Committee of Supply – Head O (Ministry of Health)

Affordability of Healthcare System

Dr Lam Pin Min (Sengkang West): Mdm Chair, I beg to move, "That the total sum to be allocated for Head O of the Estimates be reduced by $100".

I would also like to declare my interest as a medical professional working in a restructured hospital.

Healthcare has always been an emotive issue for many Singaporeans, as it affects all of us in one way or another. Everyone seeks healthcare services at one point in our lives, whether we are newborns, children, adults or senior citizens. It is also one of the essential services expected of a responsible government.

Singapore's healthcare system has developed and evolved through the years to what it is today, through a mix of pragmatism and eclecticism, learning and adapting from best practices to arrive at a formula that works for us. Our healthcare system is generally cost-effective with a National Healthcare Expenditure (NHE) at 4% of GDP. In comparison, OECD's average is 9.6%. Even then, I am glad to note that Singapore has achieved good health outcomes, in spite of spending less than many other developed countries when measured as a percentage of GDP.

However, I have often received feedback from residents and friends on the increasing cost of healthcare. The old adage that "It is better dead than to be sick" seems to resonate with many Singaporeans. Why is this so? MOH has always pledged to provide affordable healthcare for all Singaporeans.

As parliamentarians, we have debated for years in this House on affordable healthcare. What then is affordable healthcare? Many academics have tried to define what affordability is. Some measure affordability as the amount of money a household can spend on healthcare costs, while still having enough left to pay for other necessities. Should it be measured as a percentage of total income, such as 5%, 10% or even 15%? Or should it be measured as a percentage of the total bill size in the form of out-of-pocket costs for the patient?

1.00 pm

While I do not have an answer for that, I would like to highlight some issues and concerns that have contributed to the perception that healthcare in Singapore has become less affordable.

Mdm Chair, Singapore's version of healthcare financing hinges on one of the key philosophies of individual responsibility. Coupled with the time-tested 3M framework of MediSave, MediShield and MediFund, the Government has been able to keep our national healthcare expenditure below 4% of GDP, of which only one-third comes from the expenditure from the Government. However, with the rapidly ageing population and the ever escalating medical inflation, the burden of bearing the higher cost of healthcare has begun to fall significantly on Singaporeans.

Many Singaporeans have called for the Government's share of healthcare expenditure to be increased. Compared to many OECD countries, the Singapore Government's share of the national healthcare expenditure has remained enviably modest.

While the 3M system has served us well, we need to ensure that the 3Ms remain relevant, to commensurate with the socio-economic-political situation and needs of Singaporeans. The restriction imposed on the use of MediSave is a big bugbear amongst Singaporeans. Many lamented: "What is the point of having so much money in the MediSave when they cannot even pay for their current healthcare needs?" Many young parents also shared their concerns of potential financial strain on the family should their newborn be inflicted with congenital illnesses. On this note, I would like to thank the Ministry for finally including the MediShield coverage for congenital diseases. Many of my parliamentary colleagues and I have been lobbying for this for many years.

While I would be happy if most Singaporeans can stay healthy and not require the use of healthcare services, the reality is that at some point in time, all of us would have to utilise the healthcare system. It would be extremely sad if any Singaporean were to be made bankrupt as a result of seeking medical treatment for themselves or for their loved ones.

In view of this, I would urge the Government to conduct a major review of the 3M system, in particular, with the view to enhance MediSave usage, MediShield insurance protection and MediFund assistance to low- and middle-income Singaporeans. MOH should also take a closer look at the high deductibles and co-payment which inevitably result in more out-of-pocket expenses for Singaporeans.

With increasing integration of social and medical care under MOH, should we also consider allowing MediSave usage for social care facilities like senior care centres? MOH should also regularly review Means Tested Subsidy Levels, MediShield and ElderShield insurance payouts to ensure that they keep pace with medical inflation.

I have also received numerous feedbacks on the affordability of drugs. MOH's classification of standard drugs seems to be too stringent, resulting in many drugs that are commonly used for many common conditions being listed outside the standard list for Government subsidy. One way the Ministry can help lower the out-of-pocket payment for Singaporeans is to subsidise the cost of more essential drugs.

