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Wednesday, February 1, 2023
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PM LEE – OUR HEALTHCARE SYSTEM IS OPEN AND HONEST WITH THE PUBLIC

Prime Minister Lee Hsien Loong was speaking at the Lecture and Formal Dinner at Singapore General Hospital yesterday (24 April), where he looked back on Singapore’s handling of the pandemic and what we have learned.

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Here is his speech

I am very glad to be with you at tonight’s Lecture and Formal Dinner to celebrate SGH’s illustrious journey. I accepted it first in 2019, and I am glad finally to have  this opportunity tonight to deliver on that, and at a good time for us to gather, look back, and enjoy the evening.

Since its establishment two centuries ago in 1821, SGH has gone through remarkable transformations. From a wooden shed in a British military camp near Bras Basah nursing injured soldiers, to the largest hospital in Singapore today, caring for more than one million patients annually, and flying Singapore’s flag high as a world-class centre for leading edge clinical care, research and teaching.

SGH’s success mirrors our journey as a nation, and the tremendous improvement in our healthcare standards. Today Singapore has one of the highest life expectancies and lowest infant mortality rates in the world.

SGH supported the nation during moments of great need and crisis. Caring for casualties of the Hock Lee Bus strike and racial riots during the tumultuous years of our independence struggle; treating victims of the Spyros oil tanker explosion and Hotel New World building collapse in the 1970s and 80s; and standing steadfast on the frontline of public health services in this ongoing pandemic.

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COVID-19 is our latest trial, but it certainly will not be our last. So tonight, as the pandemic gradually subsides, I would like to assess where we stand, how we got here, and how we should move forward.

Where we stand

We have come a long way since our first local COVID-19 case two plus years ago.

The journey has not been easy – the virus surprised us repeatedly, and each time we had to move quickly and to adapt. Battling the surge in our migrant worker dormitories. Imposing a Circuit Breaker, followed by multiple rounds of easing and tightening. Implementing contact tracing, TraceTogether and SafeEntry. Procuring precious medical supplies such as surgical masks and ventilators. Securing vaccines early and inoculating the whole population. Dealing with the Delta variant, and then Omicron. Going from “Zero COVID” to “Living with COVID”. We experienced anxious moments when we were not sure how things would turn out.

Finally, now we are approaching our goal of living with the virus, though not yet out of the woods. The virus may yet surprise us again. But overall, we are in good shape.

We just announced another major step to relax our COVID restrictions, and you can feel the city coming back to life. We are quietly confident of dealing with whatever may come, and continuing to progress towards the new normal.

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How we got here

How were we able to get here,safely and successfully? Let me cite three factors.

A Resilient Healthcare System

First, we established a strong and resilient healthcare system over the years. At its heart is a highly professional healthcare team. We invested heavily in our healthcare workers, equipped them with the right set of skills, and kept them up to date with medical developments. We regularly reviewed remuneration packages to keep healthcare jobs competitive. We recruited and retained the right people – doctors, nurses and healthcare professionals – who are not just technically competent and at the top of their fields, but just as importantly, dedicated to their calling.

We also invested heavily in our healthcare infrastructure. Since 2010, we have constructed and expanded eight public acute and community hospitals.

Crucially, after SARS we enhanced the capabilities for isolating and managing infectious diseases in all our hospitals. We built the National Centre for Infectious Diseases (NCID), which integrates clinical services, public health, research, training, and community engagement all within a single purpose-built facility to manage disease outbreaks. NCID opened just in time for COVID-19.

We also expanded our network of affordable and accessible primary care. We increased the number of polyclinics from 18 to 23 over the last five years. We partnered more than 1,000 General Practitioner (GP) clinics through the Community Health Assist Scheme (CHAS), the Public Health Preparedness Clinics (PHPC) scheme, and the Primary Care Network (PCN) scheme.

All these proved their worth when COVID-19 hit us. The public healthcare institutions were instrumental in caring for COVID-19 patients, and supporting MOH in making evidence-based decisions.

Our hospitals geared themselves up for surges in case loads. Built up stockpiles of essential medical supplies. Ramped up ICU capacity. Reorganised and mobilised resources to support the Emergency Departments and COVID-19 wards.

