Ministry of Health: Committee of Supply 2018 – Cuts by WP MPs and NCMPs

(Delivered in Parliament on 7 March 2018)

Silver Towns – Leon Perera

I declare that I am the CEO of an international research consultancy whose Korean arm has researched this subject. Sir, the Korean Silver Town model is worth a closer look since it is a roughly S$ 10 billion industry and has had a long runway in Korea, evolving over the decades.

In Korea, private sector Silver Towns emerged in the 1990s. Initially they were driven by big conglomerates or chaebol, who developed a site for senior residences but also built in proximate facilities like retail, personal services, sports and recreational facilities and even in some cases child-care and play facilities for the grand-children when children visit their parents.

The Korean Silver Town model emphasizes high-rise, high-density living, integrating smart technology, which is a little different from the assisted living and retirement community models seen elsewhere.

Silver Towns have since evolved. There are different Silver Towns in Korea with different mixes of facilities, catering to different price points.

Silver Towns embody a balance point between, on the one hand, personal independence and freedom for seniors and on the other hand, the presence of medical staff, facilities and a more structured daily routine administered by professionals for those seniors who need it, such as those having dementia.

I do not suggest Silver Towns as a substitute to seniors staying with their children. However for some seniors, this is not possible, while for others this is not desirable. So Silver Towns could be part of the eco-system catering to the needs of our seniors, offering one option for living arrangements.

Lest I be misunderstood, I do not advocate that Silver Towns be run by the government, as some are in Korea, or come with 100% subsidies.

The roadmap to this could be, after the concept has been studied, to issue a tender to invite master developers to build and operate a Silver Town. A pilot project could be used to test demand. Means-tested subsidies can perhaps be applied in some cases.

Government could also nudge Silver Towns to become test-beds for the trial of new, disruptive concepts catering to the senior community and make it convenient for NGOs to target and trial programs aimed at seniors.

Sir, Korean Silver Towns are not without their negative points but I hope that the government will study this idea further.


Mental Health Support in the Heartlands – Daniel Goh

Chairman Sir, we have many agencies and programmes promoting mental wellbeing and assisting Singaporeans with mental health issues. The National Council of Social Service publishes the Mental Health Resource Directory on its website. The Directory is sixty pages long and there are 11 helplines listed in it. By 2021, the Agency for Integrated Care will manage 50 community outreach teams to raise awareness of mental health, identify those at risk and conduct preventive care programmes. Also by 2021, the Mental Health GP Partnership Programme run by MOH will partner 180 GP clinics to manage patients with mental health issues.

With these programmes and resources, we have the elements of a mental health support system in place in HDB estates. By themselves, the programmes and resources can be too complex for a person with mental health issues to navigate. The next step thus is to bring the elements together and integrate them to build a system that is easily accessible to people with mental health issues or their family, with a No Wrong Door policy to direct persons to the most appropriate help.

I have two questions in this regard. Just as AIC has been designated as the central agency to coordinate diverse senior care services to better deliver care to our seniors, should there be a central agency to coordinate mental health care services? Secondly, we already have an accessible network deeply embedded in HDB towns that coordinate the delivery of services to residents. This is the network of Social Service Offices under MSF. Would it make sense for MOH to partner MSF to leverage the SSOs to coordinate mental health care services in the heartlands?


National Dementia Plan – Daniel Goh

Dementia is the most prevalent neurodegenerative disease that affects an estimated one in ten people aged over 60. There were over 40,000 seniors suffering from dementia in 2016. This is expected to rise to 92,000 by 2030. Dementia poses significant health and socio-economic burdens to patients and caregivers and to society as a whole.

I would like to propose for the Ministry to seriously consider a National Dementia Plan that systematically addresses the needs of dementia patients, promoting public awareness and improving the quality of health care, social care and long-term care support and services for all affected. Countries like Korea, Japan, and Australia are implementing similar high-level plans, making dementia a public health priority. These plans include accessible early detection services, access to information, pre- and post-diagnosis care and support, as well as supporting people with dementia in aged communities to remain socially engaged and active.

In 2016, the Agency for Integrated Care was discussing plans with stakeholders to develop a national registry of dementia patients so they can be more easily located if they go missing and their caregivers contacted. However, these plans were put on hold last year. Would the Minister give an account of why the plans were put on hold? Were there issues with getting the consent of families? Were there issues with implementation linked to the registry held by the neighbourhood police centre in Yishun as part of the dementia-friendly community initiative launched there in 2016? Will the plans for a national registry be revived?


War on Diabetes – Chen Show Mao

In 2015, the International Diabetes Foundation reported that Singapore has the second highest proportion of diabetics among developed nations.  In 2016, the Minister of Health declared War on Diabetes. In 2017, the Prime Minister spoke of diabetes as one of the three key long term issues  for Singapore.