Another way to ensure that healthcare stays affordable is to make the fee structure transparent. Physician charges in the private sector can be rather arbitrary, especially after the Singapore Medical Association (SMA)'s schedule of fees was discarded in 2007. The recent introduction of the ethical limits on doctor's charges by the Singapore Medical Council (SMC) has also taken many practitioners by surprise as this will have implications on the way doctors charge. Can MOH elaborate and better define what this ethical limit is to avoid ambiguity in future? I would also like to suggest to MOH to introduce some form of consolidated information on bill sizes and professional fees for all private and public sector hospitals and have them published and updated on a regular basis for the benefit of both doctors and patients.

The Minister had announced MOH's Healthcare 2020 masterplan in last year's COS debate. To quote the Minister on the objectives of this masterplan, he said: "Healthcare 2020 will focus on three strategic objectives – enhancing accessibility, quality and affordability of healthcare for our people. This means that Singaporeans will receive healthcare when we need it; our healthcare services will be of good quality and effective and Singaporeans will be able to afford such services." I would like to ask the Minister for an update on the masterplan.

Mdm Chair, affordable and accessible healthcare must remain a basic right for all Singaporeans. The Government must ensure that healthcare remains affordable and will not deny any Singaporeans because of their inability to pay.

The Chairman: Mr Low Thia Khiang, you have two cuts. Please take them together.

Specialist Care and Hospital Resources

Mr Low Thia Khiang (Aljunied): Madam, the MOH website states that: "Restructured hospitals are different from the other private hospitals" and "they are to be managed like not-for-profit organisations".

At present, restructured hospitals appear to be managed like profit-driven companies. International Medical Services that solicits business from foreign patients is present in most of the restructured hospitals. The common argument is that money earned from private and foreign patients is used to support treatment for local, subsidised patients. If so, then what proportion of the overall patient load should private and foreign patients constitute – 20%, 30% or more? Who provides and oversees the implementation of the guidelines?

If they are such guidelines, are they department-specific or hospital-specific? I understand that while the hospital as a whole may see more subsidised patients than private or foreign patients, how about individual departments? Moreover, given the current patient load of restructured hospitals, is it justifiable to allocate resources to serve foreign patients?

Next, I would like to discuss remuneration schemes for specialist doctors. Many specialists in restructured hospitals are under a remuneration scheme that rewards them for treating private patients, that is, non-subsidised patients.

I believe that the remuneration scheme is one of the factors hindering the hospitals to improve the situation of long waiting time, especially for subsidised patients. Despite the long waiting times to consult a specialist in the hospital, there is little incentive for the hospital to re-appropriate the ratio of subsidised to private out-patient specialist clinics.

There is also a policy for selected specialists from SGH to see private patients at Gleneagles and Mount Elizabeth hospitals. The Minister for Health explained that this frees up physical resources for subsidised patients. However, if the specialists are outside of SGH to treat those "off-loaded" private patients, then one may assume that junior doctors have been delegated to treat the subsidised patients in SGH.

The waiting time for surgery is also long, especially for subsidised patients. This is because the current remuneration scheme favours shorter waiting times for private patients. In addition, subsidised patients may also be encouraged to upgrade to private status.

I am of the view that the current remuneration scheme incentivises specialists to treat private patients over subsidised patients. As a result, there is unequal distribution of workload among specialists. Morale drops and specialists leave. Over the years, pay increases alone have not been able to stem this tide of resignation.

Other remuneration schemes should be considered to incentivise doctors to treat both subsidised and private patients equally. Perhaps, remuneration should be based on the number of patients seen and the complexity of patients managed.

A variant of this scheme already exists in some restructured hospitals where specialists accumulate "points" for care or service rendered. Each "point" has a monetary value. However, such a scheme has been overshadowed by the more favourable incentives to treat private/foreign patients over subsidised patients. I think it is time for restructured hospitals to remove the incentives for the treatment of private or foreign patients and to move to a "point-based" remuneration scheme. Madam, my next cut in Mandarin.

Traditional Chinese Medicine Education Programme

( In Mandarin ) : [Please refer to Vernacular Speech on Pg xx.] This year, the TCM Practitioners' Board decided to implement a two-year voluntary TCM Continuing Education Scheme. According to the guideline, participating in continuing education courses is voluntary.

