Head O – Ministry of Health

Healthcare Beyond 2020

Dr Chia Shi-Lu (Tanjong Pagar): Madam, I beg to move, "That the total sum to be allocated for Head O of the Estimates be reduced by $100".

Over the past few years, the Ministry of Health has made significant steps to fine-tune the service delivery and financing framework for healthcare in Singapore. Primary healthcare flexibility and financing have been significantly improved through various schemes, such as the Community Health Assistance Scheme (CHAS), the Pioneer Generation package and, more recently, Flexi-Medisave.

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Infrastructure as well has been improved with initiatives, such as Family Medicine Clinics and Community Health Centres. The capacity and capability of our hospitals have also been steadily improving, reducing concerns about the bed crunch, with more acute and community hospitals coming on line in the near future. Nursing home capacity and quality have also been resolutely raised over the past few years, and we look forward to the formal roll-out of MediShield Life next year.

This grand vision of the direction in which healthcare in Singapore is heading was outlined a few years ago under Healthcare Vision 2020 Master Plan. If I may be so bold, I would like to first ask the Minister to share with this House his vision for healthcare in Singapore beyond 2020.

Beyond lingering concerns about how we can continue to afford and sustain healthcare spending, and in spite of what has been achieved thus far, I see three key challenges in the decade ahead and beyond.

The first challenge is how to empower and encourage our citizens to live healthier and to live better. We all recognise the importance of keeping healthy and disease prevention, but walking the walk is far more difficult than talking the talk. How do we get our people to make healthy life choices?

The Government Parliamentary Committee (GPC) for Health believes that the approach should be multipronged: firm or gentle, nudge or push. Firm pushes, such as legislation, may be necessary, for instance, in the arena of tobacco control or even eating choices. But we should be more prepared to try more gentle approaches as well. One of the central new proposals in this year's Budget was SkillsFuture with SkillsFuture grants and accounts, and this encourages Singaporeans to invest in themselves and in their careers.

Should we not consider perhaps a HealthFuture scheme, with financial grants and a HealthFuture account which Singaporeans can use for health maintenance or promotion purposes? Should we not be encouraged, as a people, to invest in our own health, for now and for the future?

This HealthFuture account would be a distinct entity, apart from our Medisave account. The HealthFuture account could take one of many forms. For example, it could be a unique account into which the Government, employers and individuals contribute. Or it can be ear-marked from one's Medisave account, or perhaps even take the form of a tax credit. Singaporeans can make use of their HealthFuture credit to participate in healthy lifestyle programmes, such as smoking cessation or weight loss programmes, exercise classes perhaps in collaboration with ActiveSG, or use it for tailored health screening tests or health monitoring. Those that use their HealthFuture credits wisely and show consistent good health outcomes can receive additional credit, incentivising their proactive health choices.

I just want to make it clear that this is different from providing financial incentives for Singaporeans who do not make use of medical services. It has been previously suggested, of course, that, for example, if one does not see a doctor, then perhaps there could be additional top-ups to their Medisave accounts or perhaps additional rebates for MediShield Life.

The idea against this no-claim bonus type of scheme is that it could deter some patients from seeking early medical treatment in order to receive more financial gains. I believe that this programme which I am suggesting would prove to be a good way to nudge more Singaporeans towards living healthily. After all, it can be argued that every dollar that goes towards health promotion and disease prevention would go much farther if that same dollar went towards disease treatment.

The second challenge concerns how we can make access to health and medical information more equal and symmetrical. Empowering patients with the right information allows them to make better choices for themselves in regard to their own care, and this could help deter over-treatment and over-consumption.

I would like to renew my call to the Ministry to set up a medical therapy and health technology advisory board, which can build consensus on the best available scientific information and provide easy-to-understand information to the general public on the merits of various types of treatment. Such a mechanism will become increasingly important in the years to come as treatments become more varied and complex, and also more expensive, hence placing increasing cost pressures on healthcare spending.

I also foresee more and more conditions becoming medicalised. This is not new. Having high cholesterol in the blood is one good example. The majority of patients with high cholesterol alone are generally well and have no symptoms, but billions of dollars are spent every year on medicines that reduce cholesterol with the aim of avoiding or reducing the risks of getting a heart attack.

Many of us take this as a truism. But actually, controversies rage in the medical community about who we should treat, how much to treat, and given that all these drugs have their fair share of side effects as well, what is the actual value that these drugs have in terms of averting significant disease? We will have more challenges and controversies of a similar nature in the future.

Recently, there has been news about promising prospects for drugs that could soon be developed that would "cure" obesity. For such a drug, should taxpayer monies be used to subsidise the use of such a drug? What would be the true value of such treatment? And would it also abrogate personal responsibility for one's health?

Let me now move on to my final area of concern. Another challenge concerns post-hospital care, otherwise referred to as intermediate and long-term care sector. Nursing homes, day care, home care, rehabilitative services, these all fall under this broad category. Due to remarkable advances in medical treatment over the years, more and more patients are surviving horrifying injuries and previously what would be fatal diseases. But that does not necessarily mean that these patients return to their original functional state. More and more patients will need long-term assistance with daily living, and I hope that the Minister can comment on our plans to address the challenges in providing these services in a sustainable way, given our tight labour market and infrastructure constraints. Are there plans to leverage on information technology or perhaps automated or mechanised technologies to provide access to good quality post-hospital care?

There are already many countries which are experimenting with remote systems where caregivers can actually communicate with their charges over information technology systems, such as Skype or various forms of mobile devices. I think this would be a good way of trying to reduce the infrastructure and also manpower constraints or requirements of such care delivery.

As a final point, I would like to ask the Minister for an update on the national plan he mentioned last year on addressing the needs of an ageing population. I have said previously in this House, and will reiterate this again, that an ageing population does not necessarily signify a crisis to the nation, unless we as a nation are unprepared for it. Think not of a "silver tsunami" but of a "silver boom" or a "silver dawn".

Recently, a radio listener remarked that we have to change our attitude from regarding an older worker as "no good", to looking towards an older worker to show us "something good". And this is an admirable way of looking at this. A healthy senior may actually be more productive in both the social or work environment, than a younger but unfit person.

Many discussions about age perhaps miss the point that perhaps the problem is not so much about age itself, but rather the overall fitness of the individual. Increasing age has typically been associated with increasing infirmity, but this paradigm can and should change if we all learn to live better and healthier from our youthful days. I would like to ask the Minister how his Ministry intends to mould Singapore into a nation for all ages, and how we can go about changing the national conversation on ageing so that we bring about mindset shifts that reject ageism. Thank you, and may I move to my next cut, Madam.

The Chairman: Yes, please proceed.

Capacity Building

Dr Chia Shi-Lu: Thank you. Mdm Chair, I would like to ask about the progress of the Ministry's plans to build healthcare capacity, in terms of both manpower and infrastructure across the whole of the healthcare delivery continuum.

Deputy Prime Minister and Minister for Finance Mr Tharman mentioned in the Budget Statement that by 2020, we will be increasing the number of beds in acute hospitals by 25%, community hospital beds by 100% and nursing home beds by 70%. In the five years leading to 2014, acute, community and nursing home beds had increased by a not inconsiderable 2,000 beds. Now, in a slightly longer time span, we are planning to add 11,000 beds altogether. This is a huge increase and I would like to ask the Minister to elaborate on how this number will be achieved, the challenges involved and strategies to overcome them.

The opening of the new Ng Teng Fong General Hospital had been postponed by six months to July this year due to construction delays, and I am happy to hear that this is now all on track. But in the midst of tightening of work permits, does the Ministry foresee any issues with the construction of other facilities, including four new community hospitals at Jurong, Yishun, Sengkang and Outram which are opening this year, 2016, 2018 and 2020 respectively, and the Sengkang General Hospital slated for opening in 2018 and, finally, the 12 nursing homes and six new polyclinics slated for the end-2020?

In view of our rapidly ageing population, I am also interested in the "one-stop" Senior Care Centres where the elderly can receive day care, dementia day care, rehabilitation and nursing services. How many centres are currently in operation and what is their total capacity? How many places are expected to be added every year and, of these, how many would be available for patients with dementia?

The Healthcare 2020 plan had projected that 20,000 more healthcare professionals – including doctors, nurses, pharmacists and allied health professionals – will be needed between 2011 and 2020. Last year, the Ministry shared that 6,000 healthcare professionals had joined the workforce between 2011 and 2013. Were there any increases last year, and would the Ministry share details of the increases in the various professions?

Data on Health Inequalities

Mr Gerald Giam Yean Song (Non-Constituency Member): Mdm Chair, MOH has released a good amount of health-related data on its websites and in response to Parliamentary Questions, and I appreciate the Ministry's willingness to release this data. However, there remain some information gaps which I hope can be addressed.

We typically see health reports from MOH stratifying disease rates by ethnicity, gender and age, but seldom by income level. Several studies in other countries have found an association between income and health, with lower income households tending to have poorer health.

Collecting data by income brackets could help the Government better calibrate social and health programmes. If socio-economic factors indeed affect Singaporeans' health status, then social interventions should be used to complement healthy-lifestyle campaigns targeting particular races, genders or age groups. If such data has already been collected, then it should be made available to researchers and the public.

Publication of the Price of Drugs

Mr Pritam Singh (Aljunied): Mdm Chair, the MOH's Standard Drugs List does not include the price of drugs, much less a breakdown of the cost of drugs in public or private hospitals, or between private and subsidised patients. The MOH website points to the Pharmaceutical Society of Singapore's website for prices of drugs prescribed for common conditions. But the Pharmaceutical Society of Singapore's website only covers medication for asthma, diabetes and high-blood pressure and lipids. The list also does not appear to be updated regularly; it was last updated in September 2013.

The Minister mentioned in his speech last year at the official opening of the Mount Elizabeth Novena Hospital that the Government has been a strong advocate of information transparency and wants to work to improve transparency of healthcare charges so that patients can make informed decisions. To this end, would public hospitals take the lead and extend this philosophy to publishing the price of all drugs sold as the next logical step after publishing the cost of surgical procedures, a move which has been well received by many Singaporeans, in order to reduce the information asymmetry for patients and to lower costs in particular?

The Minister has also previously mentioned that different cost structures and purchasing decisions, amongst other reasons, account for the flexibility afforded to various hospitals to purchase drugs directly from pharmaceutical manufacturers, even if they are all subject to general subsidy guidelines and that some drugs are used to cross-subsidise others that may be very expensive. To this end, the price of drugs would logically vary at different public and private hospitals. However, publishing the price of drugs can potentially result in more competitive pricing by pharmaceutical companies and between hospitals even, effectively lowering the cost of drugs to Singaporeans and, in the short to medium term, for the Government, too.

Mdm Chair, these calls for greater transparency in the healthcare sector with regard to the pricing of drugs are not new. The Minister for Finance during his closing speech of the Budget debate identified healthcare financing as a key fiscal challenge, with the Government's projected healthcare expenditure expected to triple to $12 billion by the year 2020, up from $4 billion in 2011.

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Would the Ministry consider publishing the price of drugs as one pillar of the strategy to better manage the prospect of rising healthcare cost in Singapore? And if not, can the Minister identify the factors which prevent the Ministry from publishing the prices of drugs in view of rising healthcare expenditure in the years to come?

IT Investment for Healthcare

Mr Alex Yam: Madam, as Singapore moves towards becoming a Smart Nation, one of the key sectors that could see benefits is the healthcare sector. IT has the advantage of increasing quality and productivity within the healthcare industry as well as reducing medical errors and thereby helping to keep overall costs low.

In the last decade, various breakthroughs in IT have contributed to the ease of info gathering, medical research, innovative treatments, and better communication of health informatics among healthcare professionals and patients.

As a wired nation, the Internet has also become an easy source of medical information. Improved technological research has also made healthcare even more effective than before. Patient care and worker efficiency has also improved. Healthcare trends are also easier to track with technology. Therefore, what plans does the Ministry have in place to increase productivity and further invest in IT? Has the Ministry also thought about using IT enablers to promote healthier living?

Rehabilitation

Mr Low Thia Khiang (Aljunied): Madam, the large number of patients who drop out of prescribed rehabilitation programmes after being discharged from hospitals has been an issue of concern. A study conducted between 2002 and 2005 found that that one in three patients continued with supervised rehabilitation after being discharged. The problem seems to have worsened.

It was reported last year that the number of patients who returned for supervised rehabilitation had dropped to one in five. Patients who do not go for regular rehabilitation, especially in the first three to six months after discharge, may not recover fully. They also risk deterioration of their physical functions and more frequent hospitalisation in the future. I would like to seek the view of the Ministry of Health (MOH) on the above situation.

MOH has said that they have looked into providing home-based rehabilitation services and subsidies have been given and made available from April 2014 to patients who wish to use these services. How many patients are currently utilising this home-based service?

The lack of manpower and infrastructural capacity in our Intermediate and Long Term Care sectors are problems that have been with us for the past 10 years. The demand for rehabilitation services will only increase with a rapidly ageing population. I hope the Ministry will share its roadmap to meet the rising demand for rehabilitation services.

In terms of manpower, it was reported in 2011 that Singapore would require at least 1,500 physiotherapists by 2015. Have we achieved this target? There were also plans to tap the pool of retirees and homemakers to train them as para-occupational therapists. Can the Minister give us an update on these plans? Are they effective in addressing manpower needs in the sector?

Polyclinics

Mr Liang Eng Hwa (Holland-Bukit Panjang): Mdm Chair, polyclinics play a vital role within the primary care sector especially in serving the low-income residents. I remember in the 2013 COS debate, Minister Gan shared that we would need to expand the polyclinic capacity and build new polyclinics.

Bukit Panjang Town has grown significantly in population as well as it is ageing rapidly. We now have new rental blocks that house many of the lower income families as well as seniors. The urgent need for a polyclinic at Bukit Panjang Town is unmistakable. We do have the land space within the town for a new polyclinic. We hope that MOH will not overlook Bukit Panjang Town as it increases the capacity of polyclinic services across the island.

The Chairman: Dr Teo Ho Pin is not here. Dr Chia Shi-Lu.

Liberalisation of Medisave

Dr Chia Shi-Lu: Mdm Chair, with the advent of the Pioneer Generation Package and other Government grants and subsidies which are more generous towards the elderly, especially those in the lower income groups, the amounts needed to be withdrawn by senior citizens from their Medisave accounts will be reduced. Hence, the burden on Medisave as a means of healthcare financing will be lower. I also welcome the introduction of the Flexi-Medisave scheme from April this year, which will allow seniors to further reduce out-of-pocket expenses.

However, as I often call for during the COS, I would like to once again ask the Ministry to include more chronic conditions under the Chronic Disease Management Programme (CDMP). I have always felt that this is an excellent programme and that it should be expanded wherever possible. I hope the Ministry will review this once again this year. Including more conditions will reduce the cash outlay required and encourage patients to be more compliant with treatment.

I would also like to renew my call for the CDMP withdrawal limit to be calibrated perhaps to the number of chronic conditions that a patient has. Thus, a patient suffering from three chronic illnesses should be allowed to withdraw more than a patient with only one chronic illness.

