Mr Speaker
It comes as no surprise that big changes are needed in the way we approach healthcare to keep our care systems sustainable. The plans announced are ambitious, and are meant to address the long-term well-being of an ageing Singapore. As always, the actual execution and implementation of these plans and strategies bear scrutiny and discussion, along with the effect that they will have on our doctors, healthcare workers, and most importantly, our residents.
Such a shift in approach to put preventive health and our family doctors front and centre of our efforts to improve our population’s health, and to integrate our care systems in the heart of our communities, requires that a multi-faceted set of issues are tackled. My Workers’ Party colleagues have and will over the course of this debate share our thoughts and positions on important topics relating to financing changes, preventive care, patient responsibility, and how we can better integrate the primary healthcare system with our ILTC and social care systems to reduce the burden on care workers, patients, and families as we set our foundations to navigate the new golden age of a maturing society.
I will speak today on the measurement of success for the new Healthier SG approach, on ensuring that our family doctors are set up for success, and finally, on some care areas that I believe need more attention.
First, an observation: the White Paper most often refers to increases in life expectancy as a measure for good healthcare outcomes. Yet, this approach obscures the quality of those long years of life.
Thus, we must look at other indicators, such as healthy life expectancy, or the proportion of life spent in poor health, that are more telling of the situation. The Government has alluded to this, attributing the rising costs of our healthcare budgets over the years partly to the increased impact of chronic disease on our population. Our population is living longer, but not necessarily more healthily. I hope that these other metrics start to form the backbone of how we measure good care outcomes.
And today, as we debate a motion that will see our health and social care systems shift towards placing family doctors at the heart of our care system, I cannot help but remember Dr Goh, who provided exceptional primary care for me and my family from when I was five. It is because of his gentle humour, patience and smiling countenance that doctors’ visits never felt stressful – whether it was for a flu infection, or a routine follow-up. And his practice nurses too eventually got to know our entire family – including my two ageing grandmothers – well enough to automatically pull out our patient cards without us having to provide our registration details, and to chat with us about the latest family updates. As my father was often away for work, I know that it was a great comfort for Mum to know that she had a trusted team that she could call up and ask quick questions over the phone to when she had any medical or even quasi-medical concerns, especially when they related to her two young children. I also remember him nagging Dad to get the usual tests and health-checks done, despite Dad’s aversion to all things medical.
Of course, I recognise that we lucked out in having Dr Goh and his team there for us, and indeed we hope that more – if not all – of us in Singapore will have the chance to have such excellent care through our various life stages. Indeed, the White Paper notes that just 3 in 5 Singaporeans have a regular family doctor, and that most relationships between doctors and patients are still largely transactional in nature, with most interactions only happening during acute illnesses or episodes. The current system does not allow much space or resources for the care team to be able to support a patient’s health more holistically and to develop and work out a long-term approach to each patient’s care. It is therefore good that we are moving towards institutionalising and formalising that important relationship between family doctors and Singaporeans.
However, as we work on getting Singaporeans more familiar with registering with a family doctor, we must also ensure that this new shift does not end up unfairly burdening family medicine and GP practices and their associated ecosystems, and that care workers do not end up bearing the brunt of well-intentioned but unintended consequences, even as family doctors – and I quote the White Paper – ‘do much more’. It also must be noted that in order to deliver the objectives outlined in the White Paper, the paradigm shift in care would mean that family doctors will inevitably end up spending more time with each patient, and this would mean longer hours, the number of patients being equal.
At the end of the Financial Year 2021, the membership of the College of Family Physicians Singapore registered just over 2,600 doctors providing primary care, of which there are approximately 1,600 doctors holding a graduate diploma of family medicine qualification. MOH previously estimated that in order to implement our plans, 3,500 family physicians are required by 2030 – effectively doubling the number in just seven years. Could the Minister clarify if these targets remain valid? Given the long time needed for doctors to be trained – five years of medical school in Singapore, plus the five years to serve the bond – would the Ministry clarify how it intends for such an increase in numbers to be catered for by 2030? And could we look at lowering the barriers for foreign-trained Singaporean doctors to come home to practice and serve communities back home here in Singapore?