According to the understanding of TCM practitioners, however, the first two years is the trial stage and from the third year (2015) on, it will become compulsory. No licence will be issued to those whose scores are not up to the requirement.

I would like to ask the Minister what is the purpose of this TCM Continuing Education Scheme? Will this be misinterpreted as a tactic to reduce the number of registered TCM practitioners? Does MOH believe that if the Chinese physicians do not undergo continuing education, they will necessarily be eliminated?

Within the TCM industry, besides professional TCM practitioners, there are also many voluntary TCM doctors who practice a few hours a week at their spare time. They are concerned that with the compulsory credit accumulation system for licence renewal, it will be a challenge for them to find time in their busy schedule to practise on a voluntary basis. In addition, they have to pay out of their own pocket for the continuing education. Even if their license can be renewed for one year, next year they will face the same concern all over again. Under this circumstance, how long can they last? If the number of the voluntary practitioners drops, what impact would it have on the VWOs providing TCM services?

In view of the current TCM status, if the purpose of the Board is to improve the TCM standard, expertise and skills, then I suggest establishing a TCM Specialist Registration regime, which is more stringent than the current TCM registration system. We can then incorporate the continuing education requirement into the new registration regime.

Referrals and Subsidies

Ms Tin Pei Ling (Marine Parade): Mdm Chair, I would like to ask the Minister whether the MOH will look into shortening the waiting time between the point of referral to the point of appointment scheduled? This is so that those who require further examination or medical attention can receive them promptly.

Secondly, will the MOH be reviewing the adequacy of subsidies to help the majority of Singaporeans, especially the elderly, better cope with healthcare expenses?

The Chairman: Mr Low Thia Khiang, you have two cuts. Please take them together.

Medical Referral System

Mr Low Thia Khiang: Madam, the increasing and ageing population has further stressed our current healthcare delivery system. The mechanism for referral to subsidised specialist healthcare in the Government-restructured hospitals can be improved.

I understand that currently, the provision of primary healthcare is shared between the Government-run polyclinics and the private general practitioners (GP). Polyclinics provide only 20% of the primary healthcare while GPs provide about 80%. There is, thus, a much higher chance that a patient will consult a GP rather than a polyclinic doctor.

However, if a patient sees his GP and is deemed to need a specialist consultation at the Government-restructured hospital, he will not be considered as a subsidised patient by the specialist clinics of the hospital on the basis of his GP's referral.

To qualify for subsidised outpatient specialist care, he has to make a trip to the polyclinic, wait many hours to see the polyclinic doctor and pay for this additional consultation in order to get a referral letter that allows him to be seen as a subsidised outpatient at the hospital.

Such a cumbersome referral system increases both direct and indirect healthcare costs, that is, double consultation with two primary healthcare doctors in addition to time lost from work for the patient and possibly for the accompanying family member. With the increasing and ageing population, the limitations in the current system will be aggravated.

I believe that it is timely for MOH to review the referral system and allow patients the same default subsidised status for outpatient specialist clinic care regardless of their referring primary healthcare doctor.

Regional Health System

Madam, during last year's Budget Debate, the Minister for Health spoke about strategies to improve the quality of healthcare delivery. The twin pillars of achieving this goal are the Regional Health System and the National Electronic Health Records.

With regards to the Regional Health System, I would like an update on the progress of the formation of this system. One such example is the Eastern Health Alliance that was established in late 2011. What are the main lessons learnt from the initial planning to the final implementation of the Eastern Health Alliance? How have patients benefited either directly or indirectly from this Regional Health System? How does the Regional Health System address the overall health issues of the community that it serves? And what are the plans for the other regions of Singapore?

1.15 pm

With regards to the National Electronic Health Records, to what extent has this programme been developed? Is it a single system applicable to all institutions across different health clusters or multiple systems stitched together?

To what extent have we achieved the goal of shared electronic medical records between Government restructured hospitals, community hospitals, nursing homes, private practitioners and other users, such as the Agency for Integrated Care (AIC)? What information is shared through the National Electronic Health Records? Examples include laboratory results, radiology results, histopathology results and clinical notes.

Lastly, has the National Electronic Health Records been able to reduce the need to print out hard copies of patients' records thus reducing the carbon footprint of our healthcare system?