Finally, in line with the on-going review of the CPF system, I would also like to ask that consideration be made such that the Medisave Minimum Sum may be adjusted for the elderly, as they may have difficulty meeting this requirement following retirement. I already said earlier on that because of all these schemes, the burden on the Medisave account will actually be less for seniors. And some seniors have expressed that they found it difficult to have to top up their Medisave account from their CPF monies before they can withdraw money from their CPF accounts when they reach the age of 55.

Assoc Prof Fatimah Lateef: Madam, the 3 "M" system forms a fundamentally sound basis of financing healthcare costs in Singapore. Over the years, it has evolved and adapted to appropriate changes, to suit the needs of our population and healthcare demands.

Medisave use for outpatient payment and chronic disease management too has been liberalised over the years. Healthcare costs too have increased. Drugs have now moved on from first generation ones to third, and even fourth generation ones, with greater bioavailability, safer profiles and lesser side effects. With schemes like CHAS and the Pioneer Generation Package, we are also steering more towards preventive care, primary care, ambulatory care and community-based care.

With the increasing and rapidly ageing population as well as the rapid upsurge in the numbers of those with chronic disease burden, can the Ministry consider further flexibility and liberalisation in outpatient Medisave usage? This can be in the areas of the ceiling allowable for deductions, annually, and the addition to the list of 15 diseases that can be currently covered under the Chronic Disease Management programme (CDMP) – for example, to include Parkinson's disease, dementia management, epilepsy and chronic arthritis such as rheumatoid arthritis; and for the Flexible Medisave scheme which will be introduced later this year, for those more than 65. Can we consider these for patients who are younger and have chronic diseases? This is the group that is struggling much with out-of-pocket payments.

The Chairman: Mrs Lina Chiam, please take your two cuts together.

Kids with Eczema

Mrs Lina Chiam (Non-Constituency Member): Thank you, Madam. Eczema is a chronic skin irritation that is seen more often in children and it greatly reduces the quality of life for many sufferers. Most of these children suffer intense discomfort because of intense itching. They are victims of bullies because of their appearances and become socially withdrawn due to discrimination. Doctors and parents should pay close attention to their children's emotional and psychological well-being.

In France, the cost of the treatment for eczema is heavily subsidised under their national healthcare programme. In Singapore, caring for children with eczema is costly and cannot be claimed under the current insurance scheme.

To a reply in Parliament, there is currently no plan to include eczema in the Chronic Disease Management Programme in which Medisave can be used. Would the Minister reconsider including eczema as a claimable medical condition under the chronic disease subsidy scheme?

Community Rehabilitation Hospitals

Mrs Lina Chiam: Rehabilitation stay in community hospitals usually takes months for elderly patients to recover and incur high costs. Medisave coverage is much higher in restructured hospitals than it is in approved community hospitals, which is limited to $5,000 only for the whole duration of hospital stay. In approved community hospitals, there is no pension coverage for pensioners to offset their hospitalisation bills. Even with MediShield plans, the out-of-pocket hospitalisation bills can come out to a substantial amount costing thousands of dollars.

I would like to urge the Minister to consider extending the Medisave withdrawal limit to $10,000. This will greatly help defray the out-of-pocket hospitalisation bills for pensioners and CPF members. I would like to seek a clarification from the Minister on whether pension coverage is now allowed to be used in approved community hospitals.

Update on MediShield Life and Standard Integrated Plan Schedule

Dr Chia Shi-Lu: Mdm Chair, I would like to request for an update on the progress of the discussions on the fate of Integrated Plans (IPs), with the advent of MediShield Life, specifically on the standardised IP schedule that was previously announced, which is supposed to be pegged to the B1 rate in Government hospitals. Is there any indication when this standardised IP schedule will be rolled out?

Presently, about two-thirds of Singaporeans have Integrated Plans, which cover B1 and higher class wards in public and private hospitals. This is partly because many patients continue to value being able to have greater choice when it comes to hospitalisation for medical treatment. B1 class wards offer an attractive choice for patients because patients still receive Government subsidies yet still offer the choices and many of the benefits offered by private hospitals.

The Government has accepted the MediShield Life Review Committee's recommendation that the five private insurers offer a standardised B1 plan IP. However, there are concerns that there would be little room for insurers to offer competitive benefits since the B1 plan is standardised. What are the Minister's thoughts on this?

Another concern would be the escalation of IP premiums once policyholders reach the age when they are more likely to make claims and yet, this is exactly the time when they face tightened finances with retirement. As their Medisave accounts get depleted, such policyholders will naturally downgrade to MediShield Life, leaving the IP providers to cream off all the premiums already paid off over the years when the policyholders were younger. How does the Ministry intend to address or look at this problem?

Finally, I would like to ask if the plan to launch MediShield Life by the end of this year or earlier next year is on track, as many Singaporeans are looking forward to the implementation of this landmark universal health insurance programme.

MediShield Life

Mr Ang Wei Neng (Jurong): Mdm Chair, almost all Singaporeans that I know of are looking forward to the implementation of the MediShield Life, and they want it earlier. At this point of time, MOH has not shed much light about the implementation details. For example, many Singaporeans with minor pre-existing conditions are anxious to know if they have to pay the 30% extra premiums. Is there an avenue for appeal if they have reasons to believe that their pre-existing conditions are minor and should not be paying the additional premiums? How would MOH carry out the means testing to determine the premiums subsidy level? How to apply for the additional premium subsidy? All these questions are not answered yet.

In addition, a good 60% of Singaporeans currently bought private integrated plan on top of their basic MediShield plan. They are eagerly waiting for MOH to announce the details of the Standardised Integrated Plan that provides B1 class wards coverage. Companies are also waiting for the information so that they could streamline the medical benefits for their employees under the new regime. I hope MOH could share the details as soon as possible.

Portable Medical Benefits

The Senior Minister of State, Prime Minister's Office (Mr Heng Chee How): Mdm Chair, some 10 years ago, the Labour Movement advocated the concept of Portable Medical Benefits (PMBS) for workers. The rationale behind that was that with continuous economic and company restructuring, workers are likely to work with several organisations in the course of their working lives. Without the stability and security of a medical benefit insurance that covers them throughout their working lives, they may be caught out badly if they should fall seriously ill while being in between jobs, or when working for a company will little or no medical insurance coverage.

At that time, the national MediShield system was already in place. However, it did not fully serve as the de facto portable medical benefits system for workers and companies. This was because of its relatively low payouts, caps and limits, and also because workers are expected to claim against their company insurance policies before claiming against MediShield.

At the company level, it was also difficult to make PMBS work, because of exclusions for pre-existing conditions and how workers should be incentivised to move from first-dollar-coverage company group health insurance coverage to portable arrangements where deductibles and co-payments apply. The tax incentives given to companies to move to PMBS were also not considered attractive by some companies, given the complexities involved. As a result of all these, that effort toward the PMBS did not succeed.

The coming of MediShield Life by the end of this year offers a fresh chance to push this important concept to better protect workers. Unlike the original MediShield, MediShield Life helps overcome several critical problems. It does not exclude pre-existing conditions and it has no lifetime claim limit. All citizens are automatically included and there is no opting out, so coverage is lifelong. With substantial Government subsidies, the premiums will also be kept affordable on an on-going basis and offer good value for money.

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There are still important hurdles to be overcome. For example, the MediShield Life offers B2/C inpatient treatment coverage, whereas more than one in three workers are covered in the company group health insurance policies at ward classes above B2/C. There are also no details on the MediShield Life B1 product, such as its premium structure and whether it would exclude the pre-existing conditions. The questions of how to move from first-dollar-coverage from the company group health insurance coverage to portable arrangements where deductibles and co-payments apply must still be tackled. It is not that easy.

Nonetheless, I feel that this time the gap has at least has been narrowed and there is a fighting chance for PMBS at B2/C level to become a basic company level insurance coverage economy wide, with employers incentivising workers to defray their premiums for MediShield Life and anticipated deductibles and co-payment riders, and the Government perhaps incentivising employers to move decisively in that direction.

I wish to ask when will the B1 ward coverage details be made available, so that companies are in a better position also to gauge how they can potentially transit their workers, whether into the B2/C standard coverage or perhaps even the possibility of considering beyond that and what particular arrangements. I also wish to find out if Government would consider enhancing the tax incentives for companies to move to PMBS, with particular emphasis on building company level coverage upon the MediShield Life scheme.

Long-term Care

Ms Lee Li Lian (Punggol East): Madam, this is a topic I brought up in last year's Committee of Supply (COS) and I am raising it again because I have yet to see any progress.

Both the ElderShield and Interim Disability Assistance Programme for the Elderly, better known as IDAPE, need tremendous improvement. Singapore Citizens and Permanent Residents with Medisave are automatically covered by ElderShield at the age of 40. IDAPE is a means tested government assistance scheme meant for elderly citizens who suffer from severe disability and who are not eligible for ElderShield because of their age or existing disabilities.

Currently ElderShield 400 provides a payout of $400 per month for up to 72 months. The last reform done for ElderShield was in September 2007. IDAPE provides $150 per month for per capita household income of $1800 and below, and $250 per month for per capita household income of $1,801 to $2,600.

In the case of IDAPE, the monthly subsidies of $150 and $250 are too low. This only marginally covers the cost of supporting an elderly person who is severely disabled and needs constant and specialised care. The payout period of six years is also too short considering life expectancy has gone up and the elderly person may live for many years with his or her disability, with an unlikely chance of additional income or means. Now, I call on the Government to review both the subsidies and payout period.

Next, I would like touch on the topic of Senior Care Centres. As an ageing society there is a growing demand for such centres. These centres provide a range of aged care services such as day care, dementia care, day rehabilitation and basic nursing services. In a written Parliamentary Question (PQ) reply on 21 October 2013, Minister announced plans to develop 39 more Senior Care Centres by 2016. Now, I would like to find out what is the progress of these developments. How many people are on the waiting list and what is the average waiting time to get into a Senior Care Centre?

Responsibility in the Pursuit of Health

Assoc Prof Fatimah Lateef: Madam, responsibility in the pursuit of Health. We, in Singapore, have one of the more comprehensive and robust healthcare systems globally. Access is readily available and patients do have a choice generally. Our healthcare financing system has a strong foundation and has undergone changes to evolve over the years. Patients and public's expectations too have evolved as we moved from third world to first world nation.

Healthcare is always an issue close to the hearts of citizens. Stakeholders of the healthcare system must ensure they utilise appropriately, avoid wastages, as all these are linked closely to cost, affordability and inflation, and eventually the sustainability of our healthcare system

The stakeholders of the healthcare system must demonstrate responsibility at all levels. Consumers or patients must manage expectations, make realistic goals together with their healthcare providers and plan their treatment and management. They should not demand for unnecessary tests and should keep themselves up to date and educated on their health conditions and issues.

Utilising healthcare services and facilities appropriately is also important. Patients' wish to always have it "cheap, fast and good" is very much also dependent on their choices, demands and usage patterns. They must also learn to focus on health promotion: that is the process of enabling people to increase control over his or her own health and its determinants and thereby improve their health.

For healthcare providers, they need to remain current and relevant in their offer of services and care. Not over-servicing is also important, as this can be an element that leads to increased healthcare costs in totality. Appropriate training, education, patient education, managing their expectations are all necessary tasks. Healthcare providers must also align and understand national policies and so as to best advice their patients and address their queries as well.

Whilst we do regulate and do a lot in the public sector, how about the private sector? This is an area of utmost concern for myself and many practitioners in the public sector.

Employers also must do the needful to keep work places safe and injury free, have the relevant training and education on site for certain industries and their requirements. After all workplace health promotion is the combined effort of employers and employees, as well as society, to improve health and well-being of people at work.

MOH, HPB and the Government must continue to strengthen and evolve the healthcare systems and financing as fit. Public consultations and walking the ground will help policy makers and our civil servants understand issues and policies applicability much better. The clinical practice guidelines serve as an example of an initiative to align practice, for example across both the private and public sectors employees and healthcare staff

Moving forward, how does MOH plan to have long-term sustainability of our healthcare system, align stakeholders and offer more public consultation to hear the voices from the ground? What will be the steps to enhance the often talked about productivity and value measures in our Singapore healthcare system?

Successful Ageing

Ms Ellen Lee (Sembawang): Madam, although much has been done to empower senior citizens to age graciously, there are still many who choose to conform to long held norms such as living quietly and modestly at home, reading, exercising and socialising little and focusing their attention on family and children. To our forefathers this was often accepted as growing old contentedly in a dignified and befitting manner.

Today we believe the Third Age should be lived to the fullest and that we must keep fit both in body and in mind. We should exercise as much as is safe to do so, read and pick up new skills relevant to a fast changing world, volunteer our help where needed and make a difference where we can. In this connection, could MOH please provide an update on how far we have gone in empowering our seniors and what more needs to be done?

The Chairman: Order, I propose to take the break now.

Thereupon Mdm Speaker left the Chair of Committee and took the Chair of the House.

Mdm Speaker: Order. I suspend the Sitting and will take the Chair at 4.00 pm.

Sitting accordingly suspended

at 3.38 pm until 4.00 pm.

Sitting resumed at 4.00 pm.

[Mdm Speaker in the Chair] [Mdm Speaker in the Chair]: ****

Debate in Committee of Supply resumed.

[Mdm Speaker in the Chair]

Head O (cont.) -

The Minister for Health (Mr Gan Kim Yong): Mdm Chair, I would like to thank Members for their comments and questions. If I may have your permission, I would like to show some slides, please.

The Chairman: Yes, please.

Mr Gan Kim Yong: Madam, as we celebrate our 50th year of nation building, let me also take this opportunity to thank our pioneering healthcare professionals, who have overcome a host of public health challenges arising from the lack of proper sanitation and poor food hygiene practices in the early years. As a result of their efforts, the average life expectancy now stands at 83 years, well above most countries, compared to just 65 years then. Infant mortality rates also improved from 26 per 1,000 live births to 2 per 1,000 live births.

Our pioneers also worked tirelessly to train up the next generation of healthcare professionals and nurtured in them the spirit of service and excellence. Mr Harbhajan Singh is one such pioneer. After reaching the retirement age in 2002, he stayed on and to date has chalked up a total of 55 years of service in Tan Tock Seng Hospital (TTSH). Mr Singh was also part of the team of frontline healthcare workers involved in battling the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003, and he stands ready to battle again new emerging infectious diseases such as Ebola. Because of the commitment and devotion of pioneers like Mr Singh, we all can enjoy a modern and robust healthcare system today. Let us say a big "Thank You" to all of them.

Mr Gerald Giam asked about how socio-economic factors affect health outcomes in Singapore. Health outcomes have improved for all Singaporeans, as seen through the overall improvements in life expectancy and reductions in infant mortality. However, as with other countries, there are differences in health outcomes and risk factors across different socio-economic groups.

Using education as an indicator and taking obesity as an example, the 2010 National Health Survey showed that women with PSLE education and below were 1.4 times more likely to be obese compared to those with GCE "A" Level education and above. However, men with lower educational qualifications were less likely to be obese. This compares favourably with a study of 22 European countries, in which less educated women and men were 2.8 and 1.9 times more likely to be obese on average.

