Speech by Mr Ong Ye Kung, Minister for Health, At the World Organisation of Family Doctors Asia Pacific Regional Conference On Thursday, 22 August 2024, 8.40am, At Raffles City[...]

Dr Wong Tien Hua, President of the College of Family Physicians Singapore

Associate Professor Karen Flegg, President of the World Organisation of Family Doctors

Ladies and gentlemen

1. With a room full of doctors, I am very tempted to talk about mpox, because the world is, I think, very likely on the verge of having a very significant outbreak. There is one thing I think is worth repeating to everyone: We have to understand the characteristics of this disease because our memory is COVID-19 and during COVID-19, our memory was SARS. But every disease is different. The virus has different characteristics. It is extremely important that we understand what we are dealing with, but that is for another day.

2. It has been 17 years since a global World Organisation of Family Doctors (WONCA) Conference was held in Singapore. Congratulations to the College of Family Physicians Singapore for bringing this conference back to Singapore, especially at a time when family medicine has taken on new importance, against the backdrop of an ageing world. Thank you very much for all the hard work.

Universal Healthcare in the Region

3. Professor Karen Flegg talked about universal healthcare (UHC). This has become a key priority for many governments in the world and also in our region. The foundation of UHC is accessible and affordable primary care, delivered by family doctors.

4. I was in Beijing only recently. I visited two of their community health centres. These are outpatient centres, with many services integrated into one setting, but they also provided some inpatient beds for step-down care.

5. The Chinese government has been building many such centres in Beijing, and probably in other cities as well, over the past decade. I was told there is one centre for every 50,000 residents. This is a massive effort to bring primary care into communities. Residents are encouraged to register and enter into primary care contracts with the health centres. In other words, it is an enrolment programme. In Beijing alone, millions have joined the scheme.

6. Likewise, Indonesia has expanded its network of community health centres, called "Pusat Kesihatan Masyarakat", throughout the archipelago of 18,000 islands.

7. Places like Thailand and Australia have very strong traditions of good UHC, which is highly respected. In both countries, healthcare professionals, newly graduated doctors, and doctors doing their residency are regularly deployed to rural areas to practise, and that ensures UHC. It is a most admirable practice.

8. I was just in Manila last week and found that the government in the Philippines has also been building community primary care centres, called BUCAS (Bagong Urgent Care and Ambulatory Service). They studied different models around the world, including Singapore, and decided that our polyclinic model is probably most suitable for them.

9. This is a scan of what different countries in our region are doing.

Primary Care in Singapore

10. Indeed, in Singapore, a key pillar of primary care is our polyclinics, which have improved drastically over the years. The key in this lies in upgrading the competencies of our healthcare professionals, especially the family doctors.

11. In fact, this was the objective in setting up the College of Family Physicians Singapore in 1971. Then we took a further step to upgrade the skills of family doctors in the 1990s, when the Master of Medicine (Family Medicine) training programme and Fellowship programme were introduced. Since 2011, our public hospitals started Family Medicine Residency Programmes.

12. At the polyclinics, we organise doctors, nurses, administrators and social workers together to form a team so that they deliver more holistic and effective care. We also invested heavily to improve the facilities and infrastructure of polyclinics. From the first polyclinic established in 1963, we now have 26, and the network is set to grow to 32 by 2030.

13. These efforts have transformed the quality of care at polyclinics. Today, our polyclinics attend to almost seven million outpatient visits a year - this is about 40% of all chronic patient load and about slightly over 20% of total outpatient load.

14. The great majority of patients are attended to by the other key pillar of primary care, which comprises about 1,600 private clinics, if we exclude the clinics that provide aesthetics services.

15. Private clinics have also undergone major changes over the years. Increasingly, the private clinics have become members of Primary Care Networks (PCNs) that have become an integral part of our national primary care system. They deliver subsidised primary care as well, help manage chronic patients, and help coordinate care with polyclinics, hospitals as well as social agencies.

16. Last year, Singapore launched our long-term preventive health strategy, called Healthier SG. Almost 80% of the eligible private primary care clinics came onboard voluntarily. With private clinics and polyclinics now working in concert, we have in slightly over a year enrolled more than one million residents. This is about half of our targeted population of residents 40 years and above. This is actually beyond our expectations.

Continual Development of Primary Care

17. Primary care and the practice of family medicine will continue to evolve in Singapore. The journey will continue. The developments will cut across several aspects, if I list a few - Professionalism, Practice, Platforms, Partnerships and Policies - five P's. Let me talk about them in turn.

18. First, professionalism. We will continue to invest in the competencies of our family doctors. This will happen in our medical schools, which will have to devote more curriculum time to family medicine and preventive care. It will also be carried out through continuing training and education, through the College of Family Physicians and the polyclinics.

19. Jurisdictions such as the UK, Denmark, Sweden, Australia, Malaysia and Hong Kong recognise family physicians who have undergone the necessary training as specialists. In Singapore, family doctors can be recognised as Fellows of the College after attaining their postgraduate qualifications, but they are not recognised as specialists by the Specialists Accreditation Board.