After all, it was not so long ago that our care systems were heavily strained by the Covid-19 pandemic, and many of us would have experienced long queues in clinics and our hospitals, when GP clinics were so overwhelmed that they became unable to answer phone calls from worried patients, and this is despite many PHPCs extending their opening hours to cope with the surge in demand for medical care. Doctors, nurses and practice staff naturally came under extreme stress and pressure, and while grateful, we cannot afford to take this for granted in the future. Indeed, most of our care workers will tell you that they continue to feel the strain today of continuing to work under challenging circumstances and a general tight manpower situation.
While it is true that the pandemic was a ‘black swan’ event, our experiences in the past couple of years in particular have taught us the severe risks and downsides of operating extremely lean and ‘efficient’ infrastructures – ranging from healthcare to housing and ‘just-in-time’ supply chains. It is therefore an opportune time for us to consider how we can best prepare for such instances and spikes in demand, and to ensure that increasing the role of family doctors in a ‘Healthier SG’, does not end up placing too much strain and burden on family doctors, nurses and allied care workers. The danger then is that it not only becomes unattractive for potential new doctors and health workers looking to serve in primary care, but may also end up existing workers resigning. This is particularly important during the transition period while both patients and care workers are still getting to know the new approach, and as we wait for the efforts of our preventive care programmes to bear fruit. Indeed, the Singapore Medical Journal in an article in 2020 stated that – quote – “The nature of the (GP) work can predispose them to developing burnout, which in turn impacts the physician-patient relationship and patient care.” – unquote. In short, we must not forget to care for our care workers, to ensure that they are not burnt out while they care for us.
Additionally, concerns about the amount of administrative or paperwork that doctors need to fill in, both to enrol in the programme, and also for each patient visit, need to be adequately addressed.
Coming back to the capacity of our primary care system. The White Paper mentions the need to increase the number of doctors and nurses in primary and community care from the current one fifth to at least a quarter by 2030. Given that we are now in the final quarter of 2022, this is an ambitious target. While MOH and its various partners will undoubtedly put in much effort to ensure that more will start choosing family medicine as a vocation, efforts are also hampered by what is traditionally seen to be the ‘lesser status’ of family doctors. I recall a former classmate feeling particularly down when the time came to choose specialities, as she had ‘only managed to get on a family physician track’. At the time, we discussed why she felt this way, despite knowing that being a family physician is in itself a speciality, and requires a very specific skillset, and years of training that may not be any less challenging compared with that of a consultant working in a hospital. She mentioned that the initial reaction to hearing that somebody is a family doctor is that they ‘didn’t make the grade to become a specialist’.
These concerns are backed up by a pertinent study done by the Lee Kong Chian School of Medicine under the leadership of Professor Helen Smith, which found that while half of medical students would consider a career in general practice and family medicine (GPFM), the perception was that there were less career advancement options. Perhaps of more concern was the finding that students reported having encountered derogatory comments about the area, including doctors in GPFM having ‘poor clinical competence’.
The sentiment that family doctors may not be as well remunerated compared with consultants – particularly in private practice – is also exacerbated by the high costs of setting up a private practice in the first place, when compared with the career option of a senior consultant working in a hospital. Directly addressing and removing such concerns would be essential in meeting the aims being debated here today, and I hope that these are issues that we quickly overcome, to ensure that our very best and brightest medical systems – and even mid-career doctors – see training to be a family physician as a career choice, or even THE career of choice.
Support for family doctors and their colleagues also needs to go beyond the obvious. Family doctors, and particularly solo practitioners, are also often effectively running a small business. Many of them operate in the heart of our communities, but are also beset by increasing costs such as increasing rent, and higher utilities bills. Solo or smaller practices surely would also end up seeing their financial situation strained in the current environment, and I would like to ask the Minister to clarify if the situation is being monitored, to see if extra support or grants are needed. This is especially important if we are trying to attract more doctors to provide primary care.
Also, would MOH work closely with MND and HDB in particular to ensure that our family doctors are able to easily set up clinics in our heartlands, and that their practices remain available and accessible to our communities?
Next, on to the important role that the primary healthcare system will need to play in our nation’s efforts to improve mental health. While the White Paper mentions mental health protocols will be developed, mental health does not appear to be part of the first 12 care protocols being rolled out to family doctors. A study of Singapore from 2017 found that suffering from mental health conditions was the second biggest cause for ill health that debilitates residents, without necessarily killing them. For our youth, in particular in the 10-19 year old age group, this rises to first place. Not having adequate treatment or support while suffering from mental health conditions has an impact on all aspects of one’s life, ranging from economic output to physical health. So, it is important that our plans to address mental health illnesses are firmly anchored within the primary health care system.