Re-imagining Healthcare Service Delivery

Mr Laurence Lien (Nominated Member): Madam, Singapore has done very well in a number of health areas. However, there are some areas that we struggle with. Singaporeans on average spend seven to eight years in poor health prior to death. The prevalence of risk factors such as obesity and chronic diseases like diabetes are increasing. High prevalence of these conditions reflects poor health prevention and sub-optimal lifestyle.

Even with recent improvements, we must do much better in preventive health, primary care and chronic disease management. We are investing a lot in new healthcare infrastructure and improving affordability. But our software still lags our hardware development. There needs to bolder innovations in healthcare service delivery.

Today, our model of care focuses resources on keeping people alive, not necessarily keeping them well. Downstream services, like acute care, are world-class in quality, even if there are issues in affordability, availability and accessibility. But an inordinate amount of resources is spent when the person is already unwell and in their last stages of life; too little is spent upfront to keep the person healthy. Care is fragmented and compartmentalised, with people often getting episodic care from organ specialists.

We need to focus on providing holistic care, that is whole person care and end-to-end service delivery that joins the dots so that people do not fall through the cracks.

We need to move towards a relationship-centred approach, particularly in primary care. Key attributes of primary care must include comprehensive care, coordination of care and a personal relationship over time.

We have more than 2,000 private GPs in what is essentially a cottage industry serving 80% of the primary healthcare demand. There is too much choice for uninformed patients and too much individualism among providers. This hinders interagency cooperation, and the building of relationships and a social network support that is integral to delivering effective healthcare that keeps people in good health and out of hospital.

A relationship-centred approach, which is different from the transaction-based model we have today, focuses on improving the relationships of the whole person in his or her own life context – between healthcare professionals and patient, and between the community and patient.

There must also be stronger relationships among healthcare professionals and institutions. Primary care should be delivered through a team-based multi-disciplinary approach – including home nurses, tele-carers, therapists, other allied health professionals, social workers and counsellors – who can sit in different centres, rather than through a system that depends on individual doctors. Collectively, these professionals can better understand the patient's full needs, provide comprehensive healthcare services and help them navigate the complex healthcare system to get the care they need, when and where they need it.

Government should invest significantly in developing such a regional primary healthcare ecosystem. Scandinavia and UK have examples of such cost-effective systems. Professionals need to come together to form a dense network. We cannot have lone rangers. As a proper system, holistic end-to-end care can be provided. Multi-agency integration through community groups is especially critical for preventative healthcare.

Care must be patient-focused. Patients should only register with one practice at a time, so that they can develop a personal relationship with their GP and access a continuity of care. Day and night, they should be able to call one telephone number to access services.

It will take us some time to get to the ideal state. As a start, Government should provide the incentives for both patients and GPs so that they develop good relationships. For example, Government should start networking GPs willing to change. Community Health Assist Scheme (CHAS) could also give more subsidies, or insurance companies give greater premium discounts, to patients each time they keep going back to the same GP. Alternatively, there could be a CHAS loyalty scheme, where higher subsidies and free health screening are given, if a patient is prepared to stick to one GP. Overall, out-of-pocket payment must be minimised for community-based and primary care services, as these are much cheaper than institutional care later on.

GPs themselves must be incentivised, for example, to tap into the regional and national infrastructure. GPs that function well as care nodes should be recognised, for example, with Practice Accreditation or a Quality Service Award. Some GPs can be paid by the Government directly or be even on the Government's employment, so that GPs can focus on the public good aspects like preventative health.

In addition, family, caregivers and the community must be mobilised such that the primary care ecosystem is fully functioning. It is through mobilising the larger community network that good practices, such as screening on schedule and medication compliance, are reinforced in patients. In short, we do need to slaughter a few sacred cows. But that is necessary if we really desire a healthy nation.

Means-testing for Family Income

Mr Gerald Giam Yean Song (Non-Constituency Member): Madam, currently all hospitals and nursing homes conduct means-testing to determine a patient's eligibility for Government's subsidies. Patients have to submit documentation to prove their income and that of their family members. These include up to three months' of payslips, CPF contribution statements, or income tax returns.