20. Given the rising importance and impact of family medicine, the Ministry of Health (MOH) will be working with the family medicine fraternity towards recognising Family Physicians with advanced Family Medicine training as specialists. We will announce the details when ready.

21. Second, practice. Competencies can translate into health impact as far as the practice of family medicine enables it. In the public health sector, our polyclinics are working closely with social organisations to expand primary care into communities and homes, reaching out especially to seniors and those who are vulnerable.

22. For private clinics, their patient profile is shifting, to achieve a better balance between preventive, acute, and chronic care. Most private clinics are also run by a single doctor. This is no longer ideal. Because as our population gets older, medical conditions are more complex and the clinic may need more expertise, including health screening, rehabilitation or physiotherapy work, etc. Private clinics will need to upgrade. One immediate way is to work with and support each other by joining Primary Care Networks, and for Primary Care Networks to invest in upgrading their competencies. There may be other methods, and we will talk about them when the time is right and we have some details.

23. Third, platforms. Many clinicians greatly appreciate how better flow of patients' data drives higher quality of care. Whether it is a family doctor, a specialist or a surgeon, when they see a patient for the first time, it helps a great deal when they have, at their fingertips, the medical history, drug allergies, and recent diagnostic images of the patient.

24. With this information, they don't have to repeat tests; they don't have to waste time, and they can make better and faster decisions, for the good of the patient.

25. Such information would need to be gathered, accumulated and then shared by clinicians who attended to the patient earlier. Many countries are therefore trying to develop a national medical record system for this purpose.

26. But it is not easy. There are many technical and legal impediments. Fortunately, Singapore has gone quite far in this effort. We have been operating our system - called the National Electronic Health Record (NEHR) system - for some years now. I must say not all doctors like it but it is actually very important. It holds the essential health data of patients, which can be accessed by clinicians across different care settings when they attend to patients.

27. I would say the great majority of doctors in Singapore are already on NEHR. Take primary care, public sector polyclinics, which attend to over 20% of the patient workload, are 100% on NEHR. As for private clinics, which attend to the other 80% of patients, if we exclude those providing aesthetics services, about 70% are already on NEHR. Add the two together and the great majority in primary care are already on NEHR, thanks to Healthier SG.

28. As for secondary and tertiary care in hospitals, our public hospitals, which manage about 90% of hospital workload, already use the NEHR. However, practically all private hospitals, which attend to the remaining 10% patients, are not on NEHR.

29. We intend to pass legislation, likely early next year, to require all remaining private healthcare providers to come onto NEHR. This will bring the minority of private clinics and all private hospitals onto the platform.

30. Some patients are understandably more sensitive about their medical records and do not want to share that with other clinicians. They can continue to opt out of sharing access of their data if they want to. From a quality-of-care point of view, MOH does not encourage this, but we will have to respect the patient's choice.

31. Fourth area is partnerships. For a family doctor to be most effective, they will need strong partnerships - downstream and upstream. Downstream, with secondary and tertiary care in hospitals, in order to escalate cases. Upstream, to community resources, so that social prescriptions, such as better diet and more exercise, can be followed up on. Through the Healthier SG programme, we are now facilitating this, weaving them into one system.

32. In Singapore, the primary role of family doctors in a programme like Healthier SG is not to be gatekeepers to inpatient care. Instead, they are pathfinders to community support. This is a unique strength of our Healthier SG system. Family doctors can and should leverage the support of various agencies, such as the Health Promotion Board, People's Association and SportSG, which have numerous touchpoints on the ground, established over decades, to engage and mobilise residents.

Policy to Promote Healthier Eating

33. Finally, policies. Good primary care needs to be supported by policies that promote healthy lifestyles. Doctors can do some preventive care, but most of your work is still restorative. For example, Singapore has implemented various tobacco control measures such as raising the Minimum Legal Age for smoking to 21 years, and graphic health warnings for tobacco products have been introduced.

34. As a result, our annual National Population Health Survey (NPHS) for 2023 showed that over the past year, the prevalence of daily smoking has dropped further from 9.2% to 8.8%, our lowest level ever since the survey was conducted. I hope we can drive it down further.

35. We also grant incentives for physical exercises. The National Steps Challenge uses smart wearables and gamification to incentivise individuals to achieve at least 150 to 300 minutes of moderate- to vigorous-intensity physical activities every week. If you walk 10,000 steps every day for a whole month, my understanding is that you get about $10 to $20 of vouchers for shopping. This is quite a unique policy. The NPHS results for 2023 also showed that 78.5% of Singapore residents had sufficient physical activity, up from 74.9% in 2022 , and we hope to generate a trend.

36. So we have done well in smoking and are seeing some good signs of more people moving and exercising, but we can probably do better in encouraging a healthier diet. Singaporeans are very passionate about our food. This probably originated from the fact that Southeast Asia is a mosaic of interesting culinary cultures, with masterful use of spices and cooking methods.

