Debate on Annual Budget Statement

Mr Deputy Speaker, I would like to first thank Deputy Prime Minister Heng and his MOF team for the hard work they had put in with a generous Budget that aims to address the storms in sight, whilst at the same time prepare us for the tectonic shifts ahead.

Last year, I asked for mental health to be a whole-of-Government priority. It was unintentionally prescient then to see this in action now with the multi-Ministry task force set up to tackle the COVID-19 outbreak. The psychology of our people became more than a priority for the Government to understand so as to manage the panic buying, hoarding and shunning of healthcare workers – all coping mechanisms to deal with underlying fear and anxiety. Research studies have found that these deficiencies of community resilience can be caused by poor mental health, leading affected communities to be less cohesive, adaptive and more vulnerable to shocks and disruption.

The near-term uncertainties and long-term structural shifts that Deputy Prime Minister highlighted should, therefore, alarm us to the need to prioritise mental health. I was very encouraged in the recent month by Prime Minister Lee, Deputy Prime Minister and several Ministers rallying Singaporeans around the need to strengthen social and psychological resilience, both critical pillars of our Total Defence strategy.

So, Mr Deputy Speaker, you will understand why I was disappointed that mental health was not mentioned at all by Deputy Prime Minister during his speech, despite mentioning "resilience" four times. The ability to adapt to significant and adverse changes we call resilience is not happenstance – it is enabled by good mental health.

As a nation, we clearly struggle with mental health. There has been a steady increase in the lifetime prevalence of mental illness in Singapore over two decades – 10% or more when it was first tracked in 1998 and 2007, to 12% in 2010 and now 13.9%. To put into perspective, which I also did last year to limited success apparently, the prevalence for diabetes in Singapore was 8.6% in 1992, peaked at 11.3% in 2010 and has seen remarkable improvements since the "war on diabetes", decreasing to 8.8% today. As one doctor shared with me: "Until the Government starts taking the stand that mental health is as important as diabetes, there is a limit to what individual organisations can accomplish".

Mr Deputy Speaker, despite two decades of increasing prevalence of mental illness in our society, the Government still seems to be struggling to do more for the mental well-being of our people. In fact, the Health Minister has previously shared in this House that we only spent 3% of our healthcare operating expenditure in FY2017 on mental health compared to 11% for diabetes. Under our FY2020 expenditure estimates for healthcare, there are only three expenditure items targeted to support mental health. In comparison, many other developed countries such as New Zealand, Scotland, Iceland, Finland, Canada, Norway and Australia have identified mental health as a budget priority with significant resources dedicated to support mental well-being in their societies.

Sir, at this juncture, Members may think that I am recycling my speech from last year but let me assure you that I am not, although that would be clearly so much easier for this part-time Nominated Member of Parliament with no institutional support! Last year, I shared the mental health struggles of those near and dear to me including my own close shave with depression more than a decade ago. Perhaps, these sharings did not seem substantive or representative enough to persuade our policy-makers. So, earlier this year, my amazing team of volunteers and I decided to launch the first-ever public consultation on mental health in Singapore. Rudimentary it may be – given less-than-limited resources – we were surprised and heartened by the more than 400 responses received from Singaporeans, 70% with lived experiences whilst the rest from care-givers and mental healthcare professionals! Many of these personal stories are heart wrenching – we even ended up doing "case work" with some! But since personal stories did not seem to move policy-makers last year, I decided I will focus this year’s speech on where we are falling short in the specific areas of affordability, accessibility and quality in mental healthcare and concrete urgent actions that I hope Deputy Prime Minister and relevant Ministers will take.

First, on affordability. It broke my heart when I read one respondent "having to starve to afford therapy". At least 10 respondents shared they stopped seeking help because of financial struggles. Sixty-six percent of the respondents shared that mental healthcare costs were high, with more than half of them being users of public healthcare services. How is it that our world-class healthcare system has denied so many people the mental healthcare that they need?