While designing the mental health care protocols for family doctors, I also hope that attention can be paid to the intrinsic complexity of the field, and that a ‘one size fits all approach’ will not work. After all, how a practice nurse may approach a 20 year old patient suffering from schizophrenia would likely need to be different from a 85 year old showing signs of depression. Because mental illness still carries stigma, aside from the different spectrum of mental illness symptoms, adjustments must also be made for different attitudes and cultural nuances that may be applicable to the situation. We must ensure that the doctors and their staff are adequately trained and supported to deal with patients who suffer from ill mental health. The referral system must also not be overly complicated, and doctors, nurses and other allied care workers need to have easily accessible references to know what resources are out there available to their patients.
Finally, while we speak about a paradigm shift towards preventive care and a more holistic approach to health, we can better target healthier lives for different groups – be it differentiated by age group, gender, or socio-economic status – avoiding a blanket approach to preventive health and social care, and ultimately achieving better outcomes. This is especially important in the context of our ageing society where the burden of care is without doubt only going to increase. My colleague Leon Perera – who unfortunately is currently isolating at home after a positive Covid diagnosis – in his Adjournment Motion earlier this year called for differentiated indices for health and care outcomes, and I would like to reiterate that call here.
Indeed, a 2020 European study on active ageing constructed an individual-level index of active ageing from people aged between 50 and 90 years old, and found gender-differentiated outcomes are pervasive. Like many other previous studies, it points out that women may live longer, but are more likely to suffer from chronic and disabling illnesses, and also score higher on levels of pain and depression. The study also pointed out how problematic ‘gender-blind’ active ageing policies are, as they do not adequately address the different challenges men and women face in old age.
As I mentioned during the April Women’s White Paper debate, the gender health gap is also a phenomenon observed in Singapore. While Singaporean females do have longer life expectancies, a sizeable portion of that extra time is spent in ill health. A 2017 MOH report in collaboration with the Institute for Health Metrics and Evaluation found that in 1990, the gap between life expectancy and healthy life expectancy was 2.4 years larger for females compared with males, and this had increased to 2.5 years by 2017. It was also a finding by a 2011 study in Singapore that it appears that we too suffer from the gender health-survival paradox of women having more morbidities despite longer life expectancies.
Thus far, it appears that we can do more detailed studies and data on this phenomenon in Singapore, and we must make sure that this paradox does not grow, especially since we are still trying to tackle the negative economic effects on women brought about by Covid, the gender wage gap, and an increased burden of higher Careshield Life premiums.
I therefore hope that more research and data can be done into the nature of this phenomenon in our local context, so that policies and targeted measures can both be taken and to allow the success of tackling it to be measured.
The other point I brought up during my speech earlier this year on SG Women was that research, healthcare systems, and treatments and diagnoses have historically tended to leave women out. And when it comes to gynaecological issues, it is further confounded by stigma and culturally-ingrained embarrassment. Issues such as prolapse and stress urinary incontinence due to the weakening of pelvic floor muscles – whether brought on by menopause or childbirth – are thought to affect at least 15% of women here in Singapore, yet embarrassment to discuss such matters even to OBGYNs probably means that many women suffer needlessly in silence for what is often a treatable condition.
I therefore hope that these issues can be tackled sensitively and effectively by our primary care providers, and that the necessary training and resources are given to support the providers to address these areas of concern together with their patients.
To sum up, we support Healthier SG, and believe that this approach will benefit Singapore in the long run. However, it is imperative that we quickly address any areas of concern with a positive mindset, and start to evolve a national conversation about health that is multi-sided. It must not be a top-down, patronising approach where ‘experts’ tell us what is good for us and that we must follow their approach. Instead, it should be a partnership between doctors, nurses, allied care workers, and their patients and families. Good holistic care takes time and the right investments, as does our shift in approach. I hope that this is something we will afford both our patients and especially our care workers. After all, we can talk until we are blue in the face about the twin ‘Ps’ of Prevention and the Performance of our care systems, but these will be nowhere without the most important ‘P’s of the system: our Patients, and the incredible People who make the system run.
Thank you.