Strengthening Accessibility to Mental Healthcare

Thank you, Mr Speaker. Before I begin, in the context of my Adjournment Motion, I would like to declare that I am a consultant psychiatrist in private practice, I hold a visiting consultant psychiatrist appointment in a restructured hospital and I am the honorary secretary of the Singapore Psychiatric Association.

Mr Speaker, I will begin this Motion by saying that the state of mental healthcare in Singapore has improved over the years. There is greater awareness of mental health issues, wider efforts at integrating mental health into primary care, a readiness in the use of telehealth and a greater appreciation and initiation of mental health initiatives amongst youths. There is also greater emphasis on research and local data to help inform policy decisions and allocate resource to areas most in need.

Since July 2021, we have had the Interagency Taskforce on Mental Health and Well-being look into three focus areas: the first of which relates to improving accessibility, coordination and quality of mental health services, the second seeking to strengthen services and support for youth mental wellbeing, and the third to improve workplace wellbeing measures and employment support.

My Motion speaks most loudly to the first focus area and how I think we can and must do better in delivering mental healthcare and make it accessible to all.

Mr Speaker, on the theme of accessibility, being the first-world country that we are, it cannot be the case that we are satisfied when accessibility means merely making available a path from Point A to Point B. A path itself is not enough for it to be called accessible.

Taking a leaf from the transportation industry, to get people and goods from one destination to another, we pave ourselves a myriad and network of walkways, park connectors, roads, tracks and expressways – underground, on the surface and above ground.

We maintain them to a tee to prevent potholes and disrepair. We want to make the journey smooth for our road users to get to their destinations of choice so that when they reach the destination, they are comfortable and ready for their intended tasks rather than be exhausted from the navigation of the journey itself.

We ensure there is timely intervention and quick removal of barriers for traffic to resume especially during peak hours. And we also manage capacity of our transport systems to ensure we are able to sufficiently absorb the demand on a daily basis. There are clear alternatives routes and diversions as part of the forward planning in the transport infrastructure. And to our best efforts, we also ensure that transportation and people movement are safe and compatible with the users of the day.

Mr Speaker, in relative terms, when compared to what we can and have done for transport, I put it to Members of the House that we can do better in terms of accessibility for mental healthcare.

First, accessibility means that, at the time of need, there is reasonable expedient mental healthcare and there is capacity in the system to be able to accommodate. We need to ensure our lanes are wide enough to receive and the roadside lamps are up and the potholes are cleared for passage.

A Parliamentary Question was filed in July this year by the hon Member Mr Yip Hon Weng on average waiting times and follow-up appointments for mental health treatment at public healthcare institutions, wherein the Ministry responded that, on the basis of median time, it takes 45 days to see a psychiatrist and 42 days to see a psychologist. Depending on whether one sees it as half empty or half full, it means that 50% of all cases referred to see a psychiatrist or psychologist wait no less than six weeks before an appointment can be arranged. I would be interested to see what our mean numbers are, because there could well be a long tail in terms of the waiting time for patients to get professional help beyond the 50th percentile.

Even, Mr Speaker, if we take a conservative and reasonably optimistic view that perhaps the remaining 50% are seen within eight weeks or by the second month from their referral, it is also worth noting that by the time patients need to be referred by the learned general practitioner to a psychiatrist or psychologist, it is likely the case that these patients are already struggling and are having marked difficulty in their lives. I would argue that a further six to eight weeks' wait for access to a psychiatrist and/or psychologist is much too long a wait to bear.

For psychiatric departments in restructured hospitals, manpower and infrastructure continues to be stretched to address the increasingly complex medico-psychiatric cases, cases involving vulnerable adults and those lacking mental capacity. Cases where trauma, cancer, strokes, infectious diseases and endocrinological illness overlap with mental illness, there is much complexity in the treatment of psychiatric conditions.

Our restructured hospitals have organic psychiatric departments that are smaller, yet the range and depth of complexity of the cases and the need for interdisciplinary work across specialities are no less challenging. Not all restructured hospitals have dedicated infrastructure and a ward for psychiatric patients and this makes managing even patients, who are of moderate risk, sometimes difficult in a restructured hospital setting. We can do better.

Secondly, accessibility also means that where there are limited resources within the public healthcare system, alternatives need to be possible and readily available. We are not saying that every time we need to get to the destination, it must be the expressway all the time but where that is not possible, fair and ready alternatives should be within reach.

Mr Speaker, I can appreciate that there is a utilitarian view to the delivery of public healthcare, with which practical considerations and a desire for the system to deliver the greatest benefit with the limited resources that it has.