Our extensive network of polyclinics and PHPCs also played vital roles. Initially, they helped us identify, treat and isolate infections. Later on, they also offered vaccinations, and augmented our Home Recovery Programme to relieve the load on our healthcare system.

Most of all, our healthcare workers displayed professionalism and commitment, kept our healthcare system strong and resilient, and enabled Singapore to maintain a degree of normalcy in extraordinary times. They were stretched to the limit, but they maintained the highest standards and did not break. They were constantly on the frontlines, determined and resilient, even at the start when we understood little of the virus. When the migrant worker dormitories experienced outbreaks, they fearlessly went in to test and take care of the residents. They were amongst the first to endure the discomfort of using the enhanced Personal Protective Equipment for the entire working day, and amongst the last to go off Rostered Routine Testing.

Our healthcare workers endured extremely high workloads and stress levels during the pandemic. We have done our best to give them some respite, and adequate breaks from their duties to recover and recharge.

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Still, these two years have been very challenging for them, and such a pace is clearly unsustainable in normal times. So we must continue our efforts across the board – at the institutions, clusters, ministry, and also in the community – to prevent fatigue and burnout amongst our healthcare workers. We must take good care of their welfare and well-being, if we expect them to continue doing their best for all of us.

A big thank you to all our healthcare workers, including the many who are here today, for your courage, perseverance, and commitment to the cause. Singapore is deeply grateful to all of you.

An Effective Public Health Response

While a resilient healthcare system saw us through the pandemic, a pervasive crisis of this nature cannot be dealt with solely within the confines of hospitals and clinics.

We needed also to mount an effective public health response, and we did so – this was the second factor that made a big difference in this crisis.

Public health is different from healthcare. We are fortunate to have dedicated and outstanding medical practitioners, many of whom are here tonight, but excellent clinical care must be complemented by equally competent public health management, to bring the pandemic under control and prevent the healthcare system from becoming overwhelmed.

Healthcare focuses on providing the best possible medical treatment for individual patients, whereas public health focuses on the state of health of our overall population. It seeks to reduce the burden of the pandemic on our society, and use public policies, including non-medical interventions, to manage the course of the pandemic and limit the spread of the virus.

This requires a different mindset. Looking at the whole system, and deciding how to prioritise our resources under the given circumstances to benefit as many people as possible.

One prime example was how we replaced Polymerase Chain Reaction Tests (PCR) with Antigen Rapid Tests (ART) for most use cases. From a clinical perspective, to ascertain whether a particular patient has COVID-19, PCR is preferred. It is more sensitive than ART. If we are planning to treat a patient with a powerful anti-COVID-19 drug, then it is prudent to confirm definitively that he in fact has COVID-19. But from a public health perspective, if our goal is to slow down disease spread in the population, ART is better. With ART you can pick up and isolate the most infectious cases faster and more cheaply. Some positive cases will slip through, but overall, we are able to make a bigger impact on disease transmission. Therefore, once ART kits became available, we started using them extensively, and to good effect.

We implemented many other public health, non-medical interventions, including case isolation, contact tracing, quarantine, SMMs, and cross-border restrictions. The national vaccination programme required many public health decisions – which groups to vaccinate first, how soon to administer booster shots, whether and if so how to differentiate between the vaccinated and unvaccinated.

Effectively integrating these public health tools and considerations with our resilient healthcare system made all the difference in this pandemic.

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Public Trust

The third and probably most critical factor in our pandemic response is trust.

We have built up a high degree of trust in our society over the years – between Singaporeans and the government, and most of all, in one another. This trust is a most precious resource. It is the fundamental reason why Singaporeans were able to come together during the pandemic, instead of working against each other.

We all abided by burdensome SMMs. Patiently endured repeated rounds of easing and tightening. Went for vaccinations and booster jabs. Exercised personal and social responsibility. In other countries, a precaution as simple and essential as wearing a mask became a heated point of contention between citizens and in fact, between warring factions. Fortunately, in Singapore the opposite happened.

A big part of this is the public’s trust in our healthcare system, founded on three things.

One, competency – Trust that our healthcare workers are professional, and know their job well.

