Building a Healthier SG

Minister Ong Ye Kung. Mr Gerald Giam, I will take clarifications at the end of the Debate, please.

Thank you, the speech is slightly long. Mr Deputy Speaker, Sir, I thank the Members for all their questions and my MOH colleagues for answering the bulk of them. In closing, I will address the few remaining issues and then, I will then take a step back and share the broader perspective of the challenge that we are facing concerning healthcare.

Let me start with TCM, as raised by several Members and Leader of the Opposition, Mr Yip Hon Weng, Ms Hany Soh, Ms Joan Pereira. Maybe I will start with – we seem to have this mood here where we talk about who made what speeches in the past. Let me give my version. [Laughter.]

I came into MOH about a year and a half ago, what struck me was the tremendous amount of groundwork that was done by my predecessor in laying a preventive health infrastructure, the IT system, the three clusters and all the medical protocols. So, I walked into a workplan seminar. As the new Health Minister, I had to speak to the senior doctors and management. At the workplan seminar, it was very daunting. I discussed with three very learned persons, our three Director of Medical Services (DMS), Prof Kenneth Mak, Prof Benjamin Ong and Prof Tan Chorh Chuan. I had in-depth discussion with them, discussed what was the next phase of healthcare and I think we zoomed in on preventive care.

The good thing is, so much groundwork has been laid. On 23 May 2021, I think, I made my first speech in MOH. We talked about two topics. One was COVID-19 – Living with COVID-19 and second was preventive care, that was when Healthier SG, was first talked about. But really, thank you to the several Ministers before me and the whole team who laid so much groundwork.

Then then we had COVID-19 closures and all that. We did not have many events until December. I thank Mr Pritam Singh for reminding me. I got invited in December to an event by the TCM community and that is why I spoke to them, with the indication that if we focus on preventive care, I think it is an impetus that we can make a breakthrough and feature TCM in preventive care. And that was how the thinking first started.

And my last two speeches about TCM, I made quite a few TCM speeches, they are all in Chinese. The coverage has been uneven, so it is good that I have this opportunity now to explain it in English. The two speeches I last made was quite recent, Mr Patrick Tay was there, in one of the events in September last month. In summary, this was what I have been telling the TCM community and what we have been doing.

One, MOH has always recognised the tremendous value of TCM and the benefits they have brought to the community. I specifically always mention, during COVID-19 – and the Leader of the Opposition mentioned this as well – I personally wrote to our TCM clinicians to say: "Please advise your patients to take the vaccines." They were a great help and really helped us moved the needle in getting heartlanders to take the vaccine.

But, I also explained, we must recognise that Western medicines and TCM, they evolve very differently throughout history. They are two separate systems, complete systems with their own disciplines and their own know-how. They may intersect at some point, they may overlap, but you cannot make one to be like the other. It is not possible. They are two complete holistic systems.

Take for example, you ask a western doctor, "how do you balance the five elements of a human body to keep him healthy?" Most western doctors would profess they would not know. We have doctors in the House, I do not think you would profess that you know. If you ask a TCM doctor, "This patient need a life-saving, urgent operation, can you replace it with herbal medication?" They would say "No, go for the operation." Most TCM practitioners I know, would say that too. I think they respect each other's space, their strengths and their disciplines.

When it comes to regulation, there is a fundamental difference as well. Western medicine is a lot about research, clinical evidence, efficacy, safety. You get the data, then, the drug, the treatment can be approved. It is tightly regulated and by law.

TCM is passed down from generations, great-great-great-great grandfather took that and passed down to great-great-great grandfather. Culturally, traditionally, they trust that herbal medicine. And you ask for clinical evidence? They do not have. You want to go for MediSave? Today's rules mean it must be a medicine, it must be certified by HSA with clinical data. For TCM, that is hard to come by.

What TCM is very strong in is preventive care. More than 2,000 years ago there was already the saying: 养生三法：“饮食有节、起居有常、不妄作劳.” Very hard to translate, but let me try. Even the literal translation does not capture the full meaning. It means there are three key aspects to health: you eat not just in moderation, but 饮食有节 means you eat what your body requires, you go according to the seasons. 起居有常 means you have a healthy daily routine that follows the rhythm of the day, the month and the year probably, and not to over-exert your body, heart and mind.