However, for patients suffering from mental health conditions, they find themselves also stuck between a rock and a very, very hard place. For many of them, to search for alternatives beyond what is available in the public healthcare system remains both a rarity and at steep expense.

In our last September Parliamentary sitting, the House would recall hon Members Dr Tan Wu Meng and Ms He Ting Ru asking about insurance coverage for individuals with mental health conditions.

Yet, the response from the Ministry, in my humble view, skirts the point.

While I am grateful that Singaporeans and Permanent Residents are covered under MediShield Life regardless of pre-existing conditions, the tenor and the spirit of the questions were that of stigma and a lack of parity and transparency for patients who have a history of mental illness, in procuring insurance coverage for themselves.

There are challenges that people with mental illness face with insurance coverage that goes beyond the scope of their mental illness or the insurance underwriting on their risk of self-harm. Some find it disproportionately more challenging to secure insurance coverage even for physical health conditions, even though the specific mental health condition they have, or may have had in the past, does not necessarily bear a correlation to a prospective risk of physical ailment per se.

Mr Speaker, we cannot paint mental illness with a broad brush. Sometimes, depression can be the result of a temporary but extraordinary loss of a loved one and the likelihood of recurrence may be no different from anyone here in the House. Attention-deficient hyperactivity disorder (ADHD) can be outgrown for many, with little reliance of medications into adulthood for some. Dyslexia can be overcome and strategies learnt to manage reading challenges. Anorexia can be stabilised, self-esteem restored and meaningful relationships blossom thereafter.

My proposal, Mr Speaker, is for the Government to study this issue more deliberately and have a deeper look at the evidence and reasons for refusing, for loading and making exclusions for insurance coverage relating to mental health conditions. Give each mental illness the proper airing and stratification it deserves. If we get it right, more people will be willing to get themselves insured. More people will take active steps about declaring their conditions and many more others will start taking care of their mental health by seeking treatment early.

I am not saying that insurance is the silver bullet to mental healthcare, but it signals to people that we take it seriously, that we want to prevent it and that we want to make mental healthcare as accessible as possible, especially to those who take a keen interest in wanting to manage their health needs proactively.

Thirdly, accessibility also means ensuring that we manage the intersections of mental healthcare well. Sometimes, even with the best roads, jams can occur if intersections are not well-designed or if traffic junction timings are poorly thought through.

I am heartened, Mr Speaker, that the Government has had a renewed push for Healthier SG, as espoused by its White Paper, with an aim of 32 polyclinics by 2030 and an increase of public hospital capacity by 30%. In fact, just yesterday, a further 500 beds were added to the healthcare system as the hon Minister for Health initiated the opening of the TTSH Integrated Care Hub.

My hope is that, in tandem with this increase in capacity, that the Government takes heed to the increasing demand of mental healthcare in the coming years and that alongside this, so too would the resources for mental healthcare improve and increase at both primary and tertiary levels of care.

In wanting improving accessibility through health and mind clinics, my hope is that all future 32 polyclinics will see mental healthcare as part of their staple baseline services by our family physicians.

The Government should also harness stronger lateral linkages across public, people, private sector partnerships as part of a layered approach to deal with mental well-being, mental illness and mental healthcare.

I also hope for better vertical integration of services such that the delivery of mental healthcare from community to hospital and then back to community can be seamless and less disjointed.

Efficiency, Mr Speaker, sometimes inadvertently means that the handoff from one point of care to another becomes narrow but steep because the boundaries can be so well-defined and mutually exclusive. I urge the Government to consider some overlaps at the intersections of mental healthcare so that the patient journey is seamless and gaps are prevented by design.

When care touchpoints become more coherent and less fragmented, the patient will feel that the intersections are less ominous and less overbearing and that their last-mile experience in this journey is one of care and deep concern. This directly ties to their confidence in the quality and delivery of care, their willingness to continue in the care journey and that should they relapse again, they will have little difficulty in navigating the system to find their way to recovery.

Fourthly, accessibility also means accounting for socio-cultural needs and being sensitive to community-specific factors to mental healthcare. Not all vehicles are made the same, but every vehicle needs servicing even as they each may be unique in some ways.

Mr Speaker, in dealing with the private and very personal nature of mental health conditions, compatibility of care to the cultural, religious and social influences of the individual needs to be considered as part of the ecosystem.

It is not uncommon that symptoms of depression, obsessive compulsive disorder (OCD) and psychotic disorders, much as they are recognised and established mental illnesses, take root, shape and form in the socio-religious and cultural background of a patient.