Two, commitment – Trust that our healthcare workers are dedicated and selfless, committed to the care, treatment and well-being of their patients, and put their  patients first.

Three, transparency – Trust that the healthcare system is open and honest with the public, even when things fail to go as intended.

For example, during the vaccination campaign, MOH regularly reported statistics on serious adverse events. When there were errors in execution, and someone received the wrong vaccine or the wrong dose, we proactively investigated and explained to the public what had happened.

Some may be tempted to think that it would have been easier to keep things quiet, and avoid causing unnecessary alarm with bad news. It would have been expedient and convenient, but it would have been very unwise. If we kept quiet, it might work once, or twice. But rumours will spread, people will gradually lose faith in the system, and we will eventually pay a high price – the loss of public trust. We should always be upfront when we encounter problems and setbacks, and address them honestly and transparently.

If we make a mistake – own up, take responsibility, and strive to put things right. This is not an easy thing to do. It requires courage, discipline, and integrity. But it is absolutely essential to strengthening public trust, especially during crises when stakes are high.

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These three factors: a resilient healthcare system, an effective public health response, and a high degree of public trust, together made a big difference for us during the pandemic. But at the same time, we also had some lucky breaks.

Had COVID-19 been like the Spanish flu that swept the world a century ago, which was a lethal disease for young and healthy people, our COVID-19 outbreak in the migrant worker dormitories would have been much worse. We were lucky that COVID-19 was not only generally a mild disease for the young and healthy, but even for other patients it was less virulent than SARS, though more transmissible.

And fortunately, super-transmissible variants of COVID-19 like Delta and Omicron only evolved and spread a year or two later. By that time countries around the world had painfully learnt how to cope with COVID-19, and were able to limit the damage these new variants did.

Coping with Delta and Omicron was made easier by a final piece of good fortune – highly effective mRNA vaccines for COVID-19 had become available within a year. This was much faster than any other vaccine had ever been developed and produced. It was the result of sustained advances in biotechnology over decades, and the collective efforts of governments, international institutions, pharmaceutical firms, and universities. Scientists could not have done this at the time of SARS, 17 years ago. Nor might they have succeeded if COVID-19 had been a different virus, like HIV, for which after four decades a vaccine is still elusive.

So while we count our blessings, we must prepare seriously for the next pandemic, lest we are not as lucky next time.

How we should go forward

What should we learn from our COVID-19 experience to better prepare for the future?

One day we will encounter Disease X. A new pathogen that is highly transmissible, highly lethal, and mutates easily.

With COVID-19, countries already struggled to cope, and humankind paid a heavy price in suffering and death. It is entirely possible that within the next few decades another novel pathogen more lethal and infectious than COVID-19 will sweep the world, within our lifetime and within your working lives. We must prepare for it early, the best we can, so as to be ready to mount a swift and effective response when it happens.

Beyond future pandemics, we must make the most of the changes forced on us by the crisis to improve the way we do things. We cannot thoughtlessly revert to the status quo ante after this crisis. Or let valuable lessons, for which we have paid dearly, go to waste.

What does this mean for Singapore healthcare?

First, we must keep up our high standards of medical excellence, as the backbone of a strong and resilient healthcare system. Keep investing in our healthcare workers, provide them the recognition and support they deserve, and continue to develop their professions: work with our Institutes of Higher Learning and healthcare institutions to equip our workers with skills for the future, and thus ensure that healthcare jobs remain attractive and relevant.

We must also support our healthcare workers with good medical facilities and healthcare infrastructure. We are adding 9 more polyclinics, and 6 more acute and community hospitals by 2030. The overall capacity of our hospitals and laboratories should include reserves to cater to surges in demand from time to time.

SGH is an integral part of our healthcare system. The SGH Campus Master Plan, now underway, will redevelop SGH into a new complex combining the best in facilities and technology, with future-proof capabilities, so that SGH can offer best-in-class services spanning the entire care continuum, from home to rehabilitative care.

At the same time, we need to build up our scientific and biomedical capabilities, to deepen and capitalise on the R&D expertise that we have spent the last two decades building up. We will need to collaborate internationally with researchers in many other countries, because we cannot do everything ourselves, and will benefit enormously from keeping in touch with progress and developments worldwide.