So, in the area of preventive health, that is where I think Western medicine and TCM share a common understanding. You would notice in my opening speech, I have a symmetry, where I talk about preventive care and how the other side also has been emphasising on it. Both disciplines believe that early management of risk factors and disease can stave off problems and complications later on in life. Therefore, I believe, when we focus on preventive care under Healthier SG, we hope TCM can play a role.

While we work that out, in the mean time, we encourage TCM practitioners to continue to do what you are good at, advise the patients to take care of their health, pick up good habits, live healthily and take care of their health holistically.

But like I said in my Parliamentary reply, TCM is self-regulated, with varying standards of practice. So, over the last year, MOH and the TCM community have established two workgroups. They work on issues such as enhancing TCM clinical training and improving career development. And once completed, this can be a basis to explore how to involve TCM in support of Healthier SG. But I do not think, as one Member suggested, I do not think we should impose the regulation of Western medicine on TCM. I think self-regulation for something that is traditional and cultural, would be more appropriate. But we need to strengthen that self-regulation.

We have recently also finalised the succession plan of the Chairman of the TCM Board. This is MOH's partner in the TCM community. Mrs Yu-Foo Yee Shoon has been Chairman for I think at least three terms or more, a lot of contributions. The incoming Chairman will be Dr Teo Ho Pin, another familiar colleague of ours. He has taken up the Chairmanship with gusto. I have had several discussions with him. He understands the big shoes he has to fill, MOH's position and thinking, especially in the context of Healthier SG, and I think he understands his task as the TCM Board Chairman. Once we can feature TCM in Healthier SG, then the suggestions that the Leader of the Opposition has put forth, I think will be considered. And there will be a certain natural forward movement in our policy thinking.

I just have one last thing before I move to another topic. Mr Pritam Singh mentioned psyllium and fybogel. I think it is the same thing. It is not that one is Western medicine and one is TCM, one is funded and one is not – I am not wrong. There are doctors in the House, please correct me. I think it is the same thing. Psyllium is the seed for fibre supplements, fybogel is essentially psyllium with a brand, called Fybogel. Both are not medicine, both are dietary supplements, fibre supplements. But like all things sold in the polyclinic, including the gauze used to dress your wounds, they will all be subsidised, including supplements. But there are doctors in the House; so, please correct if I am wrong.

Let me move to the next topic, crowded GPs, raised by several Members. Dr Tan Wu Meng, Mr Yip Hon Weng, Mr Ang Wei Neng, all expressed concerns that if GPs become very popular, residents can get squeezed out by the huge demand. I tried to explain some of this in my opening speech that we will try our best to manage this. We will ask GPs to set a limit on number of residents they can enrol. How many will depend on the clinic and the doctor's own judgement, how many more can he take. So, it will differ from clinic to clinic.

We are also implementing enrolment in phases; we will prompt residents to enrol with their usual GPs, the dropdown list, your most frequented GP will be first; and we will encourage residents to enrol early and not wait.

I take comfort that we are discussing this because we are worried the demand will be overwhelming. It is in a way, a good problem. It is better than if the feedback comes back as, "We think nobody will enrol". That would be a bigger problem.

But if GPs are to over time accept enrolment from the entire population and help keep them healthy, they have got to shift out of some current load. And I am glad that a couple of Members have given a good suggestion. Mr Melvin Yong suggested for employers not to insist on workers producing medical certificates (MCs) whenever they are sick. Many common ailments like cough and cold can be managed with more rest, drinking more water and perhaps some off-the-shelf, over the counter medication, including TCM medication. Ironically, the disease where this is most practised now is COVID-19.

But if we insist we want to see a GP, we queue up and see the family doctor in order to get an MC – today, a lot of people practice that – but actually it is not the best use of the doctor’s precious time and resources.

Many employers already do not insist on MCs for COVID-19. Mr Melvin Yong mentioned that our healthcare clusters today accept up to three days of sick leave without the need to produce an MC; the Civil Service grants officers up to two days for mild conditions like cough and cold. I hope this can become a prevalent practice.