Obtaining salary documentation is onerous for some patients, including those who are not IT literate, who do not have a SingPass to retrieve their CPF statements, or are odd-job workers who are not issued payslips. Some need to contact their employers to request for letters to prove their income. Others may have difficulty obtaining documentation from family members, whom may not want to reveal their income or may be estranged from the patient themselves.

All these present administrative and emotional burdens to patients at a time when they are already with saddled with worry and pain from their illnesses. As a result, many of them do not complete their applications and lose out on receiving subsidies that could ease the cost of their treatment. I hope MOH would review its means-testing process to ensure that it does not burden patients or their family members, so that patients receive all the subsidies that they are eligible for.

To reduce the hassle for patients, can means-testing be conducted without the need for the patient or his family to submit their income documentation? The process should be automated such that the patient and his family only need to give their consent for the hospital to assess their income records with CPF Board or IRAS. This is much more convenient for the patient and it better preserves their confidentiality.

I know that this is already being done for the CHAS applications. Can the same be done for all hospital and nursing home means-testing?

Healthcare Infrastructural Development

Dr Lily Neo (Tanjong Pagar): Madam, our Healthcare 3M system, an envy of many countries, is supposed to adequately take care of the medical needs of our citizens. MediFund guarantees that no one is deprived of medical care due to the lack of funds. Why then are so many of our elderly still concerned about healthcare costs? It cannot be explained simply that they are less knowledgeable or less well-informed about the various available schemes. Otherwise, their concerns would have been resolved and not be perpetuated till today.

My analysis is that their concern is not unfounded especially for those with the lowest incomes and for many retirees. This group often has little personal savings and MediSave accounts. Our system requires everyone to co-pay the initial amounts for any medical care.

Although I personally believe in having some co-payment to prevent the buffet syndrome, I think we need a tier-system with reduced co-payments for the retirees and the lowest income Singaporeans. Even hospital outpatient treatment costs can be hefty out-of-pocket payments for this group; this is quite apart from co-payments for hospitalisation. It is time to tweak our medical financial framework in view of an ageing population with increasing smaller families. It is getting difficult for siblings of small and especially low-income families to share the healthcare burdens of parents.

I believe in insurance risk pooling. It is definitely a necessary way forward. May I ask the Minister whether he can further strengthen this insurance framework? Are there too many retirees or low-income families who cannot afford to join MediShield? Is it not better to assist them to join MediShield rather than to face costlier payments in the end when they need hospitalisation?

In view of the increasing healthcare needs of an ageing population, there is an urgent need of planning task for MOH in the area of medical infrastructure, to cope adequately and in a timely manner.

My concern on healthcare is the exponential increase in demand for nursing homes, community hospitals and acute hospitals. It is, thus, necessary to have good projections on demand, early planning and proactive measures in place. We also need to increase our healthcare personnel, nurses and doctors, especially geriatricians.

Preventive healthcare has and should always be the hallmark of our healthcare system. It is ideal if we can keep our citizens healthy for as long as possible through prevention of chronic diseases. Let us spare no effort in promoting preventive healthcare. Can MOH, therefore, provide incentives for our people to eat healthily and exercise regularly?

Obviating long-term care in institutional settings should remain the basis of eldercare. Step-down care facilities such as community hospitals, day-care centres and community-care centres must be adequately provided so as to reduce the overload on expensive hospitals beds.

We need one new aspect of preventive healthcare in the community for the elderly. It is to facilitate the elderly to live as independently and for as long as possible in their own homes, with given support as in homecare and community support as with Seniors Activity Centres.

Long-term Healthcare

Mr Sitoh Yih Pin (Potong Pasir): Mdm Chair, this year is the 10th Anniversary of the severe acute respiratory syndrome (SARS) outbreak in Singapore. The SARS outbreak was arguably the worst health crisis we ever faced. Our healthcare workers displayed tremendous courage and professionalism to pull us through. Unfortunately, we lost a few healthcare workers and quite a few patients. But, during SARS, we turned our darkest hour into our finest moment.

One of the lessons learned in SARS was that we run the danger of over-optimisation to the point of vulnerability. Our public hospitals and polyclinics are very optimised in terms of service delivery. But optimisation is based on assumptions. To quote Henry Ford, "Any customer can have a car painted any colour that he wants so long as it is black."