Secondly, we must further develop our emphasis on public health. In normal times, many other “popular” medical specialisations are more sought after. Yet, in a pandemic, as we have seen, public health expertise is absolutely crucial.

We need to be able to understand how a new disease is spreading. Make sense of disease trends, and devise models to assess and predict them. Evaluate alternative public health measures, and devise non-medical interventions that can help bring the outbreak under control in our population. We must strengthen our skills in these areas and high-quality public health input must inform policy making.

Beyond pandemics, we also need to shift our centre of gravity to focus on “health” rather than just treating the “disease”. In particular, we must address the pressing needs of our ageing population and the burden of chronic diseases. That is why MOH recently announced plans for the next bound of healthcare reform, Healthier SG.

Healthier SG will shift decisively from hospital-centric care to a patient-centred, preventive care. Focus on healthcare outcomes, starting early while the person is still healthy, and tackling illness at the root, before it progresses to the point of needing treatment. This will help bend the cost curve downwards, and in the long run keep our population healthier and our healthcare expenditure more sustainable.

Healthier SG is clearly the right strategic direction to take, but implementing it will be a huge challenge. It will demand considerable commitment and effort from many stakeholders – not just from the Government. It calls for a mindset shift and a fundamental reorientation of how the whole system works.

We will encourage everyone to enrol with one regular family physician as the first line of care, rather than to hop from doctor to doctor. And work with your family physician on preventive health plans, including regular screening and addressing risk factors, instead of seeing the GP for treatment only when you fall sick.

Family physicians will in turn work with community partners like the People’s Association and Sports SG to fulfil their patients’ ‘social prescriptions’, such as better diet and more physical exercise.

Our three health clusters, together with MOH, will coordinate all these efforts. MOH will be publishing a White Paper this year, to discuss the concepts with
stakeholders and come up with an implementable plan.

Which brings me to my third point – trust. I spoke earlier on the importance of the public trusting the healthcare system in a crisis. We must continue to nurture this trust during normal times. Always maintain high standards of competency, commitment and transparency in our healthcare system. Instil this trust in our people, so that in the next crisis we can again draw upon the same deep reservoir of trust to see us through. And of course, even when the going gets tough, and especially when the going gets tough, we must continue to live by these cardinal values, and continue to strengthen the trust that we depend on to stay together and pull through.

I have been emphasising the importance of trust to good social outcomes of all kinds for some time now. It is not just trust in the healthcare system, but general trust levels in our society, in our institutions and in one another that greatly influence health outcomes.

You do not have to take my word for it. There is now a peer-reviewed academic study, published in The Lancet, which confirms this. The study found that higher levels of trust in the government and among the population were associated with greater compliance with COVID-related restrictions and higher vaccination rates. In fact, by this measure, trust levels mattered much more even than the quality of healthcare and access to universal healthcare.

I do not believe this means a good healthcare system makes no difference – it is absolutely necessary. But it does show how crucial trust levels in the society are to public health and healthcare outcomes.

Singapore is fortunate to be a high-trust society. The strong public trust that we have built up over the decades between Singaporeans and the Government, and in one another, sets us apart from many other countries. Trust that the Government has the best interest of Singapore and Singaporeans at heart; trust that the Government is competent and will make the right decisions on behalf of Singaporeans; trust that every citizen will play his or her part, not just for themselves and their loved ones, but also for others, out of respect and regard for fellow citizens, and concern for our collective well being.

Let us long maintain this happy state of affairs, not just to achieve good healthcare outcomes, but to deliver good governance, progress and prosperity to our people.

Conclusion

Tonight, I have spoken about where we stand, how we got here; and how we should go forward.

COVID-19 was a baptism of fire for our nation. But that is how we have written every chapter of our Singapore story. We are a nation born and forged in crises. We have weathered many storms to get to where we are today.

Looking ahead, Singapore must continue to grow in maturity and resilience, learning from our experiences and those of others, and so must our healthcare system.

I trust that SGH will continue to contribute your talent and leadership to this endeavour, and in so doing help to achieve good healthcare outcomes for Singapore for many years to come.

Thank you.

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