Let me talk about drug prices. Mr Gerald Giam asked a series of questions about our effort to substantively remove difference in drug prices, between GP clinics and polyclinics for residents enroled in Healthier SG. As I said in my opening speech, the basis of subsidy for polyclinics and for CHAS in GP clinics are different. The former, which is polyclinic, takes into account age. But for CHAS in GP clinics, a major factor for consideration is income.

So, we cannot remove the differences up to the last cent and for the higher-income households, the difference may well remain in dollars. But parity of drug prices is an important concern, told to us by many residents when we did our consultation. And we will try our best to make sure there is drug price parity, especially for the lower income.

Let me move on to the next subject which is delivering outcomes and KPIs. A number of Members talked about KPIs and outcomes and there was an exchange between Mr Gerald Giam and Ms Mariam Jaafar yesterday. Of course, we have to measure outcomes and set targets. That is why we listed short-, medium-, long-term KPIs in the White Paper. The work has just begun. Healthier SG is a dynamic multi-year transformation exercise. There will be twists, turns and uncertainties along the way. MOH is having extensive discussions with clinicians and other stakeholders to set out the technical definitions and our approach to data sharing and measuring these outcomes. And from there, we will establish the baselines of various indicators and then, determine what targets we want to achieve and by when.

While it is important to measure outcomes and targets, those who have run organisations before will know that this is not straightforward. I used to be involved in workers' training, so I interacted a lot with HR practitioners. And HR practitioners always lament – and this is not just for Singapore, it is the whole world. They always lament employees are over-managed but under led. The unions always say that.

Because if you are manager and you are in the middle of a big change management exercise, you will likely instinctively say, what are the targets, let us measure the targets, whatever gets measured, gets done. That is what the manager always says. Ms Hazel Poa went further to say, let us measure the targets achieved by the GPs. And if they do not achieve, clawback the service fee. But as Dr Tan Yia Swam cautioned, it is important for GPs and MOH to work together, for GPs to feel that they are integral part of this change. And I agree with Dr Tan.

Ms Mariam Jaafar, my colleague from Sembawang, and an experienced management consultant, immediately raised a red flag. I think she has seen enough organisational changes to notice the danger of blindly chasing KPIs and targets. Because I talked about what the manager would do.

But what will a leader do? A leader that is driving the change will have a different starting point. He or she, the starting point is, bring everyone on board, make sure everyone understands and buys into the mission in objective. Then, we jointly set KPIs and targets and then do our best to achieve them in the right spirit.

If we do not do that, then we are not leading. We are only managing. And if in our zeal to over-manage, we penalise people for not meeting targets in the middle of a big change, that is when people become cynical and they lose heart, and then you get perverse outcomes like what Dr Lim Wee Kiak said.

Imagine if we really say to the doctors, "If you do not meet your KPI, we will claw back your service fee". Then, it is very simple for the doctors. Number one, either I do not join Healthier SG; or two, I join, but I cherry-pick the healthy residents. So, the way we look at KPIs, always, you are able to differentiate the leaders from the managers.

Since we are on the topic of outcomes, I want to respond to Ms Mariam Jaafar. She is not here today, she has to fly off for work. But she had a very thoughtful and insightful explanation of value-based care and I think it is worth responding to her. She cited several good international practices. I want to assure the House that our hospitals have already been implementing value-based healthcare through many such initiatives too. We just did not feature them in the White Paper under Healthier SG.

There are many examples. One, all the community measures taken to help resuscitate out-of-hospital cardiac arrests by making defibrillators available in the community, training members of the public to perform CPR, alerting them through apps, that there is a cardiac arrest nearby. And so far, the survival rate of out-of-hospital cardiac arrest has improved by 10 times – 2% to 22% over the years.

Changi General Hospital has set up a post-acute myocardial infarction clinic to support patients in their post-heart surgery recovery. The idea is to review the patient's condition early within two weeks. This has resulted in a reduction of the 30-day re-admission rate from 14.3% to 9.6%. There are many such examples and I hope Ms Mariam Jaafar and the House will be comforted that our clinicians are always thinking of better ways to deliver better clinical outcomes.

Let me now comment about capitation. A few Members have raised the issue of capitation. I agree with Members on the benefits of capitation funding, but we are doing it step-by-step and carefully. I explained how we are doing it at the GP level during my opening speech by extending them a standard base fee per enrolled resident. So, it is loosely a capitation payment.