Our survey shows that the lower educated have good access to healthcare services and reasonably good outcomes for key chronic conditions, such as diabetes. Healthcare 2020 focuses on further improving access and affordability of healthcare to achieve better outcome for all Singaporeans and especially the more vulnerable. At the same time, we will also help them to have stronger awareness and better understanding of health issues so that they can take personal responsibility of their health outcomes. This is why the Health Promotion Board (HPB) has targeted its health promotion outreach and messages to ensure that these messages and outreach will reach all socio-economic groups. My Parliamentary Secretary Assoc Prof Faishal will elaborate on our health promotion efforts later.

Let me update the House on the progress of Healthcare 2020, as requested by Dr Chia Shi-Lu.

First, on infrastructure developments. Over the last decade, we have added more than 1,200 acute beds, and 500 community hospital beds. From now till 2020, we target to add at least 1,700 acute beds, from our two new general hospitals. This rate of expansion of development is more than double that in the last decade. The Ng Teng Fong General Hospital is scheduled to open by July 2015. I am pleased to let Members know that we have achieved Temporary Occupancy Permits (TOP) for both the Specialist Outpatient Clinics (SOC) tower and the ward tower of the hospital.

Our care model will evolve as our population ages. Mr Low Thia Khiang asked about rehabilitative care. Rehabilitation plays a pivotal role in our care of an ageing population. We are strengthening rehabilitative care by more than doubling our capacity for community hospitals. Minister of State Dr Lam Pin Min will talk more about plans on this area and my Senior Minister of State Dr Amy Khor will share how the Ministry is developing manpower to support rehabilitation, as well as strengthening home and community care.

Our specialist centres are also being expanded and upgraded to better serve Singaporeans. Last year, we opened the new National Heart Centre (NHC) building. By 2019, we will open a new Centre for Oral Health (COH) at the NUH. This will allow us to expand dental services for Singaporeans and provide more training capacity for dentists and dental therapists.

We are also improving Singaporeans' access to quality primary care within their communities. Last year, I announced that we would be building two new polyclinics in Jurong West and Punggol.

This year, I am pleased to announce that we will build a new polyclinic and, in answer to Mr Liang Eng Hwa, this new polyclinic will be in Bukit Panjang. This will serve residents staying in the region. This will also relieve pressure on nearby polyclinics, such as Choa Chu Kang Polyclinic. We will also be redeveloping Yishun and Marine Parade polyclinics to better serve residents there.

Mdm Chair, even as we build more facilities, we also need to continue to find new ways to give better care to our patients.

Our healthcare Clusters have been working with community partners to provide more holistic care for our patients in the community setting. For example, the Eastern Health Alliance (EHA) and its community partners have been deploying professionals together with neighbourhood volunteers to reach out to at-risk residents, through their Neighbours for Active Living programme.

Take Mr Sim, for instance. He is an 82-year-old resident living in Tampines, suffering from multiple chronic conditions. He has difficulties walking after a fall and is currently being cared for by his 75-year-old wife, Mdm Liew. The EHA team checks on Mr Sim to make sure he takes his medication, and applies for the various medical and transport subsidies for the couple. They also bought a walking frame and guided Mr Sim on how to use it. Today, the team regularly calls and visits the elderly couple to make sure that they are well.

Let me now move on to healthcare financing. The Ministry of Health has made three major policy shifts to give patients and their families greater peace of mind about healthcare costs. First, the Government would shoulder a higher share of national healthcare spending. Second, we expanded the use of Medisave and helped Singaporeans to save more in their Medisave accounts. Third, we will increase the role of risk-pooling through MediShield Life.

We have significantly enhanced subsidies, especially for the lower- and middle-income families in the subsidised SOCs and for outpatient drugs. To date, about 360,000 patients have benefited from the higher subsidies. Pioneers also receive additional subsidies. Since September last year, about 340,000 or about three-quarters of all Pioneers have enjoyed the benefits.

One such patient is 70-year-old Mdm Lee Soon Meng. She visits the National Neuroscience Institute four times a year. She used to pay a subsidised rate of $50 for tests and consultation a visit. In September last year, her bill was reduced to $30 due to the enhanced subsidy, then further halved to $15 as she is a Pioneer. For medication, she can expect to pay only $20 a visit this year instead of the usual $80, after taking into account both the enhanced subsidies and her Pioneer benefits.

For those requiring longer term care, we have progressively extended subsidies to drugs prescribed by Intermediate and Long Term Care (ILTC) providers since 1 January this year. Mrs Lina Chiam asked about pensioners' eligibility for pensions coverage in approved community hospitals. Pensioners are eligible to claim for their stay if they stay in Ang Mo Kio-Thye Hua Kuan Community Hospital. Mrs Chiam also suggested that we extend Medisave limits for pensioners in community hospitals. The current withdrawal limit is generally sufficient as it covers eight out of 10 bills. With MediShield Life which covers community hospital stays, almost all patients would see their community hospital bills fully covered by MediShield Life and Medisave. Those who still need help can appeal and we will exercise some flexibility on a case-by-case basis.

Assoc Prof Fatimah Lateef and Dr Chia Shi-Lu have asked about further flexibility for outpatient Medisave usage. We have made steady progress on this second front. Recent Medisave changes include extending Medisave use to outpatient scans. From 1 April this year, under the new outpatient Flexi-Medisave scheme, the elderly aged 65 and above can use another $200 per year from Medisave to pay for outpatient medical treatment at SOCs, polyclinics and participating Community Health Assist Scheme (CHAS) clinics.

We just expanded the list of chronic diseases covered under Medisave and CHAS last year. I am glad to announce that four more chronic conditions – epilepsy, osteoporosis, psoriasis and rheumatoid arthritis – will be covered under CHAS and Medisave use from 1 June this year. This brings the total number of chronic conditions covered to 19, which covers the most common chronic conditions.

Mrs Chiam has proposed for the Chronic Disease Management Programme (CDMP) to cover eczema. CDMP conditions are selected based on professional inputs, taking into consideration various factors, such as disease prevalence and the effectiveness of early intervention to reduce complications. There is currently no plan to include eczema in the CDMP but we will take note of Mrs Chiam's request. We regularly review this programme from time to time. But, meanwhile, Singaporeans can enjoy subsidised treatment for eczema at the polyclinics, SOCs and CHAS GP clinics, a point that Mrs Chiam asked. Those with difficulties can also approach the Medical Social Workers at our public healthcare institutions for assistance.

We will continue to review Medisave use, but this has to be balanced against the need to ensure that our Medisave savings are adequate for our retirement healthcare expenses. In January this year, we increased the Medisave contribution rate from employers to help Singaporeans save more. I hear Dr Chia's call to fine-tune and simplify our Medisave rules, and so we will do that.

Today, let me just explain. There are two limits on the Medisave account. One is the Medisave Minimum Sum (MMS). This is the minimum amount you need to have in your Medisave before you can withdraw your other CPF monies from age 55. The other is the Medisave Contribution Ceiling (MCC). This is the upper limit on your Medisave savings. Any additional Medisave contributions beyond this amount will flow to your Retirement or Special Accounts. Dr Chia has asked if we can consider adjustment to these limits and we will do so.

To simplify the rules, we will remove the Medisave Minimum Sum (MMS). This means that you will no longer be required to use your CPF monies to first top up your Medisave account to the MMS when you apply to withdraw your CPF monies from the other accounts at the age of 55. You only need to follow the withdrawal rules as explained by the Minister for Manpower earlier.

Second, from January 2016, the Medisave Contribution Ceiling (MCC) will be renamed as the Basic Healthcare Sum. This is line with CPF terminology and reflects more accurately that the sum is estimated based on what is needed for basic subsidised healthcare needs in our old age. So, MMS will be removed; MCC will be renamed Basic Healthcare Sum.

Any additional Medisave contributions beyond the Basic Healthcare Sum will continue to be channelled to your Retirement and Special Accounts, and, eventually, will help to increase your CPF LIFE payouts.

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The new Basic Healthcare Sum will be set at $49,800 on 1 January 2016. This is a 2.7% increase over the current MCC of $48,500 set last year. Beyond 2016, we will need to adjust the Basic Healthcare Sum annually to keep pace with the growth in Medisave use by the elderly. This is necessary given rising life expectancy and healthcare expenditure, and given the expanding use of Medisave.

Currently, the annual MMS adjustments are applied to all cohorts, including older Singaporeans who are well into retirement. From 2016, we will fix the Basic Healthcare Sum for each cohort when they turn 65 years, with no subsequent changes in their lifetime, so that members can have more certainty on the amount of Medisave that they should keep for their retirement healthcare needs.

This cohort-based approach for the Basic Healthcare Sum is also similar to the approach that has been taken for the Retirement Sum. We hope that this will make it easier for members to understand and to plan their retirement.

Mr Ang Wei Neng asked for an update on the implementation details of MediShield Life. I thank Members for their unanimous support of the MediShield Life Scheme Bill which was passed in Parliament in January.

There is much for MOH and CPF Board to do before MediShield Life coverage kicks in at the end of 2015. Singaporeans need not apply to join MediShield Life. You will automatically be included. You will be notified of the new premiums and the subsidies you will receive as and when your existing MediShield policy is due for renewal during the one-year period starting end of 2015, when MediShield Life coverage starts. Let me just clarify: the coverage for MediShield Life will start by the end of this year for all Singaporeans, but premium payments will only be due when your existing policy is due over the course of next year.

I want to assure Singaporeans once again that MediShield Life premiums will be affordable. Singaporeans will be able to pay for the premiums using their Medisave. The Government will also help through various forms of subsidies.

The Pioneer Package and the Transitional Subsidies will be given independent of income and wealth. For Premium Subsidies targeted at the lower and middle-income, there is also no need for individuals to apply. Government will use information available in our records to identify those who are eligible and the amount that you are eligible for. But you can help by doing a simple check to ensure that your household information is up-to-date and accurate. In a few months' time, Ministry of Health will be sending out a letter with more details on what Singaporeans need to do. We will guide you along step by step so there is no need to worry.

Mr Ang and Dr Chia also asked about the progress of the development of the Standard Integrated Shield Plan, or Standard IP.

Let me first talk about Integrated Shield Plans or IPs. IPs comprise two parts. The first part is a basic MediShield portion run by the CPF Board. This portion is the same for those without IPs and for those with IPs. They are the same. When MediShield Life is implemented at the end of this year, it will automatically replace the MediShield component.

The second portion is the additional private insurance coverage run by private insurers, typically to cover Classes A and B1 in public hospitals, or private hospitals. In other words, all IP policyholders are already covered by MediShield today and they will be covered by MediShield Life in time to come. Similarly, IP premiums also include MediShield premiums. There is therefore no double coverage, and no double premium.

Many Singaporeans also shared that it was difficult to compare IPs, and wanted a standardised option with enhanced coverage beyond Class B2 and C. Ministry of Health has been working with the Integrated Plan insurers to develop a Standard IP, based on coverage at Class B1 wards. Benefits will be aligned across all insurers, so that the plan can be easily understood. Those looking for enhanced coverage that is more affordable than Class A or private hospital plans can consider this plan, Standard IP. We aim to introduce the new Standard IP in the first half of 2016, soon after the rollout of the MediShield Life this year. This will give time for Singaporeans to focus on MediShield Life, and better understand and adjust to the changes resulting from MediShield Life before the changes to the IPs are made.

To help policy holders to make informed decisions about buying IPs, MOH is working with Monetary Authority of Singapore (MAS) to ensure that insurers present their products more transparently and more accurately. This will also address Dr Chia's concern on IPs.

Most Singaporeans use Medisave to pay for MediShield and IPs. Since every IP policy comprises two parts, it is also timely to consider restructuring the Medisave Withdrawal Limits, or MWLs, for health insurance premiums also into two components. Today, the Medisave Withdrawal Limits, or MWLs apply to the total IP premium, combining premiums for MediShield and the additional private insurance coverage.

Singaporeans are not aware of how much Medisave is being used for MediShield and how much is directed towards the additional private insurance component. With MediShield Life, we will give Singaporeans more certainty, by ensuring that Medisave will always be allowed to cover the net MediShield Life premiums including additional premiums if any, and after subsidies. There is therefore really no need to set a withdrawal limit for this component that applies to the MediShield Life premium. But beyond this, there will be an Additional Withdrawal Limit, or AWL, that will apply to the premium for additional private insurance coverage only.

Today, the withdrawal limit applies to the entire premium of the IP, which comprises two components – the MediShield and the additional private insurance coverage. Going forward, we will restructure this withdrawal limit. Medisave will cover the entire premium that is applicable for MediShield Life for everyone. Therefore, there is no need to set a limit for the withdrawal to pay for MediShield Life premiums. But we do need to set a limit for the private insurance coverage component, and that limit will be called the Additional Withdrawal Limit. The details of that limit will be shared with Singaporeans later.

In setting the new Additional Withdrawal Limits, we will have to balance between helping Singaporeans pay for their IP premiums using Medisave, and ensuring that they have enough Medisave for their other healthcare needs.

Mr Heng Chee How suggested that the introduction of MediShield Life might offer a fresh chance to revisit the concept of portable medical benefits to better protect our workers. I shared last year that a tripartite work group has been formed to look into this. Tripartite partners will be engaging employers to discuss how adoption of portable medical benefits can be further encouraged and I will be very happy to support the work group, if necessary, to ensure that we make progress on this portable medical benefit front.

We also need to help patients navigate their healthcare journey and make more informed decisions. Since 1 September last year, we have expanded our regular hospital bill publications to include "Total Operation Fees" for the public sector.

Mr Pritam Singh asked if the Ministry of Health can look into publishing drug prices. In the public hospitals, charges and subsidies that patients receive for their drugs are reflected in the patient's pharmacy bills in an itemised manner. Treatment and drugs used for different patients will vary, even for the same condition, and drugs constitute only one aspect of the overall treatment. This is further complicated by the subsidies for different groups. Private GPs also adopt different pricing structures for drugs and consultation. Hence, it is more useful to reflect the total bill, as a comparison to help patients make decisions.

Let me now come to the issue of ageing as raised by Dr Chia and Ms Ellen Lee. As noted by Ms Lee, our future seniors will have different aspirations from the current generation. Last year, the Ministerial Committee on Ageing (MCA) announced plans to develop an Action Plan for Successful Ageing.

Since then, we have gone on to engage more than 1,300 Singaporeans through many focus group discussions. Many participants shared with us what successful ageing meant to them, at the individual, community, and at the city-level. At the individual level, many seniors told us that they aspire to have opportunities for learning and employment so as to remain active. Seniors are also keen to volunteer their time and expertise and in doing so, find new meaning and fulfilment in their lives.

At the community level, seniors also enjoy social activities with their families and friends and suggested having more spaces and programmes in the community to support these interactions. At the city-level, seniors also provided useful feedback on how our built environment can be enhanced to make it easier and safer for seniors to move around and stay active, creating a city for all ages.

Respective Ministries will study these ideas and develop specific programmes under the Action Plan. For instance, we are working with Ministry of Education to study how to further expand the scope and scale of learning opportunities for seniors to enrich and empower them.

We are also working with MCCY to make volunteering more accessible, attractive and meaningful for our seniors. Ministry of Manpower and Ministry of Transport have also taken into account the feedback from focus groups and are exploring ways to enhance the employability of older workers, and make our public transportation network more senior-friendly.