Sir, you may not know that as much as a seven-time difference still exists between MediSave and MediShield Life limits imposed on treatment for physical health versus mental health conditions. A respondent shared, I quote, "I paid over $10,000 total [purely] for inpatient care after deduction of MediSave and MediShield Life for the past two years", even after "opt[ing] for class B2 and C wards to save costs". It is time to remove this entrenched stigma by bringing these limits to parity for both mental and physical health conditions. MediSave should also be allowed for services at Government or quasi-Government-funded community organisations because how can we have a community health approach if it is not?

Next, on accessibility. There are around 248 psychiatrists and 473 psychologists practising in Singapore, or 4.4 psychiatrists and 8.3 psychologists per 100,000 population which may explain why the overall median waiting time for new subsidised appointments across the public hospitals is 27 days to see a psychiatrist and 28 days to see a psychologist . Seventy-one respondents also shared that lack of relevant and trusted information was a prohibitive factor against seeking help.

I was, however, encouraged by the 23 respondents who commended CHAT, which is Community Health Assessment Team, a public healthcare initiative by IMH located within the community. CHAT provides a unique combination of: one, free and confidential mental health check service that guarantees data will not be entered into the public health system; and two, care navigation that includes subsidised referral for public mental healthcare services if required. Unfortunately, CHAT currently only serves the youth segment but I hope this model could be adapted and expanded to support all ages.

And now, quality. First, let me commend our mental healthcare professionals for their hard work, many of whom I know personally. More than 50 respondents, however, indicated grave dissatisfaction with the quality of public mental healthcare. Thirty-six percent explicitly mentioned lack of empathy in the professionals they interacted with and the dismal environment of psychiatric wards in our public hospitals.

Mr Deputy Speaker, we are not saying all mental healthcare professionals are incompetent or without heart. In fact, many respondents indicated that the poor quality could be attributed to the excessive workload which strains both professionals and the system. As one respondent puts it, "While the Government is ostensibly pushing campaigns that aim to reduce the stigma of seeking help for mental health issues, there is a lack of parallel funding for actual mental health services, such as the hiring of more counsellors and mental health professionals".

Twenty-six respondents cited the importance of feedback on treatment to improve their health outcomes. One respondent lamented, I quote, "They never asked me for feedback. I would like them to ask for feedback." Continuous improvements happen when we empower clients and patients by recognising that they are part of their care process too.

In the same vein, strategic plans such as the Community Mental Health Masterplan must involve extensive public consultation, especially those with lived experiences and their care-givers, while ensuring that aggregated public health data continues to be shared transparently. This helps to improve local research on mental health issues and better coordinate efforts in supporting mental well-being of our communities.

The recent launch of a multi-agency consultation effort on youth mental well-being is a wonderful start. Yet, to truly facilitate a SG Together response, we need such conversations to move beyond only the youth, especially since the average age of subsidised patients for the different mental health conditions was between 40 to 50 years old in the last three years. Incidentally, in the spirit of SG Together, my team of volunteers created a simple website called SGMentalHealth.com, so that we can also share what we found from the public consultation.

We also received responses on other policies, ranging from confidentiality, support in schools and workplaces to issues surrounding mental healthcare for marginalised or vulnerable communities like the differently-abled, LGBTQ+ and migrant workers. I will highlight these issues separately with the relevant Ministries during the COS debates.

These fundamental issues in affordability, accessibility and quality of our mental healthcare must be addressed by the Government with a fierce urgency or we risk another decade of increasing prevalence in mental illness, despite the well-meaning awareness and anti-stigma efforts.

Mr Deputy Speaker, this brings me to my last point on the paradigm shifts we need to make to move beyond mental healthcare to total well-being for every Singaporean.

The structural and policy issues discussed earlier aim to close the treatment gap. But what if we could reduce the number of people getting ill in the first place? What if we paradigm-shift mental health as a public health issue? What would our policies for mental health promotion and illness prevention look like? Would we then start to ask what are the causes of rising levels of mental distress in childhood that saw calls made by five- to nine-year-olds to SOS Singapore jumped by 500% over a three-year period? And the spike in the number of teenage suicides in 2018? Might we not insist on conducting mental health screening for our students every year, like physical health and dental checks? Will we begin to study the role of social justice, family and schools in mental health so that we can address the underlying social determinants? Will we also start to understand the impact of public policies on the psychological capital of our people and endeavour to create a psychological safety climate for innovation and well-being to flourish that truly binds Singapore Together?