At the healthcare cluster level, we have changed the basis of calculating their budgets to be capitation-based. They still get the same budget, except that the basis of calculation has moved away from based on workload to capitation – the population that they are taking care of.

So, they receive fixed capitated budgets for residents of different age bands. For the very young, they have to do a lot more work, at a higher capitation rate. Young adults will have the lowest capitation rates and as you get older, as you need to pay more attention to their healthcare, capitation rate goes up again. So, age bands are a reasonable proxy for both workload as well as health risks.

Ms Sylvia Lim asked whether we can publish the rate. For now, I think it is better we keep this as internal parameters within MOH. In any case, the annual reports and financial statements of the clusters are available, if you get them from ACRA.

Clusters, in turn, will cascade down Healthier SG key performance indicators (KPIs) to all their institutions and partners. But they will not yet capitate the budgets of hospitals, polyclinics or community hospitals.

So, below the clusters, healthcare institutions will still be funded the same way for now. But capitation funding is a direction we want to move towards. It is a big change and we will have to study and plan each move carefully, making sure every institution, every partner is ready before we do so.

When it happens, it must be accompanied by a significant granting of autonomy so that healthcare institutions can make the right-siting decisions properly.

I will give Members an example. Let us take a palliative care hospice, for example. Today, we fund them through workload – same formula – but we can capitate their budget. So, a palliative care provider can receive a standard based fee for each palliative patient they take care of and then they decide which services are in the best interest of each patient, whether they should go to inpatient hospice care, home care or day care. They do not have to worry about separate funding for separate services under separate settings. That is where we have a lot of potential.

Let me now move on to the next important topic, which is manpower.

Several Members – Dr Tan Wu Meng, Dr Tan Yia Swam, Ms Mariam Jaafar, Mr Dennis Tan and Ms He Ting Ru – raised concerns about manpower and I appreciate that. It is a major challenge.

The key challenge is to have sufficient nurses, allied health professionals and support care staff to operate hospitals, clinics and also eldercare centres. These few groups number about 58,000 now and MOH estimates that this will need to grow to 82,000 in 2030 – 58,000 to 82,000 from now to 2030.

We will broaden training for our healthcare workers – nurses, allied health professionals and pharmacists – so that they can take on the crucial roles alongside doctors in preventive care. For example, nurses in the community will be trained in lifestyle coaching to empower residents to make good choices according to their care needs. Undergraduate allied health courses comprise specific modules on population health, health promotion and chronic disease management.

Mr Mark Chay suggested some useful training for doctors on physical fitness. I think we will follow up with discussions with him on how we can improve or broaden the range of courses that doctors can go to for their continuous training.

Our community pharmacists are now able to provide smoking cessation and weight management services and there are plans to train them in influenza vaccination.

But first, there must be enough people to train. There is, again, a certain narrative going around – some Members alluded to this narrative – that hospital staff are leaving because they are overworked, attrition rate is at a record high, people are avoiding the healthcare sector and that we must do campaigns, reduce workload and raise salaries to attract more people. That is the common narrative now going around.

There are some elements of truth in this narrative, such as there is, indeed, a manpower crunch and hospital staff have been working very hard, especially during the pandemic. But the rest is less than fully factual. They propagate some negative energy and may not help us tackle the actual problems.

Take the attractiveness of the healthcare sector. Are young people really avoiding the sector? Ten years ago, ITE, Polytechnics and Universities in Singapore took in about 1,500 nursing students a year. Now, this has gone up to 2,100 and we are trying to increase it further to 2,300 in the next couple of years. Our education institutions receive many more applications than there are places.

At this number, we are attracting 4% of the student cohort into nursing. If we maintain that number while cohort sizes shrink, the percentage will drift up to maybe 5% of each cohort. That means that for every 20 local students you see in a class, one will be trained to become a nurse and they are applying. So, healthcare has a very fair share of the local talent pool, considering there are so many sectors vying for local talent.