Over the next few months, we will be studying and seeking inputs, such as how to promote senior learning and volunteerism, how to support seniors living in our heartlands with assisted living services, and how to promote research and innovation to transform the lives of seniors in the future. These initiatives will help equip our current seniors as well as prepare our future generations of seniors for meaningful ageing. More details will be announced when the Action Plan is ready later this year.

Madam, we are celebrating SG50 this year. Singapore has made good progress over the last 50 years as a young nation. To recognise the contributions of our seniors and to celebrate SG50 with them, we will be introducing the SG50 Seniors' package. Over the past year, MOH and the Singapore Business Federation have partnered more than 100 organisations to develop special benefits to our seniors. These benefits will be available to seniors for a time-limited period in 2015, to recognise their contribution to Singapore and to celebrate SG50 with them. Some of the benefits in the SG50 Seniors package include: i) dining discounts at more than 50 F&B establishments island-wide; ii) discounted or free entry to places of attraction as well as discounts off hotels and travel packages; and iii) complimentary courses offered by Council for Third Age's senior learning providers.

This is one way of bringing the whole society together to celebrate SG50 with our seniors and to honour them with special privileges and benefits.

Dr Chia asked about the progress on our plans to meet the long-term needs for healthcare services. What is next after Healthcare 2020? Even as we continue to work hard on implementing Healthcare 2020, the journey to transform our healthcare system is a continuous one. We have started work to look beyond 2020, to prepare for Singapore's long term healthcare needs.

As Assoc Prof Fatimah has pointed out, the Government and all stakeholders have important parts to play in ensuring the long term sustainability of our healthcare system. At an individual level, enhancing Government subsidies, MediShield Life, Medisave and Medifund will help to ensure healthcare remains affordable to individual patients. But such measures are insufficient on their own – we must also ensure that overall healthcare bill grows at an affordable pace, so that we – as individual patients and as a society – can continue to afford it. We need to ensure that we make the best use of all our available healthcare resources.

Longer-term sustainability also requires that our healthcare providers play their part in delivering cost-effective services. Patients rely on healthcare providers to advise and act in their best interests, and provide treatments that are appropriate and necessary.

My Ministry will be placing more emphasis on developing capabilities in assessing new health technologies, including devices and drugs, to ensure that they are both clinically-effective and cost-effective. This will ensure that patients get the most bang for their buck for the treatment and medications that they receive.

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Our long-term healthcare strategy will involve further and deeper transformative changes to both the way care is organised, as well as the way it is delivered. We have been taking steps towards this by developing community care and setting up Regional Health Systems. We will go further in the next phase to integrate our healthcare system.

In particular, we will also study how to bring together the public, people and private sectors, and explore more ways to strengthen partnerships among various stakeholders to optimise the use of scarce healthcare manpower and infrastructure. Over time, the aim is for one integrated national healthcare system where everyone works together as a team to serve the needs of all Singaporeans.

Mr Alex Yam and Dr Chia asked about our efforts in IT productivity. IT plays an important role in healthcare delivery and we will be launching a new Community Hospital Common System (CHCS) to all community hospitals by end of this year to link up their IT systems with partnering public healthcare institutions. This will help healthcare professionals across acute and community hospitals share information on their patients and improve the patient's care experience.

Mdm Chair, under Healthcare 2020, we have made progress towards making our healthcare system a better one. We will press on with our plans, but we must also look ahead into the future. We have started our planning processes to prepare for the future. We must continue on this journey to innovate and transform our healthcare system to ensure that it is a quality, affordable and sustainable one to keep Singaporeans healthy beyond 2020.

Home-, Centre- and Community-based Care

Ms Tin Pei Ling: Madam, the subject of an ageing population has been extensively debated in the House and I am aware and encouraged that many of the initiatives are underway to meet the demand arising from the ageing population. However, the number of baby boomers reaching their silver years continues to increase annually. With the increase in retirees, the demand for home and community care is expected to rise rapidly as well. Hence, could the MOH share what is the current ratio of applicants for home care and community care to the vacancies available? Could the MOH also share how it plans to increase the capacity at these settings?

Secondly, the growth of qualified manpower must align closely in tandem with the expansion of infrastructure. Caring for elderly requires much human touch and many aspects cannot be automated through productivity measures.

In the UK, for example, one in five nursing homes was found to not have enough staff on duty to provide adequate care. Hence, could the MOH share how it plans to ensure adequate manpower supply for home and community care settings? Could the MOH also share the timeline for the capacity and manpower plans?

Finally, the quality of care services is important, especially for the vulnerable elderly and terminally-ill patients. How does the Ministry plan to improve the quality of care as demand for home and community care rises rapidly?

Providing rehabilitative services is also an important component of delivering good quality healthcare. Facilitating access is therefore just as important. Will the Ministry increase access to rehabilitative services for our elderly within the home or community care settings? These elderly tend to be less mobile and, thus, more vulnerable. Travelling too far from home for rehabilitative services will be too much of a struggle for them and their family members who may have to ferry them to and fro.

Ms Ellen Lee: Madam, with a rapidly ageing population and more people leading a longer life, care for the elderly is inevitable. However, ageing couples who have two or fewer children or no child at all are confronted with the prospect of there being no one to take care of them and their daily needs, especially when they are sick, feeble and weak.

As such, more homes and centres will have to be built to take them in. What is the current take-up rate for home-, centre- and community-based care among the elderly? Given the anecdotal feedback about the long waiting time at certain care centres, what measures have been put in place to reduce waiting time and could MOH provide an update on customer satisfaction levels?

Active Ageing and Hearing Aids

Dr Janil Puthucheary (Pasir Ris-Punggol): Madam, Singapore's fast-ageing society will bring about a host of challenges and issues in healthcare that may require a rethink in terms of how we provide assistance to those who are in need.

One particular area which I would like to highlight which requires more attention is people who suffer from hearing loss. The increase in number of seniors who have gone through evaluation tests from hearing loss: 6,800 in 2010 up to 8,600 cases in 2012 and the figures will keep increasing. There is no single cure for age-related hearing loss because there is no single disease and often there is no specific disease but rather a process of associated with advancing age.

People of any age with hearing loss become more socially isolated, become less able to contribute to conversations and are unable to engage effectively with family and friends and be part of everyday social life. This can lead to a significant reduction in the quality of life as it impacts on social interactions, the willingness to venture out of one's home, the ability to easy access public resources and the enjoyment of culture entertainment in public spaces.

Hearing aids help and often can be life changing but they are extremely expensive, especially those that are comfortable and provide good sound quality. Prices range from $500 to as high as more than $6,000. With an average life expectancy of a device about five years, there is also a significant recurring cost. Very often a senior using a hearing aid for the time will choose a simpler, cheaper model but then becomes frustrated with the fit and the sound quality, and end up not using it, retreating back into relative social isolation.

There are a number of mechanisms to assist in the purchase of hearing aids from the Centre for Enabled Living, the Agency for Integrated Care. These are means-tested and much appreciated by the beneficiaries. The real problem is the underlying cost which is a significant barrier.

A hearing aid is essentially a microphone, a speaker and a processor. These are components in every smart phone which retail for significantly less. The engineering has to be of a high quality for it to be adequately miniaturised. But the two main reasons for the high cost are the market oligopoly – there are about six companies worldwide, three are active in Singapore – and the regulatory framework for these devices. The second factor, the regulatory framework, imposes a high cost on the development and testing processes of a new model and further constrains the process by which can be made available in the market only through licensed practitioners.

I would like to suggest that this is an area ripe for disruptive innovation. If we in Singapore could develop a cheap and effective hearing aid, leveraging on the excellence in precision engineering that we have, together with the biomedical sciences we could have a product or a series of products which will have significant market as the rest of Asia ages along with us. We will engage two of the growth clusters – applied health sciences and advanced manufacturing – described in the Budget.

How might we do this? We could begin by supporting this initiative within the engineering departments of our Institutes of Higher Learning with dedicated research grants. We could have a prize offered on a shared basis by both the public institutions and the private sector to incentivise the Singaporean start-up to translate the engineering into a product to bring to market.

We would also need to change to the market environment, firstly, by making the use of hearing aids more socially acceptable. I am always struck that the taxi uncles and various people are quite happy to have a very large Bluetooth earphone, sometimes with a blinking light, but the seniors, including my elderly relatives, are very concerned that their hearing aid are as discreet as possible. What if we develop a hearing aid that was externally indistinguishable from the Bluetooth headphones or the iconic white headphones of a particular brand of smart phone.

Further, in order to incentivise the research and the business, we could make some changes to ensure that they will have a larger market to serve by increasing the number of seniors who would be eligible for a subsidised hearing aid provided that it was locally developed and below a certain affordable cost.

One further variable would be the issue of the regulatory framework. I agree that the recommendation, prescription, maintenance and ongoing service of the device and the user should continue within a well-regulated framework as cause of hearing loss may well be a disease. However, headphones that are used for listening maybe worn for just as much time and may potentially generate just as much damage if used incorrectly.

To classify one as medical device and the other as an IT peripheral is anachronistic and adds to the cost burden of developing a new product. I would suggest that this regulatory framework should be studied and reviewed with the aim of reducing the cost required to develop and own a new product.

All these would, hopefully, give a few Singaporean businesses the foundation, the research grounding, the market and market experience to have high quality, affordable locally-developed hearing aid that might be able to serve the needs of a rapidly ageing Asia.

We spent millions of dollars in altering our physical environment so as to provide barrier-free access to our citizens who face challenges in mobility. There are other barriers that can prevent one from seamlessly integrating with the society on a daily basis. I have highlighted hearing loss as one, and I hope that the Ministry will see this as a pressing need in making Singapore a more inclusive society for all.

Disability Prevention

Ms Chia Yong Yong (Nominated Member): Mdm Chair, disability is not someone else's problem. It can affect anyone of our loved ones. It can affect any of us, at any time, at any stage of our lives. Even without accidents or illnesses, we lose our functional abilities as we age. It is therefore important that we should effectively create greater awareness and understanding of the risks of disability and the measures to prevent or mitigate disabilities.

I request the Government to consider public education initiatives to reduce the incidents and to mitigate the degree of disabilities. I know we can never achieve zero disability but let us try to reduce and do what we can to mitigate. Such initiatives may address risk factors, early detection and management of complications and loss of functions. I am not talking about medical intervention. I am not even talking about Allied Health Professionals being involved in this. But how do we educate our members of the public, people who live in our own HDB flats, in our own homes to be able to detect the early onset of a disability or the early onset of complications arising from a disability?

Relevant measures also would include taking such public education initiatives to schools, to workplaces and to just the public in general. As such, public education should be taken on a focused basis as well as holistically because it is a part of public health. As much as we good in conducting campaigns, I hope the Government would also consider more public education initiatives in this respect and I await the Government's response.

Mental Health and Wellness

Assoc Prof Fatimah Lateef: Madam, mental health considerations and interventions must continue to be mainstreamed into healthcare development plans and policies. We must also continue to support and strengthen organisations of people with mental health problems, psychosocial disabilities, as well as their families and caregivers. With the Mental health Blueprint, progress has been made but we still have far to go.

As in other areas of medicine, there must always be considerations for evidence- based protocols and practices, incorporation of human rights principles, respect for individual autonomy and effective collaborations.

Moving forward how does MOH plan to align with the Global Mental Health Action Plan 2020? Will there be new programmes or framework to enhance and integrate with the existing ones: at the primary level, through mental wellness programmes and intervention strategies; at the secondary level, from early intervention and control of symptoms and to maintain stability of disease; and, at the tertiary level, for rehabilitation and recovery to be optimised for all our patients.

The issue of stigma continues to plague us as well. There are still patients and relatives who refuse to seek care and treatment at IMH. They would rather be attended to by psychiatrists and doctors in other hospitals. Can MOH work with the relevant mental health partners to help with publicity, creation of awareness and appropriate understanding to help reduce stigma and to assist the public and family members to be empowered to handle persons in mental health crisis? The mass media, too, has a critical role to play in aligning with this. Better still, a whole-of-government and media approach and alignment would be optimal.

Finally, can I ask MOH if we can consider having some empowerment course such as skills to handle family members with mental health diseases under the new SkillsFuture scheme?

Mental Illness

Mr Low Thia Khiang: Madam, in December last year, the state coroner concluded that a woman was found to be in a "profoundly unsound" state of mind when she killed her elderly mother before jumping out of her flat to her own death. Her teenage daughter was in the flat at the time while this tragedy unfolded. The state coroner also found that the woman had never been formally diagnosed with a mental illness while alive, although she told her family that she was hearing voices and was displaying signs of paranoia.

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This tragedy illustrates how difficult a problem mental illness is in the community. Often, patients who suffer from mental illnesses or conditions refuse any efforts at intervention, medical or otherwise. Those who have been treated may also fail to follow-up on their treatment or medication, resulting in their conditions relapsing or even worsening. Their family members may also find it difficult to know what needs to be done or even recognise that their loved one may be suffering from a mental health condition and need intervention. Fear of social stigma together with the lack of awareness by both the patient and the family only serves to make matters worse.

In 2012, when I raised the same subject in this House, Minister of State assured us that MOH will take a whole-of-Government approach to meet the needs of persons with mental illness and their caregivers. In 2014, we were told that there have been measures put in place by Institute of Mental Health (IMH) to track those receiving outpatient treatment.

Minister of State mentioned that IMH is enhancing its capacity in this area. Does this mean that IMH is now effectively tracking outpatients? If so, what is the frequency of contact with the patients? Also, what would IMH do in cases where patients or potential patients refuse treatment, or do not respond to home visits?

Community Mental Health

Ms Ellen Lee: Madam, the Community Mental Health Plan had a three-pronged focus: increasing awareness, expanding early intervention capabilities and integrating care with the community care. Could MOH provide an update on progress made so far?

Specifically, what outreach efforts have been effective in improving early detection and was there a focus on depression which is on the rise among senior citizens? Was the pioneering effort by Changi General Hospital to develop home-based mental health services duplicated in other hospitals? What is the number of adult Singaporeans who have benefitted from the impetus to integrate care with the community? Finally, how will initial directions in the Masterplan be taken further?

Ms Tin Pei Ling: Madam, mental health stigma remains an issue. Raising awareness and educating the public about mental health issues are not enough to combat the stigma that sufferers face and therefore, not enough to encourage them to step forward to seek the help that they need.

Real day-to-day problems, for example, neighbour disputes over alleged smells and conspiracies to fix each other, poor personal and home hygiene, littering, noise disturbances to neighbours, and the list goes on. These issues that are left unsolved threaten to deepen the prejudices that people may have of those suffering from mental health issues. The animosity in turn makes it more difficult for those suffering from these conditions or even their family members to consider the issue and seek professional help. As a result, the problems such as the ones highlighted above continue to worsen and the rift between neighbours continues to widen.

Allow me to share an example. There is a retiree couple living on the ground floor of one of the HDB blocks in my area. Their neighbour on the top floor was alleged to have been pouring liquids out of the window on a daily basis, thereby soiling the clothes of the nine other family members below this unit. Affected neighbours believe that these acts were committed by a person of unsound mind. The retiree couple are very troubled by the daily recurrence of such acts, with the wife observably distressed. The retiree couple's daughter, who is well-educated and apparently working in the legal profession, has been very upset over the matter after observing her mother's distress.