37. That also means many dishes contain significant amounts of sugar, sodium and saturated fats - the three most problematic nutrients in our diet.

38. We have done reasonably well to moderate the consumption of sugar. We found out that the major source of sugar consumption is packaged drinks, but we also recognised that consumers value choice and autonomy where it comes to what they consume. So we decided not to impose a sugar tax, and instead labelled packaged beverages - from 'A' which has the lowest sugar content to 'D' with the highest - and let consumers look at the label and exercise their choice.

39. We call this Nutri-Grade labelling, and it has worked quite well. I think Singaporeans are quite grade conscious; we don't like 'C's and 'D's; we like 'A's and 'B's. So we gravitated to all the beverages with 'A's' and "B's'. Many producers have reformulated their beverages to support and also to suit the newly evolved taste. Labelling, I believe, has shaped the palate of the population with regard to sugar. Last year, over two-thirds of pre-packaged beverages in the market were graded 'A' or 'B', up from less than a third five years ago.

40. To complement the Nutri-Grade measures, we also called on our coffee shops and hawker centres to serve fresh coffee and tea with low or no sugar (what we colloquially call 'Siu Dai') by default. Today, within the local brew sector, nine in 10 of outlets (i.e. coffee shops, food court, café chains) are on board the "Siu Dai or less sugar by default" movement.

41. Due to all these efforts, the average sugar intake has been on a gradual but steady decline. Based on the latest NPHS data, the prevalence of diabetes has decreased slightly from 8.8% to 8.5% over the last five years. Again, we hope to create a trend.

42. However, the picture is not rosy where it comes to hypertension and hyperlipidaemia. The prevalence of hypertension in Singapore is rising, from 24% to 37% over the last five years. Amongst the seniors, it is much higher. The prevalence of hyperlipidaemia is also worryingly high, with about a third of Singapore residents having the condition. Both are significant risk factors for heart disease.

43. Two key nutrients that can lead to these diseases are sodium and saturated fat, which we are over-consuming. In fact, Singapore residents are consuming almost twice the daily limit of sodium.

44. We should therefore also try to moderate our consumption of sodium and saturated fats. Learning from our experience in moderating sugar consumption, consumer choice and industry buy-in are key factors for success.

45. For consumers, our starting point is to again target the key sources of intake. For sodium, these include salt, sauces and seasonings added in food preparation, and instant noodles. As for saturated fat, it largely comes from cooking oil.

46. Since healthier alternatives for all these ingredients and foods are already available, and we should label them. This means that we should expect, in time to come, soya sauce, chili sauce, sambal, cooking oil, instant noodles etc that are sold in supermarkets to carry Nutri-Grade labels, but instead of Nutri-Grade labels 'A' to 'D' for sugar, it will indicate the level of sodium or the level of saturated fat, for that particular ingredient, just like packaged drinks.

47. For the industry, over the last few months, MOH and the Health Promotion Board have been conducting a series of dialogues with over 80 industry leaders across the food supply chain on our approach to label ingredients for sodium and saturated fat.

48. Generally, the industry supports this and agree that more can be done. In anticipation of possible policy changes, many players have already begun their reformulation journey and are committed to doing more. We will conduct further consultation with the industry, define the nutrient thresholds for different ingredients, and will provide ample time for the industry to adjust to the new labelling rules.

49. However, there is a major difference between labelling for sodium and saturated fat and labelling for sugar. Packaged beverages that contain sugar are consumed directly. Sauces and oil that contain sodium and saturated fats are used as ingredients for cooking, before being consumed.

50. This additional step makes all the difference. A chef can use regular salt instead of low-sodium salt, but he is careful in using it, and still produces a healthy dish. The converse can be true when a cook is over-generous in adding low sodium soya sauce to his dish, making it an unhealthy dish. The range of recipes and ways of cooking add variability to how much sodium or saturated fat ends up in the dish.

51. Hence, beyond labelling the ingredients, we should also help consumers identify eateries and stalls that produce healthy dishes. We should adopt a voluntary approach, at least as a start. Eateries that practise healthier cooking, either by using healthier ingredients or by using less salt or sauces, can apply to HPB to display store-front labels to inform consumers. This will be useful information to consumers.

52. These are our broad plans. We will announce the details when ready.

Closing

53. In closing, health ministries all over the world are focused more on acute hospital care, because sickness is where there is most public expectations and scrutiny, and where political pressures are most felt.

54. However, hospital care is often restorative. If we take a longer-term perspective, the area that needs more urgent investment is preventive care, delivered through primary care and family doctors, which are the foundation of health. Investment in primary care therefore has become an imperative, especially given an ageing population.

55. We have made good progress in placing more importance on family medicine and building primary care, but a lot more needs to be done and can be done. I thank you for your strong support in this journey. This conference shows a global resolve to enhance primary care and elevate the practice of family medicine.

56. I wish all of you an enriching and rewarding conference. Thank you.