On attrition rate – is it really at a record high? If we look at local nurses, the normal annual attrition rate every year is about 6.4%, which is not high by any industry standard. In 2020, when the pandemic struck, it went down to 5.4% because many of our nurses who were planning to retire or resign, in the face of the pandemic, decided to stay and fight. In 2021, there was a slight rebound to 7.4%. In 2022, this year, so far, the numbers have reverted to that of normal years. There was no mass exodus of local nurses. These are the numbers. Nurses have remained dedicated and steadfast and bravely stood their ground in the face of the pandemic.

What has gone up is the attrition of foreign nurses – from about 8.9% in normal years to 14.8% in 2021. This is where there is record high attrition, at least, over past few years. We know the main reason, and Dr Tan Yia Swam talked about it, which is that the pandemic has increased the demand for nurses all over the world and our foreign nurses are being poached by other countries. They go to New Zealand, Australia, the UK, UAE.

So, if we want to tackle the manpower crunch in healthcare, the starting point is to hold on to our foreign nurses in the face of heightened international competition. Only then can we reduce the workload for all nurses, which many Members have called for. But we must be clear where our starting point is.

Remember, healthcare is one sector that is directly affected by our demographic changes. An expanding aged population needs more healthcare and more healthcare manpower. A shrinking young population limits the number of new local talents that we can bring into healthcare. Therefore, if we are honest with ourselves, we know the numbers simply will not add up if we just rely on local nurses or local manpower, no matter how hard we try to expand the local pipeline.

Therefore, if we want to take care of our seniors and the sick, if we want to reduce the workload of healthcare workers or at least make it more manageable, we must expect foreign healthcare workers to play a bigger role in the coming years. This is especially so in areas where there is a more severe manpower crunch, such as aged care or palliative care.

The great majority of our nursing workforce will still be locals but the number and role of foreign nurses will need to grow. MOH is, therefore, securing various pipelines of good foreign healthcare workers from different source countries to bring them here and further train and develop them. Some may leave us after a few years but we will try to keep the majority, especially those who have become an integral part of our care teams.

Dr Tan Yia Swam suggested granting the good performers PR and MOH is supportive of this. ICA always assesses PR applications holistically, including taking into account the economic and social contribution of the applicants. So, when it comes to evaluating applications from foreign healthcare workers, ICA will certainly consider the important contributions of healthcare workers and MOH's support for the applicants.

At this juncture, Mr Deputy Speaker, I would like to say a few words to our healthcare workers through you.

I believe the great majority of Singaporeans respect and appreciate our healthcare workers. We have seen the outpouring of public support in the recent past for the sacrifices made by frontliners as they steadfastly battled the COVID-19 pandemic.

However, many of our healthcare workers have also experienced abuse by patients and family members who lashed out at them because hospitals and clinics are high-stress environments.

I hope that our healthcare workers will look past a small minority that show disrespect and have faith that the great majority salute you, which includes everyone in MOH. I believe I speak for every one, every Member of this House, that we, too, respect them and their work, whether they are men or women, young or old, locals or foreigners. [Applause.]

Abuse against healthcare workers cannot and should not go unaddressed. We hope to raise public awareness on abusive behaviour that should be stopped and equip healthcare workers to better handle such situations.

Mr Deputy Speaker, Sir, ultimately, we need to squarely tackle the challenge before us, which is that our society is ageing fast.

It is a worldwide trend. By 2030, the old will outnumber the young in the world – the first time in recorded human history.

East Asia, in particular, is ageing faster than any other region in the world due to declining fertility and people living longer lives. Within East Asia, the countries ageing the fastest are Japan, South Korea and Singapore. We are called the "advanced agers".

Members have heard this statistic many times. By 2030, one in four Singaporeans or thereabouts will be 65 and above, up from one in six today. But it is not just a statistic. The number translates into real impact on our lives and we have yet to feel the full brunt of it.

For companies, you will face a shortage of workers, requiring you to move into automation, adopt less manpower-intensive business models while using foreign workers judiciously.

For schools, shrinking student intakes, which is why MOE has to merge schools and some of us find our alma maters gone.

Within communities, we have to make sure estates are now barrier-free. At traffic light junctions, the green man will have to appear longer because people take longer to cross the road. If you are a driver, you will have to slow down in the HDB estates and we already have silver zones.