Let me quote parts of her email, "While one sympathises with the perpetrator whom we understand is of unsound mind, his family members should be put in place in terms of the responsibility of the perpetrator's action. However, it does not change the fact that at the very least, nine other households have suffered and are still, as a result of his actions.

Action may be taken against the family of the perpetrator, who should be responsible for his well-being and in ensuring that he does not commit acts which causes nuisance, suffering to others. If the family in question is incapable of fulfilling such a basic task, then perhaps he should be placed in the care of those who are capable."

Meanwhile, the unit on the top floor felt that they had been bullied by the lower floor neighbours and became defensive.

While we had sought help from various agencies, ranging from NEA, HDB, Town Council and AIC, and while they are still investigating the matter, it is clear from the statements made by the daughter that if we do not resolve the root cause of the matter, the vicious cycle will perpetuate. Moreover, such statements coming from a well-educated individual whom I believe should understand reason. Hence, it is imperative for the Government to put in place stronger measures to ensure professional help and adherence to treatment for those suffering from mental health conditions so as to help them better control their behaviours. Otherwise, the rift will never close and the stigma will never go away.

More importantly, let us help those people from mental health issues get back on track in life. At present, there is no effective mechanism to ensure that those suffering from mental health issues seek help or treatment unless they pose a threat to others or if they have pre-existing records with IMH. However, many of the protagonists in these problems do not meet these criteria. They may engage in verbal fights but pose no physical harm to others. Given that they resist seeking professional help, it also suggests that they never had an insight to their condition and with the stigma against them, that possibility is even more remote. Through community engagements and partnerships, I have observed the commendable effort put in by agencies and community partners in persuading family members to convince the person to seek help. However, this too has limitations.

Therefore, I would like to ask, what measures will the MOH take to resolve this?

Meanwhile, I am aware of and I am appreciative of the various community mental health efforts involving community partners being rolled out in recent times. Therefore, could the MOH also give an update on the latest community mental health plan, its implementation so far, whether there have been positive tangible outcomes observed and how does the MOH intend to proceed from here.

Manpower Issues in Public Healthcare

Mr Patrick Tay Teck Guan (Nee Soon): Mdm Chair, with the set-up of many more public healthcare institutions and facilities across Singapore in the coming years, I am particularly concerned with three areas and urge MOH to pay particular attention to them.

Firstly, whether we can find sufficient healthcare staff and manpower to fill the positions. Secondly, whether we can ensure healthcare workers stay motivated and not be over-stretched. And thirdly, whether we can continue to maintain the quality and high standard of care.

Our healthcare tripartite cluster workgroup set up in September 2012 has set our sights to do more in the next three years in the area of productivity. I therefore urge MOH and the management from the six public healthcare clusters to provide the much needed support and to help drive and implement the initiatives.

Recently, MOH has been paying special attention to the compensation and retention of doctors, nursing staff and allied health professionals. I therefore urge MOH to also review the salaries and retention of the non-nursing staff and employees who work alongside these healthcare professionals in our public healthcare institutions as they too provide the necessary support and are the backbone to ensure the entire healthcare eco-system works.

Workplace Health Grant for Women

Ms Tin Pei Ling: Madam, women today are adept in playing multiple roles as mothers, spouses and employees. In trying to fulfil these roles and responsibilities well, it is imperative that the woman's own health must first be well taken care of. I am heartened to know that the Workplace Health Promotion (WHP) Grant for Women's Health was offered at workplaces. By taking advantage of the grant, employers are helping women employees to benefit from better access to programmes such as health screenings and talks on women related health issues.

I would like to ask the Minister if he could share the take-up rate of the WHP Grant for Women's health since its implementation, types of services and activities implemented by workplaces so far with this grant and if the Health Promotion Board has achieved its outreach target of 100 workplaces. Also, I will be keen to find out if the Ministry has plans to increase the awareness, accessibility and scope of the WHP Grant to promote screening and education on general women's health.

Ms Ellen Lee: Madam, at its annual conference in 2014, the PAP Women's Wing highlighted the widespread tendency among women to place their health low down in their list of priorities. Coupled with the demographics on the number of years women spend in managing chronic diseases in old age, there is an urgent need for more incentives to be provided for women to pay attention to their health. Could MOH provide an update on the proposed workplace health grant for women?

The Senior Minister of State for Health (Dr Amy Khor Lean Suan): Mdm Chair, with your permission may I display some slides?

The Chairman: Yes. Please.

Dr Amy Khor Lean Suan: Mdm Chair, in the next few decades, our population will age more rapidly, and we need to plan ahead to ensure that our aged care system is future ready.

Ms Tin Pei Ling and Ms Ellen Lee spoke about ageing in place and asked about our plans for home and community care. MOH will expand home and community care as the anchor of our aged care system, because we want to fulfil our seniors' aspirations to age in place and enable children to take care of their parents at home for as long as possible.

Over the past four years, MOH has been building up capacity rapidly, and enhancing the quality and affordability of home and community care. Since 2011, we increased the number of home care places by 2,700 and the number of home palliative care places by 1,200. We have also increased the number of day care places by 1,000. This expansion will be an on-going effort that will span a number of years, because population ageing will be massive in the next decade. By 2020, we can expect 10,000 home care places, 6,200 day care places and 6,000 home palliative care places.

Dr Amy Khor Lean Suan: This year, we will open the provision of subsidised home and community care services to the private sector just like what we have done for nursing homes. Operators whether VWO or private can tender to provide these services. These operators will be selected based on care models and affordable fees. Recently, we launched a Request for Proposal (RFP) under the Build-Own-Lease model for a Senior Care Centre at Ci Yuan CC that is open to both the VWO and private sectors. Providers have to tender to operate day services in the senior care centre as well as offer home care services out of the centre.

Ms Tin Pei Ling and Mr Low Thia Khiang asked about rehabilitation services. Yes, we anticipate an increase in rehabilitation needs with an ageing population, so we have been adding capacity in community hospitals, day centres and home rehabilitation, including an upcoming day centre at Kaki Bukit. In addition to the expansion of day centres, which will mean more day rehab places, we are also adding capacity in community hospitals.

The fact that elderly may not follow up with rehab could be due to other factors as well, such as no transport to day rehab. This April, we will enhance transport subsidies under the Seniors' Mobility and Enabling Fund (SMF) so that more seniors can benefit from it. We will extend transport subsidy under SMF to all seniors requiring some form of mobility assistance and not just to wheelchair bound seniors attending rehabilitation and dialysis services or those attending dementia day care services, to get to MOH-funded eldercare and dialysis centres. The level of funding support given will be based on mobility needs, and MOH will provide more funding support to eldercare providers to arrange for specialised transport for less ambulant seniors.

MOH expects to provide additional funding of some $14 million from the SMF to support eldercare providers to provide transportation to clients. An additional 1,000 elderly will benefit from this enhancement, up from some 2,000 seniors now.

We are also piloting tele-rehab which can further enhance the access of patients to rehab services, without even needing them to leave home.

We raised subsidies for intermediate and long-term care in 2012, including for day rehab services. We also started subsidies for home rehab last year. Since subsidies started from 1 April last year, some 370 patients have benefited as at the end of 2014. The number of patients on home rehab annually has steadily increased from 302 in 2012 to 731 in 2014.

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Between 2010 and 2014, the number of physiotherapists, occupational therapists and speech therapists in the public healthcare and ILTC sectors has grown by about 40% to more than 1,200 today. The total physiotherapy and occupational therapy intakes at Nanyang Polytechnic have increased by 58%, from 104 in 2007 to 164 in 2014. Similarly, the biennial intake for speech therapy at the National University of Singapore has increased by 15%, from 20 in 2007 to 23 this year.

We will continue to review the manpower demand and supply regularly, and build up the local training pipelines. We have also worked with some home and community care providers to redesign jobs and train Singaporeans to take up jobs in providing maintenance rehabilitation.

While it is important to enhance capacity, we have also worked to improve the quality of home and community care. Last year, we announced the development of the new home-based care, community care and palliative care guidelines. We have since conducted a series of focus group discussions with providers, patients and caregivers. There has been overwhelming support and some suggestions to enhance the guidelines, which we have incorporated. The home-based care and community care guidelines have now been finalised and AIC will work with providers to make improvements to their quality of care based on these guidelines.

Sir, we agree with Dr Janil Puthucheary that more can be done in the area of innovation related to successful ageing. MOH's National Medical Research Council has earlier provided grants for innovations related to hearing problems in seniors. We will study with A*STAR and NRF on how to promote research, innovation and market access of products needed by our seniors, including hearing aids. Currently, Singaporean seniors who are 60 years old and above with hearing difficulties can apply under the SMF or Seniors' Mobility and Enabling Fund for up to 90% subsidies to defray the cost of hearing aids. So far, more than 1,400 seniors have benefited from SMF subsidies for hearing aids. The SMF is the main source of help for Singaporean seniors while the Special Assistance Fund (SAF) targets persons with disabilities of other age groups. A senior who is eligible for SMF will not be eligible for the SAF. AIC works closely with SGEnable to refer applications to the appropriate fund. Since July 2013, close to $17 million in subsidies have been disbursed from the SMF.

Caregivers are the unsung heroes of home and community care. We need to support them and encourage them. Last year, we announced the establishment of respite care services in Eldercare centres during weekends on top of existing nursing home respite care services. Caregivers can drop off their loved ones for a few hours to run their errands or just chill out. We now have 280 places each weekend, since introducing the service in April last year. To date, more than 500 seniors have benefited from both services.

Sir, we also need a senior-friendly urban environment so that seniors can move around independently and safely.

Ms Chia Yong Yong asked about falls and disability prevention. We have started community efforts to prevent falls among seniors. Under the City for All Ages project at Marine Parade, we took a holistic approach to preventing falls. We screened seniors for fall risk, and conducted seminars for seniors and their caregivers to understand how to prevent falls. We twinned this with hardware retrofits in the town and home retrofits. The home retrofits are now part of the EASE programme under HDB. We will do more in public education as suggested by Ms Chia Yong Yong.

Assoc Prof Fatimah Lateef, Ms Ellen Lee and Ms Tin Pei Ling asked about the progress of our community mental health efforts and our plans ahead. Mr Low Thia Khiang asked about our approach to mental health patients living in the community.

Sir, we believe that it is possible for psychiatric patients to stay well in the community, if we set up a good system to support them. Let me elaborate.

First, the Institute of Mental Health (IMH) has in place an after-care programme to support discharged patients who are assessed to be at higher risk of default or had more severe illnesses. IMH reminds these patients of their follow-up treatment through regular telephone calls and even home visits when necessary.

Second, IMH has put in place a 24-hour Mental Health Helpline to provide immediate support for patients and their caregivers whenever needed. Community partners can also call the hotline, regardless of whether the cases have pre-existing records with IMH. If a patient refuses or defaults on treatment, IMH will work closely with family members, caregivers and other community partners to engage the patients.

Sometimes, it does take a village to enable patients to recover and recover well in the community. Hence, a third area is to further strengthen community support by building local community support networks (LCSNs) among grassroots leaders and volunteers, social work agencies, the Police and town councils, to enable them to respond to residents who may have mental health issues. Over the past year, we have been in touch with over 20 constituencies and trained over 400 grassroots leaders and volunteers. Take Kembangan Chai Chee (KCC) as an example. A network of volunteers comprising 120 grassroots leaders, volunteers and partners have been given basic mental health and eldercare education, and are equipped to identify residents in need and link them to various help needed.

Finally, we want to enhance the capability of primary and community care to help detect and support the treatment of mental health patients. Since 2012, we have partnered and trained 70 GP partners to attend to mental health patients. We established nine community-based specialist and allied health teams to support GPs with clinical advice and allied health services. To date, these teams served over 4,700 patients, providing them with access to holistic care closer to home.

MOH launched the Community Mental Health Masterplan in 2012 to strengthen access to psychiatric care. With the pilots that we have started in the past two years in primary care and fostering community support systems, we are ready to scale up our efforts over the next three years.

First, we aim to train and partner 120 GPs and set up a total of 17 allied health and specialist-led teams in the community with a total capacity to serve up to 21,000 clients by 2017. Second, through our outreach, we hope to set up similar local community support networks and engage a total of 50 constituencies. Third, we target to expand IMH's aftercare services and enlist more community-based VWO teams to provide long-term support. Together with the constituency-level community support, these community-based aftercare teams aim to serve around 5,000 clients by 2017.

We will also beef up our capability to support seniors with dementia, under our community mental health plans. According to a recent study conducted by IMH on the Well-being of the Singapore Elderly (WISE), we understand that the prevalence of dementia amongst seniors aged 60 years and above is 10%. Hence, with an ageing population, there will be more elderly with dementia in the future.

We will enhance the capability in public hospitals and the community for seniors requiring assessment for dementia. To date, we have expanded capacity in six outpatient memory clinics in the public hospitals to provide early assessment and intervention for dementia patients. Specialists from the RHSes will also partner 50 GPs to manage dementia clients within the community.

We will also be scaling up the capacity of community based dementia care services. As of December last year, we have put in place around 650 day dementia care places, increased the number of eldersitters to 90, and put in place 575 dementia nursing home beds. By 2020, we will increase day dementia care places to at least 3,000, increase the number of eldersitters to 160 and increase dementia nursing home beds to 1,970 beds.

We will expand our partnership with voluntary welfare organisations to outreach and educate seniors and their caregivers on how to pick up early signs of dementia and seek help. We will more than triple the number of community outreach teams from the current seven to 24 teams by 2017, to reach out to seniors island-wide.

In addition, we want to put in place support programmes to help caregivers of dementia patients cope. For example, we have the dementia home intervention services for caregivers of seniors who display behavioural issues. For caregivers who need time away from their caregiving duties, we have put in place the weekend respite care and eldersitter service.

We are partnering some VWOs to innovate new responses to support patients and caregivers. For example, Montfort Care set up the Happy Kopitiam located at Marine Drive and Telok Blangah. This is led by a social worker with the help of volunteers to provide caregivers with education, support and respite care. Both caregivers and clients are also encouraged to participate in activities together. And this is an example of a ground-driven initiative to enable our seniors to age gracefully at home without over-medicalising our care.

We will be embarking on a major ramp up of our health and aged care services in the next five years. We need more Singaporeans to join us in our mission to provide the best care for our citizens. And this is a concern that is also shared by Dr Chia Shi-Lu, Mr Patrick Tay and Ms Tin Pei Ling.

To support these expansions, we have estimated that the healthcare professional workforce will need to grow by about 50%, or 20,000 more between 2011 and 2020.

We are on track to meet our manpower needs. Our healthcare professional workforce expanded by 9,000 between 2011 and 2014. We are expanding the local training pipelines and would also like to see more mid-career entrants, especially women re-entering the workforce and retired nurses, to join us.

There is a wide choice of employment locations near home, especially in the aged care sector. AIC has been working with WDA, NTUC, e2i and CDCs to organise geographically-targeted recruitment fairs to attract more residents to take up jobs in the ILTC sector. Since April last year, AIC has co-organised 20 recruitment fairs and will continue to do so this year.