This may be an extreme example of optimisation, but the reality is the more you optimise, the more narrow, precise and accurate your assumptions have to be, which in this case is that you assume that everyone only wants a black car.

But reality is full of variations and unexpected twists and turns. So, I would suggest to MOH that even as we ramp up our healthcare services, we spend some of these resources to cater for the unexpected.

The next issue I would like to dwell on is long-term care and dementia. I am pleased to note that MOH is embarking on a comprehensive exercise to increase the number of nursing home beds in Singapore over the next three to five years. In addition to this capacity building, I would like MOH to also look into capability building. Nursing homes have to be funded better to developing capabilities to cater to dementia patients.

Madam, we will have about 500,000 Singaporeans aged 70 and above in 10 to 20 years' time. Based on comparable studies, we may have to provide for 6,000 to 10,000 patients suffering from moderate to severe dementia who will likely need institutional care then.

I urge MOH to look into this quickly and develop the capability in nursing homes to handle these patients as well as the community to handle tens of thousands of mild dementia patients.

My third issue is on community-based elderly care. Due to the very large numbers of elderly in the next 10 to 30 years, the bulk of care for the elderly will remain in the community. Unless absolutely necessary, the vast majority of the elderly will wish to stay in the community, and not in an institution. We need to help these elderly and their families to achieve this. The recently announced increase of the Senior Mobility and Enabling Fund from $10 million to $50 million is a step in the right direction.

I would also suggest that MOH enhance accessibility and affordability to homecare as well. Good homecare delays an elderly's entry into a nursing home. I hope MOH can look into funding and developing the homecare sector so that more sick elderly can remain in the community, as they would prefer to.

Polyclinic in Jurong West

Mr Cedric Foo Chee Keng (Pioneer): Madam, I join Mr Sitoh Yih Pin in paying tribute to the many fine men and women when they tackled SARS and when they lifted the nation out of the crisis. I also recall that at that time, we had the Courage Fund. I would like to ask the Minister if we have used it well to recognise the many contributions of these fine men and women.

1.30 pm

Madam, as our population grows and ages, many people will require access to primary healthcare facilities. In Jurong West, for example, the population has grown significantly, and we have seen a corresponding rise in the demand for primary care. The nearest polyclinic for Jurong West residents is at Jurong East, and many elderly residents find it very inconvenient to get there. The waiting time at Jurong East Polyclinic has also increased. Could I ask the Minister to consider setting up a new polyclinic, perhaps at Pioneer constituency and near the transport hub there?

Madam, the Community Health Assistance Scheme (CHAS) is an excellent one. With a stroke of the pen, MOH increased the access for needy residents to primary healthcare. They no longer need to visit just polyclinics but they can visit private GPs as well. However, the number of private GPs who have signed up for CHAS remains limited, especially in Pioneer constituency. So, I would like to ask if the Minister can work on this and see if more GPs can sign up.

Secondly, a suggestion to extend CHAS to dental care: whether that can be done, or is it already done? And if so, can more dental clinicians be brought into this scheme?

Polyclinics

Dr Teo Ho Pin (Bukit Panjang): Madam, polyclinics provide affordable and accessible primary healthcare services to Singaporeans especially low-income heartlanders. Today, we have 18 polyclinics in Singapore providing about 20% of primary healthcare to Singaporeans. But, many polyclinics are experiencing heavy patient load and long waiting time. This could be attributed to the high demand for their services and the short operating hours of polyclinics. Polyclinics are open five-and-a-half days from 8.00 am to 4.30 pm.

Many Singaporeans who need outpatient medical services after these hours would have to consult private GPs or go to the Accident and Emergency (A&E) departments of hospitals. The charges of GPs and A&E departments are much higher, thus posing financial burden on Singaporeans, especially low-income households.

In Singapore, medical services after office hours are not easily accessible or affordable. Many housing estates do not have 24-hour clinics. As a result, many Singaporeans have to activate our ambulance services to go A&E for emergencies.

This has put additional strains on our limited ambulance services and caused long waiting time at our A&E departments at hospitals.

