Speech on White Paper on Healthier SG

Image credit: Screenshot from CNA

I spoke in Parliament on the White Paper on Healthier SG, a national plan to transform healthcare. I love the spirit of the vision but raised several concerns for Government to look into..

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1. I stand in support of the direction set in the White Paper on Healthier SG.

This plan is a strategic move to transform Singapore's healthcare system from one that primarily cares for the sick to one that proactively prevents sickness.

2. Preventive healthcare aims to prevent illnesses; detect specific conditions early; and encourage the promotion of good health.

Regular health screens, testing, and healthy lifestyle counselling are but common features.

3. Globally, the incorporation of preventive healthcare in national plans is not new. The United States, for instance, publishes 10-year Healthy People masterplans (5 iterations now) to identify public health priorities to improve health and well being. The latest is the Healthy People 2030 plan. But well-written plans may be, many in the world, including the US, are still afflicted by poor health caused by negative habits and sedentary lifestyle choices.

4. For the Healthier SG vision to come to pass successfully, we need to get the planning assumptions, strategies and execution right. I have several concerns to which I seek Ministry’s consideration and response.

5. ON MOBILISING A NETWORK OF FAMILY DOCTORS. The first of the 5 key features of the Healthier SG plan is to mobilise a network of family doctors.

The family doctor will develop a health plan, conduct annual check-ins and help them achieve their health goals.

This in theory sounds good. In practice, most residents only see a GP when they are ill. If GPs are the first to be tapped upon, then their transition from the role of a GP to that of a family doctor or physician cannot be underestimated.

a. How does MOH facilitate the transition eg of a GP who sees say 50-60 patients a day, to morph to one that is more consultative, holistic and takes alot more time? Would there be pre-requisite skill sets and dispositions that need to be considered? Other than intrinsic motivation, would the financial incentive be sufficient to cover their time and cost?

b. Many Singaporeans visit PolyClinic doctors as their first port of call. Working Singaporeans also tend to consult their employer's panel of doctors. How do these doctors become one's Family Doctor, if they may not be the same doctor who regularly attends to one?

c. ON DEVELOPING INDIVIDUAL HEALTH PLANS .

Developing health plans for enrolled residents is one thing; following up to ensure outcomes is another. The White Paper correctly states that "while doctors can prescribe activities, it will only work if residents take personal ownership of their healthy and lifestyles and follow through with their health plans." The same challenges were voiced by residents in the White Paper and validated by many of our own lived experiences.

d. The move to take personal ownership for one’s own health is far more complicated than developing a health plan. There are many theories of behavioural changes from time immemorial. If not thought through carefully, the Healthier SG vision would remain a pipe dream.

e. What could be a highly effective combination of 'inside-out" (intrinsic) and "outside-in" (extrinsic) intervention measures to address the needed change in mindset and behaviour? How does MOH intend to address the first target group who are senior residents who may be even more rigid in their ways?

Why is there little mention of UPSTREAM interventions to shape mindsets and behaviours when one is younger such as in schools?

Surely upstream interventions in schools through proper eating, exercising and emotional management are an important part of developing good health habits for life.

f. And then for the even more vulnerable. What is MOH's recommendation for younger Singaporeans who are disabled and who are prone to earlier onset of chronic illnesses due to a lack of education and care? They are best served by healthcare professionals who are aware of their conditions such as Dr Chen Shi Ling and her doctors at Happee Hearts Movement. Who and how does MOH propose to include this group of residents and to fund doctors like Dr Chen?

6. ON ACTIVATION OF COMMUNITY PARTNERS such as the Health Promotion Board (HPB), Agency for Integrated Care (AIC), People’s Association (PA), Sports SG and NParks. I agree with the White Paper that "patients' social, mental and physical well-being, are best achieved through community assets and services.”

a. My own experience on the ground is that although the different parties are all good community assets, many of their efforts are not co-ordinated. They sometimes even 'compete' for the same clientele. Situations of, example, elderly residents being repeatedly served, under-served or not even served are common.

b. What would the regional health system player each in charge of about 1.5 million residents do differently?

How will they , as integrators, better organize efforts without losing the passion and resources of precious community partners, for a Healthier SG?

c. With so many partners and touchpoints, what would the typical experience of an enrolled resident or 'customer' look like in his healthcare journey? Some clarity would be assuring.

7. ON SETTING UP ENABLERS FOR HEALTHIER SG.

Sir, I find it hard to imagine the size of the 'beast' or initiative based on the White Paper. For Singaporeans to appreciate the big shift and the need for investments ($1b for start up and $400m annually) , I seek more clarity on the following levers:

a. On Human Resources. What are the types of jobs, skills pre-requisites, and numbers of persons required to realise the vision of Healthier SG?

b. On Technology. Beyond the one-time grant to assist clinics to convert to an appropriate IT system, how would the maintenance and upgrade costs be treated ?

What would be needed to facilitate residents who are not tech-savvy so they are not left behind?

c. On Performance Indicators. The selection of performance indicators – whether process or outcome indicators; whether lagging (historical) or leading indicators – is never an easy task.

What gets measured gets done, as they say. What gets measured and paid for, gets done even more. Badly selected measures lead to unintended bad consequences. Resident enrolment rate and health plan completion rates can easily be ramped up through aggressive marketing, without regard for quality or follow up.

I urge a further scrutiny and discussion on the White Paper’s proposed key indicators.

8. CONCLUSION. Sir, I highly support the intent of the Healthier SG White Paper. I have raised issues and concerns from my own lived experiences and from those who are serving in healthcare and community. I hope MOH will seriously consider them.

A transformation of this nature is complicated. But if any country can succeed in nurturing a healthier people, Singapore would be the one.

Sir I support the White Paper.

Denise Phua

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Full video: https://www.channelnewsasia.com/watch/denise-phua-building-healthier-sg-2985651