Our work to enhance the attractiveness of healthcare careers will continue. MOH will continue to review salaries regularly for all healthcare staff to recognise their contributions fairly and to keep pace with the market. Beyond remuneration, our public healthcare institutions and aged care providers have enabled healthcare staff to better meet their work-life priorities through flexible employment options and part-time work arrangements. There is also progress in adopting IT innovations to lessen the administrative work of healthcare staff. With less time spent on administrative work, our Patient Service Associates (PSAs) in Tan Tock Seng Hospital, for example, can then be up-skilled to take on certain roles that are traditionally performed by pharmacy technicians or nurses. PSAs' career progression is enhanced, while nurses and pharmacy technicians have their time freed up to focus on more complex work.

Let me now move on to issues on women's health.

Ms Ellen Lee and Ms Tin Pei Ling asked for an update on the workplace health grant for women's health. Sir, the Women's Health Advisory Committee (WHAC), which I chair, introduced the Workplace Health Grant for women in July 2013. Organisations may use the grant to encourage female employees to go for breast and cervical cancer screening and organise women's health talks on chronic diseases and other conditions, and it has been well received. As of February this year, 71 out of the 78 applications have been approved and we are on track to reach out to 100 companies by end of this year. Moving forward, HPB will encourage the uptake of the grant and women's health programmes at the workplaces.

Sir, our vision is to achieve graceful ageing in place in a community for all ages. We will realise an aged care system that is anchored by home and community care, as well as strong community support from fellow Singaporeans. In the next 50 years, I am confident that Singapore will remain an inclusive and caring home for all.

Primary Health Care

Mr Ang Wei Neng: Sir, in Mandarin.

( In Mandarin ) : [Please refer to Vernacular Speech.] With the introduction of the Pioneer Generation Package, MediShield Life and more outpatient subsidies, more Singaporeans will visit the polyclinics and other primary health care services. Hence, I am very pleased to hear the announcement by the Minister just now that we will be building three new polyclinics. I would like to ask the Minister whether MOH will be expanding the current 18 polyclinics and build new ones? At this juncture, I would like to add that Jurong Polyclinic is one of the most crowded polyclinics in Singapore with a high number of patients and very long waiting time. Is there an immediate plan to expand its capacity or build a new polyclinic in Jurong?

I would also like to ask the Minster whether MOH have plans to further tap the 1,500 private medical clinics to supplement the current network of polyclinics? We have heard stories that certain CHAS clinics have been overcharging patients with PG cards, offsetting the subsidies they are receiving. Will MOH consider setting up a hotline for Singaporeans to report on such abuses? Thank you.

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Enhanced Primary Care

Mr Zainal Sapari: With a growing elderly population, and a growing chronic disease burden, there is an urgent need to manage wellness and prevent or delay health problems. The primary care sector must be supported to take on bigger roles in areas such as management of chronic illness, mental health and in-community ageing. I would like to ask Ministry of Health if there are any plans for further enhancement of the primary care in Singapore.

Deal with Shortfall of Delivery Doctors

Ms Kuik Shiao-Yin: A recent poll by the Obstetrical and Gynaecological Society of Singapore discovered that almost half of our obstetricians say they will stop delivering babies within the next five years. A quarter of them actually say they will stop delivering babies within the next 11 months.

What has changed? Apparently, it is insurance. A person has up to 24 years from birth to sue a doctor for any negligence or accident that caused permanent damage. Doctors protect themselves from potential multimillion dollar lawsuits through insurance. Most of our doctors are insured under London's Medical Protection Society but the Society has just decided to lower their coverage. Given the suddenly higher cost of practice, many now feel it is either (a) not worthwhile to carry on; or (b) they need to seriously jack up their patient fees to save up for future coverage.

Our private sector insurers are unlikely to offer a solution because it is not commercially viable, so MOH may be the best solution. If it is a national imperative to keep our birth rates up, then we must make sure there are enough doctors to deliver the babies.

Can the MOH help provide post-retirement protection that will help obstetricians stay in the business? And as a Plan B, would MOH also train and elevate more qualified midwives to stand in the gap for less complicated births?

Healthy Living Masterplan

Mr Gan Thiam Poh (Pasir Ris-Punggol): Mr Chairman, I support the Healthy Living Masterplan's objective to create a conducive environment in which healthy living is accessible to all Singaporeans. I would like to ask the Ministry how it will raise the standards and quality of healthcare, about the progress of the Master Plan, how the various initiatives have been performing and if they are gaining traction among Singaporeans. Will there be new projects in this coming year? What are the areas of difficulty and what can be done to minimise potential problems?

( In Mandarin ) : [Please refer to Vernacular Speech.] As long as we can keep ourselves healthy, we shall have no worries at all. Every generation will enjoy MediShield Life and we shall live happily ever after.

The Minister of State for Health (Dr Lam Pin Min): Mr Chairman, I would like to thank Members for the points raised earlier. Sir, if I may have your permission to show some slides during my speech.

The Chairman: Yes.

Dr Lam Pin Min: Since 2012, we have taken significant steps to make primary care more accessible and affordable to Singaporeans through our network of primary care facilities.

Under the Healthcare 2020 Masterplan, MOH's key thrust for primary care was to better tap on GPs in the private sector to improve the access, quality and affordability of primary care. Part of the plans was to introduce new innovative care models such as our Family Medicine Clinics (FMCs) and Community Health Centres (CHCs).

Since then, we have developed six FMCs and six CHCs. Patients, especially those requiring care for chronic conditions, now have more options for their medical follow-up. One example is Ang Mo Kio FMC, which has been serving patients in the Ang Mo Kio and Central areas since 2013. Care managers identify suitable patients who can be referred to the FMC, and share with them the services and benefits available there. Because patient volumes at the FMC are lower, waiting times are shorter. Moreover, patients visiting Ang Mo Kio FMC will get to see the same family doctor across visits, and are also assured of the same level of care as experienced at the polyclinic.

One patient who has benefited from visiting Ang Mo Kio FMC is Mdm Betty Lee Oi Neay, aged 67 years old, who has both diabetes and hypertension. At the age of 38, Mdm Lee was referred by a heart specialist to Ang Mo Kio Polyclinic. In 2014, she moved to the FMC. She is happy to visit the FMC as she only waits 20 to 30 minutes to see the doctor. With her Pioneer CHAS benefits, she does not need to pay much for each visit.

The FMCs have also encouraged shared care programmes between hospitals and GPs, and reinforced the role of GPs as "first-line" doctors. For example, the National University Hospital (NUH) has been referring selected patients from its Specialist Outpatient Clinics (SOCs) to Frontier FMC. Linked up through a common Electronic Medical Record system, family physicians from Frontier FMC share and care these patients with their hospital colleagues, and meet regularly to jointly review their patients' care plans. Patients have benefited from this collaboration.

One example is Mdm Ang Hwea Kee, an 86-year-old lady with multiple chronic conditions. Before her first visit at Frontier FMC in July 2013, she had been admitted four times in one year to NUH. The FMC primary care team has worked together with NUH specialists to care for her, including adjusting her medication doses when needed. Since her first visit to the FMC, she has not been re-admitted to NUH nor visited its emergency department.

Mr Zainal Sapari and Mr Ang Wei Neng asked about our plans to enhance primary care services and work closely with the GP sector. We will continue to try out new care innovations to benefit patients. The FMC model is relatively new and we will continue to test it out. By the end of this year, we will open a seventh FMC at the upcoming Ci Yuan Community Club (CC) at Hougang Avenue 9.

In addition, we have planned for a new primary care development at Sembawang. The Sembawang Primary Care Centre will be developed by a team from Alexandra Health System (AHS). It will be a test-bed for the introduction of new care models, innovative ideas and care processes.

Among the CHCs, one of our CHCs adopts an innovative model of running on wheels and providing mobile services to residents living in Bishan-Toa Payoh, Hougang and Whampoa. With its pit stops at various Community Clubs and HDB car parks, patients are able to access services, such as diabetic foot screening nearer to their homes. Patients who have benefited include Mdm Sarasvathy d/o Rama Panickar, who has diabetes. With the Mobile CHC at Hougang Community Club, she can walk a short distance on her own to the CHC for her screening, and feel more independent.

As Minister Gan Kim Yong mentioned, besides building a new polyclinic in Bukit Panjang, we are also redeveloping Yishun and Marine Parade polyclinics. These expansions will allow us to meet expected demand even as the population in the estate grows and ages. Yishun Polyclinic will be redeveloped at a permanent site at the junction of Yishun Central and Yishun Avenue 9 by 2018, and expanded. Marine Parade Polyclinic at Marine Parade Central will be expanded from its current single storey to two storeys by 2016. Construction of Jurong West and Punggol polyclinics will begin later this year.

Whilst polyclinics remain an important part of our primary care system, our private GPs still provide the majority of primary care in Singapore. We have regularly enhanced CHAS since 2012, enabling us to leverage on the capabilities of GPs to expand our primary care network. Most recently in 2014, we opened up CHAS to all ages and further raised the monthly household income per person to $1,800.

With the Pioneer Generation Package, all Pioneers will benefit from CHAS. This means that there are now 1.2 million Singaporeans eligible for CHAS, more than double from a year ago. Similarly, the number of CHAS GP and dental clinics has also increased, from about 800 to over 1,300 over the last year.

I would like to reassure Mr Ang that measures have been put in place to prevent overcharging of CHAS and PG patients. Prices charged by private GPs differ from clinic to clinic and from patient to patient, depending on the patient's condition, treatment provided, medications prescribed and length of consult. It also depends on the pricing structure of GPs. But we expect CHAS GPs to price reasonably, bearing in mind CHAS patients are expected to be lower- to middle-income. MOH closely monitors CHAS claims submitted by clinics, and clinics will be called upon to account for any exceptional claims. CHAS GPs should make their charges transparent. We encourage patients to clarify charges and ask for itemised receipts if they are unclear.

Together, the polyclinics, FMCs and CHAS clinics provide good quality, subsidised care to Singaporeans – close to their home. Today, over nine in 10 HDB dwellers live within 15 minutes, by public transport, of a polyclinic or CHAS clinic.

To plan for future healthcare needs, quality manpower is also needed. We will do more to retain and train doctors within the primary care sector.

We have been training more GPs with post-graduate qualifications, such as the Graduate Diploma of Family Medicine and Master of Medicine (Family Medicine). We need to better harness existing talents in the private sector. As part of our Family Physician (FP) development plan, we will offer funding support for selected candidates, to encourage more doctors to undergo post-graduate training in family medicine. This will allow us to raise the standards of Family Medicine training, and ensure a consistent supply pipeline of capable family doctors.

So what is next for the primary care landscape? We have made progress in strengthening primary care and will continue to plan ahead and do more. We are looking at fostering stronger public-private partnerships and further integrate GPs into the national healthcare system, so that, together, polyclinic doctors and private GPs play an important role in providing primary care to meet our population's changing health needs.

Ideas and initiatives will not be developed by MOH alone. Over the next few months, we will consult our stakeholders, including primary care doctors and patients, on what they envision as the desired primary care landscape for Singapore. We can then move on to our next phase of primary care development.

Mr Chairman, I will now touch on how MOH will strengthen residential Intermediate and Long-Term Care (ILTC) services. Minister Gan spoke on improvements in rehabilitative care. One of the ways we are doing this is by expanding capacity for community hospitals. By 2020, we will more than double our community hospital beds through the building of four new community hospitals in Jurong, Yishun, Sengkang and Outram. Last December, we opened the new Changi General Hospital's and St Andrew's Community Hospital's Integrated Building. The Integrated Building not only provides additional capacity but also enables both hospitals to collaborate and develop new ways to treat and rehabilitate patients. The new model of care at the Integrated Building will focus on optimising patients' recovery to prepare them to transit back to the home.

Our hospitals are also working with their community partners to better integrate inpatient rehabilitation services with those in the community.

MOH is also looking into addressing nursing home availability. We are on track to increase our nursing home capacity by 70%, to 17,000 beds by 2020. We have just opened a new nursing home in Bukit Batok run by Renci, and will open another one in Yishun run by All Saints Home in April. By the end of the year, we hope to open three more nursing homes in Jurong West, Jurong East and Bishan.

As our healthcare sector expands, along with an increase in Singaporeans' expectations, I agree with Ms Tin Pei Ling that we will need to ensure that the standards of care provision whether in the hospitals or in the primary care, or in the ILTC sector, continue to rise.

One area that we have worked on is to establish appropriate standards of care in nursing homes. In 2013, we announced the development of a set of Enhanced Nursing Home Standards (ENHS) by an industry-led workgroup. The standards were finalised last year. To help nursing homes attain these standards, MOH has worked closely with the Agency for Integrated Care (AIC) to provide support, for example, a guide on the details of the standards. AIC has also developed new courses in Advanced Care Planning and falls prevention for nursing care staff and supervisors in nursing homes. The standards will take effect this year.

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Providers will be given a one-year grace period before the standards are enforced from 2016. With these standards in place, patients and their families can be more assured that their well-being will be taken care of.

To maintain high standards of care across different settings, MOH has also developed evidence-based guidelines to improve clinical practice. These guidelines aim to support good care outcomes and recommend the use of clinically effective treatments and were developed by professionals.

In addition to raising standards of care at nursing homes, we have taken steps to ensure affordability of long-term care services for the elderly. Ms Lee Li Lian has asked if ElderShield and IDAPE will be reviewed. MOH is carefully studying options to enhance the current ElderShield product.

We are mindful that we will be introducing MediShield Life at the end of 2015, and that it would not be best to introduce a new ElderShield insurance plan at the same time. We have taken other steps to ensure affordability of long-term care services for the elderly. For example, in 2012, we enhanced ILTC subsidies to raise subsidy levels and cover more middle-income households. We implemented the Pioneer Disability Assistance Scheme, or Pioneer DAS last year, where Pioneers with severe disability can receive $1,200 cash payouts a year.

As Senior Minister of State Dr Amy Khor mentioned, we are growing our healthcare professional workforce to ensure that we can adequately support expansions in healthcare services. Ms Kuik Shiao-Yin was concerned about the potential impact of these changes in medical indemnity coverage for obstetricians on obstetrics services and has suggested that MOH provide post-retirement protection for these doctors as an assurance for them to continue their practice. There is also concern from the ground on whether this change will affect the supply of obstetricians.

The insurer Medical Protection Society (MPS) is continuing to provide post-retirement protection for obstetricians by providing tail cover, which covers practitioners against any claims that may occur after the practitioner is no longer covered or has retired. This tail cover is available in five-year blocks for purchase. Also, the new premiums per year after the change in insurance cover will be lower. Currently, there are adequate numbers of obstetricians, including those in training, to ensure availability of obstetric services to the general public.

There will be 60 to 70 new obstetricians graduating over the next five years to ensure a continuing supply of obstetric services. Notably, we have sufficient trained and experienced midwives with the capacity to deliver more babies in our restructured hospitals.

MOH is discussing with professional leaders and other stakeholders how best to address this issue. MOH will also consider ways to work with relevant parties to minimise impact on services and expectant mothers.

In closing, MOH is committed to strengthening our primary care and residential ILTC services, deepening our infrastructural capacity, while raising our healthcare standards and ensuring affordability of care.

Vaccinations for Children

Mr Gerald Giam Yean Song: Sir, the National Childhood Immunisation Schedule (NCIS) lists seven vaccinations against infectious diseases for children under 18 months. All are free at polyclinics, except the pneumococcal disease vaccination.