If we want to make mental healthcare effective, we must consider, as part of our system of care, a deep understanding and sensitivity to the different mores of cultures, faiths and spirituality too.

When practice of mental healthcare is devoid of this understanding, a diagnosis could be misinformed, treatment becomes sub-optimal, medication compliance becomes poor and a willingness for treatment is lost. In fact, it can be a barrier to seeking help altogether. Mr Speaker, in Malay, please.

(In Malay): [Please refer to Vernacular Speech.] For example, Mr Speaker, within the Muslim community, many see the symptoms of mental illness as a spiritual disorder, instigation of evil spirits and caused by something supernatural. This is despite the fact that the symptoms and causes of mental illness are clearly displayed. Just like other communities and ethnic groups, efforts to create awareness about mental illness are sometimes challenging. It requires close cooperation and partners from the Government, community bodies, religious bodies and social agencies.

There should be a deeper conversation about mental health in society, and it should be on everyone's lips just like physical health matters and other prominent issues.

In line with that, the Muslim community must also focus sharply on raising awareness and encouraging more people to venture into the fields of psychology and psychiatry, because the number of experts managing this issue currently is very low.

In dealing with mental health comprehensively, while it is not a requirement when seeking treatment, if there are experts who possess a deep understanding and sensitivity towards cultural issues, it will provide comfort and ease to patients so that they can express their feelings and share their personal difficulties without fear of being ridiculed or having their faith, piety or masculinity feeling diminished.

(In English): Mr Speaker, through my own clinical lens, I have been educated by patients on their hallucinatory perception of visitations of the occasional deity and spiritual disturbance, whether by Guan Yin, or an omnipotent God or a memory of a distant figure of the past. This is common across very many different faiths, culture and backgrounds. And often, there is an overlay of mental illness that needs addressing and can be helped, not in isolation but through partnership with community and religious institutions playing a part.

Beyond medical-related factors, we must also recognise the interplay of culture, spirituality, faith, gender roles and familial factors as potentially being enablers or barriers to seeking help. Other than children and the vulnerable in our midst, men and the elderly, in particular, should also be given some focus as we seek to make delivery of mental healthcare culturally competent and more accessible.

Lastly, Mr Speaker, accessibility begins at home and at the workplace. The process of seeking help is a non-starter when the home and workplace are apprehensive to or unsupportive of mental healthcare.

It would be difficult for employees to seek help when the opportunity cost of declaring their mental health condition could be their entire employment.

The oft-cited question is that of stigma and how can workplaces and employers engender a better culture of mental well-being.

My response ordinarily revolves around the fact that it starts from our own day-to-day biases, how we respond organically and spontaneously to matters of mental health and how sensitive we are to what we read and what we hear of mental health conditions.

I am particularly optimistic by the announcement by the Ministry of Manpower (MOM) in August regarding the upcoming workplace fairness legislation, especially in protecting against workplace discrimination for disability and mental health conditions.

In this regard, I look forward to the details in place and the extent to which people with mental health conditions can feel assured regarding their employment.

Beyond this, we must ask ourselves how we can do better on rehabilitative mental health and improve outcomes for re-employment and re-integration of persons with mental health conditions. A negative prospect of returning back to their home and livelihoods will feed into people's fears of seeking help early, thinking that they may never return to full function and that there are few opportunities for meaningful employment after a diagnosis of mental illness.

To conclude, Mr Speaker, I would like to take the opportunity to remind the House that World Mental Health Day is on 10 October. I will confess that even as I filed this Adjournment Motion, I had forgotten about this fact and I can only posit that it is serendipitous that a psychiatrist is here, winning a ballot to speak on the issue of accessibility of mental healthcare in Parliament just a week before we celebrate World Mental Health Day.

I urge Members to consider your position on how you view issues related to mental health, its accessibility to care and how some of our citizens at their most vulnerable hour struggle to get timely accessible care, lack reasonable alternative options to support their needs and have valid worries about employability after.

Mr Speaker, as a category, the lifetime prevalence of mental illness as reported in the Singapore Mental Health Study of 2016, stands at 13.9%. This is even higher than diabetes which stood at 9.5% in 2020 on whom we rightly wage war against since 2016.

I ask this House to consider the weight of mental illness on our society and measure its funding, resource and accessibility to care accordingly. Like diabetes, mental illness is often silent and unseen. However, unlike diabetes, the impact of mental Illness on quality of life is more immediate from the point of diagnosis and the grind and burden on caregivers can be immeasurable and very quickly so.

I look forward to this House taking steps to set the tone and example through the work that we do and engagements that we have to make mental healthcare more accessible for all. [Applause.]