technical end process enhancements to improve the security posture of the NEHR to be implemented first.

Most of these security enhancements were supposed to be completed by last year, according to Senior Minister of State for Health Janil Puthucheary. Can I ask the Senior Minister of State if all the security enhancements to the NEHR have now been implemented?

I understand that MOH aims to table the Health Information Bill in the second half of this year. Is MOH reaching out to doctors to address concerns they might have about the security of the patient data they will be required to contribute to the NEHR? How is MOH assisting the remaining GPs and dentists to get onboard the NEHR?

Former Minister for Health Gan Kim Yong said in 2017 that, "Patients can realise the full potential of the NEHR only if the data is comprehensive." He added that, "For NEHR data to be comprehensive, every provider and healthcare professional needs to contribute relevant data to it."

Given the NEHR's goals and the fact that $660 million has been spent on the system so far, it is imperative that the full rollout is implemented without undue delay while addressing valid concerns from doctors.

We need to tap on the knowledge and experience of GPs who have been practising for many years, especially as we move forward into the Healthier SG initiative, which will see GPs playing a key role in promoting healthy lifestyles and promoting preventive healthcare.

Technology can be used to help GPs focus on what they do best. Many private clinics find it a challenge to manage the dizzying array of IT systems that they need to manage in their clinics, connect to the Community Health Assist Scheme (CHAS), Healthier SG and the NEHR.

I note that there is a technology subsidy scheme available to help GPs to implement clinic management systems that are compatible with Healthier SG. However, implementing these systems still requires a lot of time and effort on the part of GPs and their clinic assistants – time which they simply do not have if they want to focus on direct patient care.

MOH should explore the possibility of offering an IT manager as a service to GPs and dental clinics. This would enable them to benefit from the expertise of IT professionals who can assist them in resolving their healthcare IT-related issues.

By providing a point of contact for IT matters, GPs and their clinic assistants can then concentrate on delivering high quality clinical care to their patients. This solution would not only enhance the efficiency and productivity of GPs but also help them stay current with the latest technological advancements.

Mdm Deputy Speaker, urgent action is needed to tackle the shortage of manpower in health and social care institutions and grow the pipeline of Singaporeans entering this field. I have proposed some ways in my speech on how we can do so and I hope that MOH and MOE will consider them.

To boost productivity and augment manpower in the health and social care sector, we need to double down on the use of technology as a force multiplier and assist providers to implement and use these technologies.

As the world celebrates International Nurses Day this Friday on 12 May, which is the anniversary of Florence Nightingale's birth, I would like to take this opportunity to say a huge thank you to all our nurses in both public and private healthcare institutions in Singapore. We appreciate your selfless service, sacrifice and care for our people. Madam, I support the Motion.

Mdm Deputy Speaker : Mr Leong Mun Wai.

5.20 pm

Mr Leong Mun Wai (Non-Constituency Member) : Mdm Deputy Speaker, the Progress Singapore Party (PSP) supports the Motion which calls on the House to support healthcare beyond the COVID-19 pandemic and the whole-of-Government effort in consistent and sustainable support of Singapore's healthcare system.

PSP, once again, thanks all healthcare workers for their sacrifices and dedication to serving Singaporeans, especially during the past three years of the pandemic.

We welcome the Government's move to support healthcare through the Healthier SG initiative, which shifts away from a transactional system that reactively cares for those who are already sick towards an outcome-based system aimed at preventing Singaporeans from falling ill.

Hon Members Dr Tan Yia Swam, Dr Shahira Abdullah and Mr Abdul Samad have spoken passionately about ground-up improvements involving the doctors, healthcare workers, patients and society at large.

We support those improvements that they had mentioned but we also think that they can be better realised by first looking at how to reform healthcare financing and bringing healthcare costs under control.

PSP defines sustainability in healthcare as providing the most effective healthcare to all Singaporeans that is affordable and equitable. The focus should not be on protecting the Government's coffers alone but on how to put in place a healthcare system that has the proper incentives to encourage healthy living and, at the same time, covers Singaporeans for all medical circumstances throughout their lives.

Currently, Singaporeans shoulder much of the cost of healthcare through their MediSave savings, their children's MediSave savings, payments from MediShield Life, private insurance and cash outlay.

I acknowledge that over the past decade, the Government has spent more on healthcare, with the introduction of schemes like the Pioneer and Merdeka Generation Packages as well as CHAS. But the actual spending of these packages is small, relative to the needs of some Singaporeans of the Pioneer and Merdeka Generations who do not have much MediSave savings. The actual spending is also small, relative to the total assets of the Pioneer Generation Fund and the Merdeka Generation Fund.

Overall, the Government has not contributed enough to cover healthcare expenditure.

According to the WHO, the share of healthcare expenditure covered by our Government has increased from 33% in 2011 to 43% in 2019, but this is still much lower than the Organisation for Economic Co-operation and Development (OECD) average of 75%.

Singaporeans are experiencing first-world healthcare cost but receiving much less first-world financial support from the Government.

Healthcare spending has more than doubled over the past two decades. It is not sustainable for Singaporeans to continue footing much of their healthcare bills as well as those of their parents and children.

To reduce social inequality, the Government must do more to help Singaporeans cope with rising healthcare costs and strengthen their financial security.