Although Medisave and CDA can be used to pay for it, these have alternative uses. Some parents may decide against this vaccination if they have to pay, especially if they are not aware of the dangers of this disease. It is the leading infectious cause of death in children worldwide, and can cause deafness, brain damage, paralysis and even death. There were 146 cases diagnosed last year in Singapore.

Can the Minister share what percentage of children above two years old have been immunised against pneumococcal disease? Why is pneumococcal disease on the NCIS as recommended by the Expert Committee on Immunisation, but not provided for free? Making it free could encourage a higher take up rate and build up herd immunity against the disease, which occurs only when a significant portion of a population is immunised.

IT-enabled Healthy Living

Ms Tin Pei Ling: Sir, while the Ministry has been conscientiously ramping up our health and social infrastructures to meet the needs and challenges of a rapidly ageing population, it is paramount that younger Singaporeans are aware and appreciate the benefits of healthy living so as to avoid a life that is ridden with diseases and aliments associated with old age. In this aspect, I believe that greater efforts could be put into encouraging Singaporeans to better leverage on information technology as an enabler to healthy lifestyles.

Today's advancement in mobile applications provides greater access to data-rich information that will allow Singaporeans to make better real-time decisions relating to their well-being. People are now able to conveniently use their mobile phones, for instance, to monitor their heart rates in real time and measure the actual number of steps walked, for example. Some devices could even monitor calorie intake and other physiological changes in real time as well. In this regard, I would like to ask if the Ministry has plans to leverage on IT to promote and encourage healthy living amongst Singaporeans.

Smoking and Tobacco Control

Dr Chia Shi-Lu: Mr Chairman, the dangers of smoking are well known and the statistics continue to horrify. Tobacco smoking is the leading preventable cause of death in Singapore, and it is estimated that seven Singaporeans die each day from causes related to smoking. Second-hand smoke may be responsible for 250 deaths in non-smokers in Singapore each year. Although the rate of smoking in Singapore continues to fall, the rate in the young seems to be increasing in recent years.

And so I would like to ask the Ministry of Health what plans it has to reduce the smoking rate amongst the Singaporean population to below 10% by 2020. And beyond the Point of Sale Display Ban which comes into effect in 2016, are we considering other measures such as plain or standardised packaging for cigarettes? And what has been the effect of targeted programmes such as the Workplace Smoking Control Programme and the "I Quit" movement? And could the Ministry provide further details on the recently announced intention to disallow shisha smoking, and also if there are other plans to control similar products that have a high health risk profile?

Healthy Individuals

Ms Ellen Lee: Sir, with more Singaporeans living longer than their parents, being healthy and able to work beyond retirement age becomes a common concern for adults with family commitments. While HPB has gone to great lengths to encourage people to adopt a healthy lifestyle by eating well and exercising more, many health experts think we are facing a growing problem of obesity which leads to other health problems.

Working adults with health problems to overcome will face employability issues as they grow older. What are the challenges ahead faced in motivating Singaporeans to eat well by paying more attention to nutrition and to exercise more by making more use of sports facilities available in their estate or at the workplace? Could MOH provide an update on the progress made in helping individuals to remain employed even in old age by staying in good health?

The Parliamentary Secretary to the Minister for Health (Assoc Prof Dr Muhammad Faishal Ibrahim): Sir, I thank Members for the points raised earlier. As a nation, we have made tremendous progress in health: we have more than halved our death rates in the last 40 years, resulting in about 17 years of increased life expectancy. This can be credited to improvements in nutrition, healthcare advancements, disease prevention and health promotion. Our health promotion efforts are focused on effecting sustainable healthy habits in Singaporeans of all ages, and from all backgrounds. To Ms Ellen Lee's question, the main challenge in adopting healthy living is in translating knowledge to action. Hence, central to our approach is a greater emphasis on behaviour change, and not just public education. To do this, the Health Promotion Board (HPB) has been engaging the community and private sector to understand their needs and motivations. This enables the HPB to implement relevant initiatives to effect behaviour change on the ground.

I agree with Dr Chia Shi-Lu that investing in health is important. While we welcome innovative ideas such as HealthFuture accounts, Singaporeans do not necessarily have to spend money to keep healthy, as I will illustrate in the next few minutes. First and foremost, investing in health needs to start with our own personal decision to stay healthy. Then, it needs to be sustained across generations, to have a healthy population in the long term. Sir, if I may have your permission to show some slides.

The Chairman: Yes.

Assoc Prof Dr Muhammad Faishal Ibrahim: The Healthy Living Master Plan (HLMP) was launched last year to serve as a compass for systematic and sustained health promotion. The aim is to make healthy living every day a natural choice for everyone.

Dr Chia and Mr Gan Thiam Poh asked about the progress of the HLMP. I am pleased to say that we have been creating opportunities for everyone to live a healthy life and making it fun, with the aim of making healthy lifestyles a pervasive culture for the whole communities. Allow me to explain further.

Essentially, we want to make it easier for people to make healthier choices their preferred choice. An example is food.

For the children in school: today, only one in five of our Secondary school students eats at least two servings of fruit and vegetables every day. Yet about one in two drink sweetened drinks every day. So, we want to bring healthier meals to children in school. HPB has been working with schools and post-Secondary Educational Institutions to provide healthy food choices in canteens. Stalls are encouraged to offer healthier options: increase vegetables and fruits in menus, reduce gravy and fried food. We will also link up suppliers with canteen vendors to offer wholegrain rice, noodles, bread, and healthier oils.

Our children should have drinks with less or no sugar. Currently, only drinks with the Healthier Choice Symbol (HCS) are allowed in schools. HPB has been working with MOE to further reduce sugar content of drinks in vending machines and drink stalls. We aim to partner all schools in this effort by 1 January 2016.

At the national level, we have introduced advertising guidelines so that our children are not constantly exposed to unhealthy food messaging. I urge parents to stand with us, by reinforcing healthy eating to your children at home.

We aim to make healthier food choices the preferred choice for everyone. The HPB's Healthier Dining Programme works with 25 large-chain Food & Beverage partners, including McDonald's, Kopitiam, Swensen's and Dian Xiao Er, to offer 500-calorie meals through more than 700 food outlets and stalls. Swensen's observed that sales percentage of its six 500-calorie meals was about 15% in the three-month period after they were introduced. It is currently a small percentage of overall sales, but it is growing.

The Siu Dai, or "Life's Sweeter with Less Sugar" campaign, encourages us to remove unnecessary calories from our daily diet. More than 800 drink stalls in food courts, coffeeshops and hawker centres are taking part. I was quite delighted recently, when the drink stall gave me a Scratch n Win card because I ordered a drink with less sugar. I won a 50 cents rebate for the next "healthy" drink that I buy! I understand that prizes had ranged from this to $300 shopping vouchers.

As many Singaporeans eat out, HPB has started a pilot scheme to work with suppliers to deliver healthier oil to food outlets, restaurant chains and volume caterers. HPB provides grants to help nudge the food outlets to adopt the healthier oil. HPB will review this scheme after a year. This is one example where HPB is willing to test out different ideas, to identify those which can lead to a sustained change in behaviours and habits.

We also want to make healthy living convenient and fun through leveraging information technology. Ms Tin Pei Ling and Mr Alex Yam asked how we might do this. On average, each person in Singapore owns 1.5 phones. Since mobile applications can be conveniently used to gain health knowledge and track personal health efforts, we are developing HealthHub to do just this.

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HealthHub users will be able to access general health and wellness content, and personalised healthcare information, such as medical and immunisation records. We can access information, such as hospital fees, health financing schemes and, eventually, waiting times at A&E departments. We will launch a first release of HealthHub in the second half of 2015.

We are using IT in the community, too. We have developed a Healthy Living @ SG App for individuals to track their physical activity and find out the nearest exercise locations and healthier dining options. As part of a trial in Tampines, the app has tested a loyalty programme, translating healthy behaviours, such as attending physical activity programmes, into loyalty points that were redeemed for rewards.

For those of us without smart phone access, there is the Healthy Living Tag system, which is a small RFID tag. Let me show you. I have it here with me. It is a small one. If we go jogging with this tag, we can tap it against RFID receivers located at exercise checkpoints to collect points for rewards.

I am inspired by people like Madam Yong Yoke Chin, who, at the age of 79, still exercises regularly to keep healthy. She signed up for an RFID tag – see she is holding on there – where it shows Tampines Healthy Pathway and, at the back we have "Healthy Living Everyday" and with the HPB website. Every morning, Madam Yong will make her way to the Healthy Pathway in Tampines for her morning walk with friends. Through this, Madam Yong had made friends with other residents who enjoy exercising together. With the RFID tag, Madam Yong collected many points and rewards for her active lifestyle.

So far, I have talked about prevention of chronic diseases. Prevention of infectious disease is also important. Mr Gerald Giam suggested that vaccines for pneumococcal disease should be fully subsidised. Since 2009, Medisave can be used for pneumococcal vaccine. Singaporean babies born on or after 26 August 2012 are given a Medisave grant of $3,000 that can be used to pay for vaccinations. Mr Giam would be pleased to know that following the introduction of these measures, our vaccination coverage with regard to pneumococcal in one-year-old children has increased significantly from 24.1% in 2009 to 75.4% in 2014. In absolute numbers, it means that the number of children who were vaccinated by the time they were one year old increased from 7,180 in 2009 to 23,000 children in 2014.

Vaccines in the National Childhood Immunisation Schedule (NCIS) are fully subsidised at the polyclinics when there is a need to strongly encourage high take-up of vaccinations for highly infectious diseases. This is so that the community can develop immunity as a whole against the disease, and outbreaks are prevented. In the case of pneumococcal disease, the potential for a public health epidemic or outbreak is relatively low.

Dr Chia Shi-Lu asked for an update on tobacco control. I feel that this is an important issue. We all know that smoking can seriously harm our health. In Singapore, it is the second most important cause of premature deaths and ill health.

To quit smoking can be daunting, but it is certainly worth the effort. Quitting not only protects our own health, but also the health of our loved ones from exposure to second hand smoke. To facilitate smoking cessation, we have set up the "I Quit" campaign since 2011. It adopts a community-based yet personalised approach to build a network of support that helps smokers quit. This movement has reached 13,000 smokers through various platforms at the workplaces, hospitals, in the uniformed groups, and in the community. It has proved effective simply because it involves not just the smoker who wants to quit, but also support from his family and friends. In many cases, it has helped to bring the family closer together.

67-year-old retiree Hanafi Bin Ismail had been smoking for almost 50 years. After suffering a heart attack, he decided to quit for both his health and his family. However, going from one pack of cigarettes a day to none was not easy, so Hanafi gradually cut down. Signing up for the Ramadan Challenge, he received encouragement through regular text messages. His children and grandchildren were supportive, and constantly reminded him of his commitment to quit. Today, Hanafi feels happier and healthier. Ever since he quit smoking, he exercises at least once a week – doing push-ups and even walking up to seven kilometres. His grandchildren are also much happier for him now.

Our strategies to control smoking are multi-pronged. We want to reduce the advertising effect of point-of-sale displays, particularly on our youth. When tobacco products are no longer prominently displayed near the cashiers, it could decrease impulse purchases and help smokers trying to quit. This year, MOH will be banning point-of-display of tobacco through an amendment to the Tobacco (Control of Advertisements and Sale) Act. There will be a 12-month grace period to provide retailers enough time to comply.

While we are doing well compared to OECD countries, I worry that smoking rates are high among young men, and younger women are picking up the habit. Tobacco companies have been coming out with new tobacco products that appeal to the youth. We are concerned about the health risks of such products, and have been studying ways to address this growing trend. Shisha was the first emerging tobacco product to be banned in November last year, to prevent its proliferation and entrenchment in Singapore. We intend to do the same for other types of emerging tobacco products later this year. Compliance with the shisha ban has been good. My Ministry will continue to monitor the situation, and assess the full effect of the ban after the transitional period ends on 31 July 2016.

Our efforts do not end here. We constantly scan the world for new ideas. For example, we have been studying developments in Australia, the world's first country to implement plain packaging. This requires tobacco products to be sold in drab green boxes, with graphic health warnings, the brand name in standardised typeface, and minus all corporate logos and trademarks.

We will be conducting a public consultation on requiring the packaging of tobacco products to be standardised in Singapore, towards the end of this year. I would like very much to hear your views.

In conclusion, Sir, I am pleased to say that we are making good progress. In the last six years, more Singaporeans have rated themselves in good overall health, more young adults are exercising regularly, and more than two-thirds of Singaporeans aged 40 to 60 years have regularly attended chronic disease health screening.

Sir, I am also inspired and very pleased to see many groups, whether formal or informal groups, coming together to be part of this health promotion movement. I have met many groups who have been working together with organisations to see how we can facilitate and help in the movement of getting more Singaporeans to live healthily and to bring health promotion efforts towards fellow Singaporeans and on the ground.

We hope to work towards a growing people's movement for good health over time and encourage more members to start similar movements in other parts of Singapore. Together, a healthy nation for all ages.

The Chairman: Okay, we have a few minutes for clarifications. Mr Gan Thiam Poh.

Sorry, Mr Gan Thiam Poh. Mr Heng Chee How, you want to provide a reply? Mr Heng.

Mr Heng Chee How: Sir, I do understand that it is close to six o'clock. While we cannot say that it is early in the day, but I think the evening is still young. So, with your indulgence, Sir, I would like to speak a little bit about the effects of extended longevity in our population and ageing.

Sir, ageing has certainly been much discussed, and rightly so, since our population is ageing fast and, come 2030, one in five amongst us will be above 65 years old. We can certainly take advantage of our increased longevity and make ageing a positive experience.

Earlier, Minister Gan spoke about the Action Plan for Successful Ageing and shared Singaporeans' aspirations on how to age successfully. And some of these relate to lifelong employment and employability of our seniors. During our focus group discussions, many participants had said that they wanted to be able to work into their senior years, past the retirement age, and to have a chance and the choice to do so. Because, to them, employment brings greater financial security and also keeps our seniors meaningfully occupied and mentally active. Also, work gives a sense of fulfilment and self-worth.

Ms Ellen Lee asked how we will help seniors stay healthy longer so that they can remain employed and employable. We are investing in health promotion for seniors in two ways.

First, within the community, we started the Wellness Programme in 2008 and it has since been implemented nationwide. The Wellness Programme encourages seniors to look after their health, as well as to stay physically active and socially connected. As at the end of last year, the programme has outreached to some 400,000 seniors.

In addition, we are also bringing health promotion to workplaces so that we can also address the needs of our mature workers within the workplaces. In 2014, two pilot programmes were started: one in the transport industry and one in the cleaning sector. I will give a quick update on the two programmes.

First, within the transport industry – taxi drivers. Taxi drivers often sit for long hours as they drive their taxis around during the shift and, because of that, being sedentary, there is little opportunity for physical exercise. So, in June last year, the Health Promotion Board, together with Alexandra Health System, partnered with Comfort DelGro and the SMRT, supported by the National Taxi Association, and started a workplace health pilot for drivers who are aged 40 and above.

They brought health programmes to the taxi service centres, such that drivers can get "one for one" service. What happens is that, every month, the taxi driver will have to bring his taxi in for servicing and he has to wait a couple of hours pending the car being serviced. So, making use of that free time as he waits for the taxi, the driver can participate in health promotion programmes at the service centre.