Another paradigm shift we urgently need to make, Sir, is the long overdue recognition that mental health is a critical part of total well-being. Mental health is a continuum. It is not "I'm mentally sick, or I'm not". It’s not "I'm over it, or I'm still in it". It's not "I got it, I will never get it". We may think that mental health challenges only affect certain people, or some segments of our society. But if we just pause and have an honest conversation with ourselves, we will realise that we are navigating along this continuum at any point in time through our life. Because who has not suffered a loss? Who has not had a major life transition? Who has not felt overwhelmed with responsibility for another? Who has not been marginalised in some way? Who has not been made to feel like a failure?

None of us in this House can pretend that we have not struggled with a dearth of mental health at some point in our lives. Changing this paradigm of thought will help us think about how we can strengthen the support available within our communities. When asked what helped them most in their mental health journey, many respondents shared the importance of community support.

When we translate these paradigm shifts into strategies across the system, we may then see why it makes sense to expand physical health education to total health education in schools to include mental health. Why workplace health and safety must be beyond physical health and safety, which I am very happy to note that the Tripartite Oversight Committee on Workplace Health and Safety – of which I declare I am a member of – has started doing good work in this area with employers and employees. Why there is merit in making it explicitly clear to employers that the Sick Leave entitlement for each worker can also be used for mental health treatment and recovery and that mental health insurance is not a luxury but a necessity for employers to support their employees' total health.

Strong mental health support at schools and workplace directly impacts how we show up for our roles in our family and community – which contributes to how we support our children as parents, our elderly parents as care-givers and how we build strong ties and connections with our friends, our colleagues and our neighbours.

This returns us to the importance of resilience as individuals and communities, Mr Deputy Speaker. The mental well-being of our people – man or woman, young or old, rich or poor, working or jobless, straight or gay – forms the bedrock of our psychological resilience and social cohesion, which may be the only sure way to secure our future in Advancing as One Singapore against the headwinds ahead.

Already, a late 2019 study found that stress-related illnesses cost Singapore's economy $3.2 billion annually. So, I would like to earnestly ask the Deputy Prime Minister, what needs to happen for mental health to be a national and budget priority? Do we have to wait for one in four Singaporeans with mental health conditions, like the current global average, for us to take urgent action? Do we need to see more parents lose their children to suicide or more young people in distress for mental health to be a public health priority? Can we afford negative growth in productivity and innovation before realising how mental well-being is intricately tied to human performance?

Mr Deputy Speaker, this is likely my last Budget speech. So, I wish to conclude by imploring the Government to take action now to make quality mental healthcare accessible and affordable for all Singaporeans, to bring this on par to the world class public healthcare system for all that we are proud of. This is surely the loudest anti-stigma signal to send!

In addition, I challenge the Government to boldly take a strategic and preventive approach to deliver mental well-being and total health to our people as it has done spectacularly with economic well-being, so that we can bring and build the social resilience and psychological capital to thrive as a nation and flourish as human beings.

I also urge all Members of Parliament in this House to support the mental health needs of their constituents so as to create resilient communities as part of this SG Together effort.

To Singaporeans, I invite you to remember that wherever you are on the mental health continuum is not solely a matter of personal agency but also largely determined by your social support structures, or lack of. So, if you are struggling right now, I hope you know it is not a personal failing. We are all responsible for each other's mental well-being, including the Government and institutions. You have, in fact, shown us what true resilience is by fiercely living each day with less-than-adequate state support in mental healthcare whilst constantly dealing with structural stigma and discriminative behaviours.

Mr Deputy Speaker, I look forward to the Deputy Prime Minister's response to the hopes of the 400 Singaporeans and many hundreds more who have reached out to me over the years, including my tireless team of volunteers. They have bravely come forward to share their struggles. Their generosity and courage keep me going on this crusade for change. I share the same hope as this respondent who said, “I hope that the day comes soon where no one has to feel alone in their mental health journey.” [Applause.]