For families, more and more couples will find that they have to take care of two sets of aged parents, in addition to their own children.

In the healthcare sector, we see rising disease burden and escalating demand for hospitals, clinics, doctors, nurses, budget and so on.

Most importantly, the seniors themselves, as they see more of them, they will be asking, "How do I live purposefully and healthily, with dignity, in my old age?"

Mr Henry Kwek, Ms Tin Pei Ling, Miss Cheng Li Hui and Ms Carrie Tan raised these concerns and, importantly, they warned us of the danger of isolation of seniors and the importance of social contacts for seniors.

Ageing is a major topic. Its impact spans across various sectors. Today, let me just address the implications on healthcare.

Our basic premise must be this – ageing may be an inexorable trend but a rapid escalation of disease burden and suffering need not be a given. We can manage this, provided we stay healthy.

Many of us, myself included, are guilty of being caught in the old mould where life stages are determined by age – five years old, go preschool; 12 years old, take PSLE; 20-plus, graduate; by then, roughly, you should find a boyfriend or girlfriend and apply for BTO; late 20s, get married; 50s, beware of onset of chronic illness; 60-plus, retire; beyond 80, you may start to become frail.

The age markers remain relevant and can continue to guide us in understanding life stages, key events and risks throughout our lives. But we need not be strait-jacketed by them, especially when it comes to health and ageing. For example, there is no reason why 50s has to be the onset of chronic illnesses. We can stay healthy and not have chronic illnesses in our 50s.

There is no reason why once you cross 65, you go into the wrong side of the dependency ratio. There is also no reason that why being in our 80s must be associated with frailty. We can delay it as long as you can, well into your 80s or 90s.

Policy planners will continue to monitor the statistics based on age, but as individuals, we can choose to differ from these widely accepted assumptions. And the Government can make policy changes and reform our systems to help individuals achieve that. To do so, we need to recognise now that the healthcare system is not one system, but three interconnected systems, working together to deliver good outcomes.

The first system is the acute care system. This is what typically comes to mind when we think of the healthcare system. It comprises hospitals, specialist clinics, emergency departments – the places that treat us and cure us when we are very sick. We are expanding this system, building more acute and community hospitals in the coming years.

The second system, less known, is the public health system. One important part of the public health system is the control of infectious diseases. And we can see these systems springing to rigorous action during the pandemic. The other important part of the public health system is the one that improves the health of our population. This comprises the policies and processes for preventive care, including the network of family doctors, their long-lasting relationships with residents, the practice of regular health screening, the culture of good lifestyle habits, all of which keep a people healthy. This is the system that we are now building and strengthening through Healthier SG.

We have seen how the two systems complement each other during COVID-19. The public health system strengthened the surveillance of the virus, got people to adopt good hygiene habits, received vaccinations, stayed home if unwell. The acute care system took care of those who got infected and experienced more severe symptoms. But still, the two systems are not enough. In an ageing society like ours, the third system is equally critical and that is the aged care system.

This is the support system for the large segment of people who are advancing in age. And this system is not only about nursing homes. The nursing homes, they serve an important purpose, which is to care for seniors who are very frail and unable to live independently, whose families cannot support them. But nursing homes are not and cannot be the mainstream solution to ageing. We are building nursing homes very quickly, from 16,200 beds now, to 31,000 beds in 2030. I am sure we need them as our population ages, but the projected pace of expansion is worrying.

In our Asian culture, we value caring for our seniors at home. Our seniors also prefer to age in a familiar environment and we should not lose this. As a society, we must guard against the assumption that seniors will always become sick and frail, and unable to take care of themselves. This is quite a risky mindset because it will exacerbate our challenge. Because over time, society will, perhaps unintentionally, push more older people to become isolated – which many Members have warned us of.

Our instincts backfire from time to time. We would have come across such stories. Let us say, a senior went marketing in a wet market and then he fell. The family may, to protect him, tell him, "Do not go out anymore, we will hire a domestic helper to watch after you." Or a senior cooks forgot to switch off the stove, and fortunately, it was discovered early. The family may tell her, "Do not cook anymore, we order in for you, every meal." We might do all these out of concern for our loved ones, but in so doing, we deprive them of physical activity, a sense of agency, a sense of dignity.