Under this programme, taxi drivers undergo health screenings, followed by individualised health coaching sessions where they learn how to improve their health, like exercising more regularly in the hours that they are not driving, as well as adopting a more healthy diet.

The drivers also learn about the ergonomics of driving, like how to adopt the right posture while driving. Car decals are also given to our taxi drivers to remind them on how, even while seated, they might be able to do certain minor stretches. Together, these efforts will help reduce work-related injury or discomfort, a concern that Assoc Prof Fatimah Lateef had also mentioned.

Preliminary results of this pilot have been encouraging. To date, we have screened some 3,000 taxi drivers, of whom, more than 90% of them have since followed up with health coaching sessions.

The next one would be on the cleaning sector. The second group that has been reached out to are mature cleaners. In September last year, through the network of the Building Construction and Timber Industries Employees' Union (BATU), we worked with a cleaning company RamkyCleantech to implement a workplace health programme for mature cleaners working at the Singapore Polytechnic. Under that programme, cleaners undergo health screenings and learn how to manage their chronic conditions. They also learn how to improve work habits for better pain management, especially of the joints.

More than 60% of the 180 cleaners are now attending the coaching sessions regularly and participating in activities to strengthen their muscles and to lower the risk of falls.

Sir, so what I wanted to say is that there is something about these two pilots. What we do with the mature workers in the two industries will be different because the nature of the work is different – one is sedentary and one involves a lot of joint movements. So, therefore, whilst mature workers are likely to have common challenges like chronic diseases, but because of the nature of their work, they may also face health challenges that are specific to their work. This is something we take note of in customising programmes for our mature workers.

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Given the encouraging results of the pilots, we will extend workplace health programmes to other sectors and we are looking at retail and security for 2015. Workplace health is a meaningful area of tripartite collaboration. Workers benefit if they stay healthy longer and have the means to work longer, and concurrently save on healthcare cost by staying healthy. Employers also benefit, because mature workers who can work longer means additional manpower and being more healthy, they are certainly going to be more productive at work as well. As a whole, our nation benefits when we convert longer life years into longer healthy and productive ones.

Mr Gan Thiam Poh: Mr Chair, I would like to ask the Parliamentary Secretary if our promotional efforts have shown any impact. In fact, I also want to find out, are Singaporeans actually getting healthier in their habits?

Assoc Prof Dr Muhammad Faishal Ibrahim: Sir, I would like to thank the Member for his supplementary question. As I had shared earlier, we are making good progress. What we are seeing is that Singaporeans are getting healthier. And our health promotion efforts have shown some impact. One is with regards to the picture in terms of their habits and the other is with regards to some of the data that we have collected.

There are areas where we can do more and where we need to improve. There are areas whereby because of affluence, because of the availability of good food, we may have to do some more in trying to help to change this behaviour.

But I must say that besides HPB, there are many other organisations that are together in this journey. These include the People's Association (PA), CDC, Sports Singapore, also it relates to facilities provided by LTA, by NParks and many more, as well as organisations and small interest groups. I shared earlier about small informal groups interested in the health movement. We also want to thank them for playing a part.

But let me go back to share with you some of the data that we have. For example, if we look at smoking, between 1992 and 2013, our adult smoking prevalence improved from 18.3% to 13.3%. We see a downward trend. Another trend that we can see is also smoking rates amongst young adults aged 18 to 29 years are lower than among all adults – 12.7% and 13.3%. This possibly is attributable to the intensified intervention, targeting young adults at the Institutions of Higher Learning and also National Service training camps. Things are showing effect.

With regards to obesity, we can see that our rates seem to indicate that it has stabilised, although it increased from 6.0% in 1998 to 10.8% in 2010, but we have another survey which we did in 2013, a similar one, but a little bit different methodology, showed that the rate has gone down to 8.6%. And also, it seems to show that the rate in obesity may be slowing.

The Chairman: Assoc Prof Faishal, can you keep your response short because quite a number of Members who want to ask questions?

Assoc Prof Dr Muhammad Faishal Ibrahim: Okay, Sir, I will just summarise it very quickly. With regard to nutrition, the consumption of whole grains has increased from 8.4% in 2004 to 27.0% in 2010. This is a big jump. We must be careful in terms of the amount of saturated fats that we take. In terms of physical activity, during leisure time, it has also increased where Singaporeans of younger ages are spending more time on exercising.

I am very passionate about this issue! Lastly, screening. We can do more for cardiovascular risk factors and cancer. But for the proportion of Singaporeans who go for screening in cancer, colorectal cancer has increased from 26.8% to 33.8% in 2011 and 2013. Similarly, for mammogram, we also saw an increase.

This is an effort by the whole society, not only HPB. I hope we will continue on this journey so that it is not only about being healthy today; it is about being healthy many, many more generations to come.

The Chairman: Dr Chia Shi-Lu.

Dr Chia Shi-Lu: Thank you, Mr Chair. I just have three clarifications. The first two is in regards to primary care addressed to the Minister of State. For the first clarification, I am very happy to hear all the developments in the upgrading and new polyclinics that we can look forward to. But it seems that a lot of these improvements will only be operational in a few years' time. Given that we do recognise that our polyclinics are already operating at near to full capacity, what steps will the Ministry be taking to make sure that the primary care needs of Singaporeans continue to be served in the interim?

The second clarification is related is to the point that was raised by hon Member Mr Ang Wei Neng about overcharging in primary care with CHAS, PG and all these schemes. Are there any measures to perhaps look at over-consumption? An example has been reported recently, where some people raised concerns that with the coming of CHAS and the PG package, there has been a sharp rise in the frequency of dental visits by some seniors.

The last clarification is a short one. It is with regards to the Flexi-Medisave Scheme. When it was first announced, the Ministry said that they would open it to public feedback and they will try and see whether they can fine-tune the scheme before its launch in April this year. I was wondering whether there have been any changes to that scheme.

Dr Lam Pin Min: Thank you, Mr Chairman. I would just like to thank Dr Chia for the clarifications. I think he has two clarifications for me – one on polyclinics and the other one on overcharging.

I do understand Dr Chia's concern and also that of many fellow Singaporeans. Indeed, polyclinic attendance and waiting times are important indicators that MOH is monitoring very closely. We acknowledge that we need to increase polyclinic capacity and thus, we have committed to building four more polyclinics by 2020 and a further six to eight polyclinics by 2030. In the meantime, there are existing 18 polyclinics across the island and they will continue to serve Singaporeans while these polyclinics are being built.

At the same time, MOH is also redeveloping Marine Parade, Bedok, Yishun and Ang Mo Mio polyclinics where the attendance at these places has been noted to be on the high side. In addition to that, MOH will continue to work actively with private GPs to explore new models of care including enhancing CHAS, developing more CHCs as well as FMCs.

With this combined, polyclinic and CHAS GP network, in fact, nine in 10 HDB residents are within 15 minutes commute time from the polyclinic or any CHAS GP. MOH will continue to work with other non-CHAS GPs to see how we can encourage more of them to participate in the CHAS programme, thereby widening the primary care network.

Mr Gan Kim Yong: I will take the third question of Flexi-Medisave. After we announced it some time ago, we went to get feedback, consulted and engaged the GPs on how to roll this out, especially CHAS GPs. We have also got feedback from polyclinics and SOCs as well, who will be involved. The feedback generally is very positive. Patients like it because it gives them more flexibility. But, of course, they hope not just $200 but more. That is to be expected. We need to tread very carefully. On the one hand, we want to give flexibility to our patients but on the other hand, we have to make sure that they have sufficient savings, and that they preserve their savings for the longer term retirement needs.

From hospitals and the GPs, there was some feedback. Because some of these claims may be very small in nature, so some of the GPs may feel that they are not equipped to handle individual cases of claims for small amounts. Therefore, some of the GPs said that they would need more time. As we roll out, they will come on board the programme later on.

As we first roll out, the polyclinics and the SOCs will be involved, Government, public healthcare institutions will be involved and some CHAS GPs will be participating, but not all of them. We will roll this out in phases and we will learn from experience in rolling this out and see how we can continue to refine it.

The Chairman: Ms Ellen Lee.

Ms Ellen Lee: Sir, I have two clarifications. The Senior Parliamentary Secretary said that the mammogram screening has improved. I was wondering whether he was referring to the improvement due to the promotion of women health issues at the workplace or at the community level. I was wondering whether affordability would be one of the issues that would have confronted women who have still not responded to it.

The other clarification is that the Senior Parliamentary Secretary has also said that the incidence of people smoking seems to be coming down because of some awareness programmes. I am wondering whether something could be done to create greater awareness of smoking within a housing board flat unit because we have often heard residents complaining of neighbours smoking in their units and then, they are the ones who are inhaling the second-hand smoke.

Assoc Prof Dr Muhammad Faishal Ibrahim: I thank Ms Ellen Lee for her questions. Mammogram screening has gone up: 34.7% in 2010 to 37.7% in 2013. As the Member had mentioned before, it is due to the continuous effort that we do at workplaces and the community. Even for myself as a Member of Parliament, I have often encouraged on the ground my residents to also go for such screening. And I am very, very touched in the sense that people care for one and another, amongst the aunties, machiks together, they talk to each other and see how they can facilitate this. Even my wife recently shared with me that amongst her group of friends, that they went for classes at the mosque, and even at the mosque, they are also trying to encourage people to go for such activities like health screening.

I am happy that it is flowing down to the ground and people are seeing the benefits of it, the need for it. But, beyond that, there are other factors that we recognise – people may feel discomfort and also the issue of privacy. The Senior Minister of State, Dr Amy Khor, is working very hard together with her team to see we can deepen our engagement and make people go to the area where we can facilitate them to come forward in doing this. The more people coming forward, the better it is; the earlier you get to know what is wrong with you, the better we can diagnose and we can help you to manage it.

The second issue is about smoking. Like what I had mentioned, for smoking, we take a multi-pronged approach. Why we do smoking cessation programmes is because we care for fellow Singaporeans. We know the ill effects of smoking. It is not about not allowing them to smoke but I think we see day after day on how death can be prevented if one stops smoking and not only for oneself but also for the family members.

I am very heartened to see the positive effects of our "I Quit" programme. It is not only to the smokers themselves but it also goes beyond that, to the family members, to the community. I remember meeting a friend who smoked. When he stopped smoking, the whole family celebrated. We want to see how we can celebrate this because we care for one another. We should do more but we must make sure we do not forget to care for these smokers because I understand that to stop smoking is a daunting experience but we want to support them.

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Mr Gerald Giam Yean Song: I have two clarifications. First is regarding the review of the Medisave withdrawal limit for the Integrated Shield Plan premiums. Can I ask the Minister if MOH will ensure that the limit is high enough for the standard B1 Plan so that all policy holders do not have to pay out of pocket even as their incomes drop?

The second question is regarding the immunisation rate for pneumococcal disease. I am very happy to hear that it has gone up from 24% to 75%, just after the additional Medisave was provided. This shows that reducing the cost does increase the take-up rate. But 75% is still much lower than the 95% to 99% for the other vaccinations on that same list. Can I make another appeal for this to be fully subsidised because I am not sure if 75% is enough to ensure herd immunity.

Mr Gan Kim Yong: First, I will address the issue on the Medisave Withdrawal Limit, what we call the Additional Withdrawal Limit, designed to apply to the private insurance coverage component of the Integrated Plan.

We will have to review this and discuss with the industry as well as with the various stakeholders to determine the amount. We want to make sure that, as the hon Member said, it is sufficient but we also want to make sure that it does not inadvertently drive up the premiums. Because as you enhance affordability, there is a risk that the premiums will also be driven up.

At the same time, we also need to calibrate it very carefully to balance the desire to help individuals purchase private insurance plans but also ensure sufficient balance in their Medisave account to be able to cater to the basic premium to be paid for the MediShield Life. So, it is a matter of balancing. But I hear your request. We will bear the request in mind when determining the level of the Additional Withdrawal Limit. We will need to take into account all these various factors in arriving at the appropriate limit.

Assoc Prof Dr Muhammad Faishal Ibrahim: I thank Mr Gerald Giam for his question. As I mentioned earlier, the issue of pneumococcal disease, the potential for public health outbreak or epidemic is not as high as the others. Nevertheless, what our nurses have been doing is that they have been talking to the parents and also encouraging them to have this vaccination for their children. We will continue to do this. I want to also share that it is the responsibility of the parents to think about how this can facilitate good health for their kids.

Ms Tin Pei Ling: Thank you, Mr Chairman. I have two clarifications. Firstly, I would like to ask if there is an estimated figure on the current ratio of applicants to the number of vacancies within the home and community care facilities, if such statistics are available. This will give us a better sense of how pressing the demand is at this point. On my second clarification, I know the Senior Minister of State had shared earlier about the development of home and community care services. I would like to clarify whether palliative care is also included in such services, and if she would be able to share what is the development in this area.

Dr Amy Khor Lean Suan: In terms of the number of day-care places, I think the Member asked earlier about wait-time and ratios. For day-care places, the estimated wait-time was about 20 days in 2014. This is a significant improvement from 2013, which was about 30-odd days. As I have said in my speech, we are ramping up capacity very rapidly. Over the last four years, we have increased the number of day-care places by 1,000 and we are on track to increase the number of day-care places to 6,200 by 2020. Whilst they are waiting for day-care places, the hospitals could assist in terms of referring them for interim caregiver service or transitional care service. In order to further ramp up capacity, as I have said, we are also ramping up homecare. So, an alternative really would be homecare services.

With regards to palliative care, actually, Minister Gan did announce about MOH's plan last year to develop the palliative care sector in a holistic and comprehensive manner and it is in four areas. In terms of quality, there is a palliative care guideline which we are finalising and it will be used as a developmental guideline and to improve and enhance service. And also in terms of capacity, we are expanding capacity both in home palliative care as well as inpatient palliative care beds. In terms of affordability, we further expanded the use of Medisave for palliative care to reduce the patients' cash payment upfront. So, withdrawal limits have been increased and lifetime limits for terminal cancer or end-stage organ failure have been removed for home palliative care. Where it is the family members who pay, the life time limit has been increased. Of course, we are also looking into increasing public awareness in terms of helping the public to understand end of life issues, advanced care planning, palliative care and so on.

The Chairman: Sorry, we have run out of time. Dr Chia Shi-Lu, would you like to withdraw your amendment?

Dr Chia Shi-Lu: Yes. First of all, I wish to thank all Members who have participated in this afternoon's very healthy discussion, especially Minister Gan Kim Yong, Senior Minister of State Amy Khor, Minister of State Lam Pin Min and Senior Parliamentary Secretary Muhammad Faishal for their careful and considered replies and explanations. I would also like to record a note of gratitude to the Ministry of Health for their remarkable efforts towards keeping Singapore and Singaporeans amongst the healthiest in the world. We look forward to future steps to encourage all of us to not only live longer but also to live better. With that, Mr Chairman, I beg leave to withdraw my amendment.

Amendment, by leave, withdrawn.

The sum of $7,645,726,700 for Head O ordered to stand part of the Main Estimates.

The sum of $1,645,498,700 for Head O ordered to stand part of the Development Estimates.