People do not choose to fall ill, whether they are rich or poor. But while a wealthier family can handle a medical catastrophe better, a similar catastrophe can easily wipe out the MediSave and cash savings of a low-income family even after MediShield payouts.

As a result, Madam, I would like to make three recommendations to reduce the financial burden of healthcare for Singaporeans.

One, the Government should pay for MediShield and CareShield Life premiums for all Singapore Citizens.

Retirement adequacy for Singaporeans is a perennial issue. First, housing cost depletes most of their Central Provident Fund (CPF) savings. So, many Singaporeans must continue to work beyond their retirement age to survive without selling their HDB flats.

Insurance premiums take up another chunk of their CPF savings, which could have been used for retirement.

In my Budget 2021 speech, I estimated that the total MediShield and CareShield premiums paid by a family of four up to 65 years old for the parents and 25 years of age for two children will drain at least $110,000 from the parents' CPF savings, not including the loss in compound interest over the years – and that is at current premium levels.

If the premium increases by 10% every five years, which is highly possible, the financial drain could be more than $250,000. In other words, if the family did not need to pay MediShield and CareShield premiums, the parents would have more than $250,000 extra CPF savings for retirement at age 65.

So, I repeat my call from the 2021 Budget Debate and urge the Government to fund MediShield Life and CareShield Life premiums for all Singapore Citizens.

This will increase the Government's expenditure by about $3 billion a year, but this also means the CPF balances of Singaporeans will increase correspondingly by that amount. This will allow the average Singaporean to have their MediSave balances enjoy the compounding effect of the CPF interest for a longer period and be better prepared for a medical event.

Healthier MediSave balances would ultimately strengthen the retirement adequacy of Singaporeans, because less CPF savings will need to be transferred to their MediSave Account.

My second recommendation is for the Government to top up and expand the use of MediSave, increase MediFund support for needy Singaporeans and increase Pioneer and Merdeka Generation Fund support for older Singaporeans.

As of 2020, MediSave Account holders have accumulated $110 billion in balances. However, only $1 billion, or less than 1%, was withdrawn for direct medical expenses that year. This is a tiny percentage and has decreased from 2015, when $905 million, or 1.2%, was withdrawn from a $76 billion balance. This does not make sense, given Singapore's ageing population and increasing demand for healthcare.

Are the rules of withdrawal from the MediSave Account too restrictive? The Government has always restricted withdrawals from the MediSave Account. But, on aggregate, Singaporeans are not even fully utilising the interest they earn each year on their MediSave balances for medical expenses, let alone their principal sums.

The withholding of MediSave monies for use by its owner is even more unjustifiable than the requirement to maintain a Minimum Sum balance for the Retirement Account. I, therefore, repeat my call for the MediSave withdrawal limit to be relaxed.

I also echo my colleague Ms Hazel Poa's suggestion at Budget 2021 for the expansion of MediSave eligibility for outpatient treatment.

For low-income Singaporeans who have below average MediSave balances and, therefore, have trouble paying medical expenses, the Government should provide more help by either topping up their MediSave Account or increasing assistance from the MediFund substantially.

Currently, the MediFund only dishes out about $100 million a year, which only covers a paltry 0.4% of Singaporeans' total healthcare expenditure of about $25 billion a year.

The Pioneer and Medeka Generation Fund should also increase its payout to help older Singaporeans. Since 2018, the Pioneer Generation Fund has a balance of about $7 billion but it only pays out about $400 million, or about 5% to 7% of its total assets each year. The Medeka Generation Fund has a balance of about $6 billion but it only pays out about $200 million, or about 3% to 5% of its total assets each year.

My third recommendation is for the Government to centralise drug procurement across public and private medical institutions.

Currently, drug procurement is centralised for Singapore's three public healthcare clusters but not for private medical institutions. Consequently, private clinics generally pay more for drugs than the public sector, which can negotiate good prices. This drives up costs across the healthcare chain. Insurance must charge higher premiums to cover higher drug prices. This will cause the national healthcare expenditure to rise unsustainably.

The PSP calls on the Government to centralise drug procurement across all public and private medical institutions and distribute drugs to public and private health facilities on a not-for-profit basis. This will reduce our overall cost of drugs by maximising our bargaining power as a small nation with the big pharmaceutical companies.

In the public sector, the Government should ensure that the price of drugs charged to all Singaporean patients, subsidised or non-subsidised, is at or near the cost price of drugs. The Government can provide additional subsidies to lower drug costs for subsidised patients. But drug prices should not be marked up unreasonably for non-subsidised patients to cross-subsidise the subsidised patients. It is reasonable to charge non-subsidised patients higher prices for the better services that they receive, but not the drugs they take because they are the same.

A centralised drug procurement system at the national level would do away with the need for sudden policy changes to control healthcare costs, provide certainty to Singaporeans and strengthen their retirement adequacy.

In conclusion, Mdm Deputy Speaker, I call on the Government to make a greater effort to address the inequalities in Singapore's healthcare system. This can amplify the benefits brought about by initiatives, such as Healthier SG.

For many Singaporeans, financial pressures from the high cost of living are a major cause of their poor health, including the growing problem of mental illnesses. If more is done to improve the affordability and equity of Singapore's healthcare system, we can expect an improvement in the general health of Singaporeans as well. This should be one of the national priorities as we support healthcare beyond the COVID-19 pandemic. Singaporeans deserve better. For country, for people.