The importance to Singapore of the War on Diabetes cannot be overstated.  Our children and young people are increasingly overweight. One in three Singaporeans has a lifetime risk of developing diabetes, with serious and costly consequences.  Could the Minister give us a report of progress from the front? What are our new and continuing efforts and plans? Strategies and tactics?

In this connection, Could the Ministry explore avenues for working with the food manufacturing industry and Ministry for Trade and Industry to apply existing incentives and support local food manufacturers to release low-sugar snacks and drinks. The Industry Transformation Map (ITM) for food manufacturing is more advanced than most other ITMs, and seems well placed to develop and promote low-sugar products on an industry basis.


Quality Care & Patient Safety – Sylvia Lim

Over the years I have occasionally encountered residents dissatisfied with the quality of care received at our public hospitals.  Their grievances range from an unexpected death in hospital to a physical accident while conveying a patient, causing patient injury.

In cases of unexpected death, the Coroner and police are likely to be activated, ensuring a strong measure of independence into the inquiry.  However, in non-fatal cases, the hospital is usually the one who conducts an investigation or review into the incident.

As the hospitals are investigating their own handling of patients, a question that arises would be what safeguards there are to ensure that there is independence injected into the review process.  How far is input from patients or next of kin sought in such investigations?  Would the patient or his representative have the opportunity to contradict evidence presented by the staff?   What role does the Ministry itself play in ensuring that hospital investigations are fair and transparent to patients?

In a 2004 article entitled “Quest for quality care and patient safety” (Qual Saf Health Care 2004; 13: 71-75), MK Lim of the NUS Faculty of Medicine noted that Singapore had more than 10 years ago moved to a broader concept of quality assurance in healthcare that included the monitoring of clinical indicators and medical errors.  According to him, what was still lacking then included public involvement and patient empowerment.   Have we made any improvements in these areas?

I am aware that MOH has since moved on and now has a Healthcare Performance Group that oversees Clinical Quality and Care Effectiveness.  Could the Ministry tell us more about the priorities of this Group?

Finally, the UK in 2017 set up its Healthcare Safety Investigation Branch, an independent body to conduct no-fault reviews of incidents to enhance patient safety and knowledge-sharing across healthcare institutions.  How are we doing this here?


Pricing of Vaccines – Leon Perera

Sir, some vaccines, like pneumococcal and HPV, are not subsidised but can be paid for using Medisave.

Minister Gan said, in reply to Mr Low Thia Khiang at last year’s COS, that government Medisave top-ups can be used to pay for vaccines.

However many Singaporeans may not want to use Medisave for vaccines, preferring to keep the Medisave for bigger bills incurred later in life. The HPV vaccine, for instance, can prevent most cervical cancers, saving lives and cost, but only about one quarter of Singapore women are vaccinated.

I have two suggestions:

(a) Can the ECI consider studying and quantifying the marginal benefit in disease incidence and marginal long-term cost saving for the government in healthcare subsidies, Medifund, etc from the increased vaccine take up that a bigger subsidy for the vaccine price would bring

(b) Can MOH study by way of perhaps a trial to what extent lowering vaccine prices through targeted government subsidies for key vaccines would result in higher take-up of the vaccine

Based on these two actions and their results, my suggestion is that MOH can introduce targeted subsidies to greatly reduce the price of vaccines if there is evidence that this would stimulate higher take up and not only reduce disease incidence later in life but reap long-term cost savings for the government.


MOH Personalized (Precision) Medicine and DNA Edit – Low Thia Khiang

Chairman Sir, personalized medicine which involves the customization of medical treatments to specific patient groups based on genetic profiles seems to be a fast-emerging field of clinical research and application in Singapore. But I believe the general public knows very little about this. There is, for example, the National Precision Medicine Initiative, which appears to need supercomputing resources to gather the genomic information of whole Singapore and Southeast Asian populations to determine genetic risk and offer personalized treatment.

Can the Minister share more about the National Precision Medicine Initiative and whether MOH has oversight of the Initiative and its programmes? What is the long-term plan for the development of precision medicine in Singapore? Will a national registry of genetic disorders be developed? If so, how will it be used and how will the data be shared, nationally and internationally? Does precision medicine research here involve DNA editing? If so, what are the bio-ethical rules governing the research?

In March last year, MOH announced that the standards for the provision of clinical genetic testing were being drafted and would be ready as a code of practice by late 2017 before becoming enforceable in late 2018. Is the Ministry still on track with this timeline?

It was reported in the Straits Times in August last year that hundreds of patients have already benefitted from personalized medicine treatments in Tan Tock Seng Hospital, KK Hospital and Singapore General Hospital. I would like to know how will ordinary Singaporeans benefit from precision medicine and how will the Government manage the cost of its widespread usage?