We want to protect them, but we unintentionally expose them to an even greater risk of isolation and loneliness. That is when the spirit wears out, the body gives way. If that mindset becomes entrenched, then over time, seniors become a problem to be contained, put aside in nursing homes – out-of-sight, out-of-mind. It is like a room in your house, where you put all your problems and you do not want to see. One day, that room will burst.

We must support as many seniors as possible to continue to live in the community, independently or with some help, contributing to the best of their ability, able to choose their own activities, having a full social life with friends and family.

I visited Block 115 that Mr Henry Kwek talked about. It is not run on a big budget, a lot of passionate volunteers, we all know who got involved, but it is doing such heavy lifting and making such a huge difference to the seniors living in that block. I came across this piece of research, which estimated that the health impact of loneliness for a senior is equivalent to smoking 15 cigarettes a day.

We estimate that today, 97% of our seniors above 65 can either live independently or with some help in the community. We must maintain or improve that share and not inadvertently give them the equivalent of 15 cigarettes a day, and weaken their health and ability to live independently.

For the large majority of seniors, what they need most is social care, more than healthcare. The way to deliver that is to enable ageing in communities. We will need a range of solutions to anchor ageing in communities. These include building more Community Care Apartments that Second Minister Masagos Zulkifli talked about, on releasing land for private assisted-living facilities. But the greatest asset for managing ageing is actually right before us – and that is our HDB estates. Most estates already have ample shared spaces for interaction and activities, you got your void deck, your coffeeshop, your supermarket, your RC centre, our Eldercare Centre, your community clubs. We did not specifically build them as infrastructure to support ageing, but they are extremely valuable in our ageing society.

And that is why MOH is rapidly expanding our network of Eldercare Centres to activate these existing spaces and create more shared spaces and social networks for seniors. We are working closely with AIC to provide training opportunities for our centres to take on an expanded role under Healthier SG.

As a social worker told me, a very effective initiative is to simply bring the seniors to that shared space to cook and enjoy a meal together and once they eat together, they socialise, they start doing different kinds of activities together. There is no risk of forgetting to switch off your stove and we will definitely improve the way the Eldercare Centres work.

As suggested by Ms Janet Ang, for those who are in their last lap of their health journey, we are expanding palliative care, especially at home, to allow our loved ones to pass on as comfortably and with as much dignity as possible. This is the wish of most seniors and we should try our best to fulfil it. Ageing in communities will be the next major area of change and reform in healthcare that we need to work on.

When all three systems – acute care system, public health system, aged care system – work together synergistically, healthcare happens everywhere and not just in medical facilities.

So, I thank Dr Tan Wu Meng for sharing the story of Ah Ma, and pointing out that the healthcare subsidy should not be tied to services being delivered in brick-and-mortar facilities. This will naturally have to be reviewed as we shift our paradigm.

Mr Deputy Speaker, Sir, let me conclude. Some countries may place a stronger emphasis on just one of the three systems or organise them in a way that they end up working in silo. For example, Japan, as a super-ageing society, has a great focus on aged and institutional care. The US acute care system is state-driven, but public health is driven at the federal level.

In Singapore, we take an integrated approach. Acute care, public health, aged care, all come under MOH. The Minister for Health, is also the Minister in-charge of ageing issues and chairs a multi-Ministry task force going beyond healthcare.

And this is an important advantage for us. MOH is in a position to develop a cogent and comprehensive plan, muster resources to transform and fire up all three systems, to deliver health outcomes for our people. Healthier SG is a key effort to activate and reform the public health system, empower individuals to choose health and lay the foundation for the aged care system I spoke about.

We need all stakeholders – doctors, community partners, healthcare clusters, employers, residents – to join us in this effort, to shape a healthier Singapore. We do this for ourselves, we do this for each other.

All societies, at some point, will have to confront population ageing. It is an urgent and stern test, and some societies end up with bankrupted healthcare systems or let healthcare cripple their society and economy. We are determined to overcome this test. We have the resources, ability, organisation and determination to do this.

I seek the support of this House and of the people of Singapore to endorse this Healthier SG effort as the basis to transform our healthcare system, so as to strive towards the vision of long and healthy lives for Singaporeans. [Applause.]