Madam, this situation will aggravate if we were to have more babies and elderly in the future. With such population profile, our existing hospitals and medical facilities will not be able to cope with any National Emergencies such as disease outbreak or disasters. Thus, I would urge the Ministry to consider building more polyclinics, operate polyclinics 24 hours, seven days a week, and equip polyclinics to be National Emergency medical centres.

Madam, I wish to ask the Minister the following questions. How many polyclinics will be built by 2030? Can the Ministry consider building a polyclinic in Bukit Panjang Town? Can the Ministry operate polyclinics on a 24-hour basis?

Primary Healthcare

Dr Lam Pin Min: Mdm Chair, the primary healthcare sector's importance to the overall health landscape in Singapore cannot be overstated. Today, there are some 2,400 private medical clinics and 18 polyclinics in Singapore. Primary care professionals are often the first point of contact with the patients in the community.

During last year's COS, Minister mentioned that the Ministry would seek to explore new models of care for this sector. I would like to ask the Minister for an update on MOH's strategy in delivering better primary care services to Singaporeans.

With the ageing population, many age-related medical conditions including mental illnesses, will become more prevalent. How will the ministry ensure that our primary care sector, especially our family physicians, stay relevant to cater to the needs of the elderly?

The current 18 polyclinics serve about 20% of the primary healthcare market. They provide affordable primary healthcare services to many Singaporeans, especially those from the lower- and middle- income families. What is the number and capacity of polyclinics required to meet our future needs? What role will the polyclinics play in ensuring affordable primary healthcare for Singaporeans? I have received much feedback on the long waiting times and over-crowding in polyclinics, especially the one in Sengkang. Like Dr Teo Ho Pin, I would like to request the Minister to consider introducing some 24-hour polyclinics in certain areas with extremely high demand to help alleviate this problem.

CHAS is very helpful in providing affordable and accessible primary healthcare services to lower-income Singaporeans above the age of 40. However, younger low-income Singaporeans, below the age of 40, are deprived of this subsidy and convenience of seeking treatment from the nearby participating family clinics. Will the Minister consider lifting the age criterion for this scheme so that all low-income Singaporeans can benefit from the scheme?

The Chronic Disease Management Programme (CDMP) has also benefited many Singaporeans by minimising the out-of-pocket expenditure when they consult their doctors for the management of their chronic diseases. However, I have received many negative feedback about the administrative fees imposed when using their MediSave for this programme. Can Minister consider waiving this administrative fee, especially for those from the low- and middle-income families so as to allow them to stretch their MediSave dollars further?

The Chairman: I am beginning to think that Christmas has come early. Miss Penny Low.

Punggol Polyclinic and Healthcare Services

Miss Penny Low (Pasir Ris-Punggol): Madam, I too wish that my Christmas wish can be fulfilled. So, like some Members who have clamoured for hawker centres for 10 years, or some have clamoured for this and that for many years. In the case of polyclinics, it is the same. As one of the fastest growing new towns in Singapore, the demand for primary healthcare services continues to grow in Punggol New Town.

At the 2011 Committee of Supply, MOH had announced the building of a polyclinic in Punggol. Can the Minister give Punggol New Town residents an update on the progress of the polyclinic's development? And also, could the Minister elaborate on what residents can expect, from this new and much needed facility, whether it will have 24-hour service or not?

Punggol is a young town and we want to encourage fertility as well. So, what is MOH's planning parameters in catering to residents on: (a) gynaecology and paediatrics care; (b) facilities for the elderly, step-down homecare; (c) dental services; and (d) the need for affordable healthcare?

As Punggol 21 is being developed to be a model town, perhaps MOH can also review its current planning parameters, and apply design thinking into meeting the healthcare needs of the residents, making it a role model in the care of our residents.

Health Promotion

Dr Lam Pin Min: Mdm Chair, according to the Bloomberg Global Health Survey in 2012, Singapore has emerged top as the healthiest nation in the world. This is, in part, due to our highly efficient healthcare system, as well as the major role played by HPB in promoting healthy living among Singaporeans.

Yet, let us not rest on our laurels. We need to do more to promote healthy living, with regard to obesity and smoking. Obesity is of particular concern. While our obesity rates are much lower than that of the Organisation for Economic Co-operation and Development (OECD) average of 17%, USA 34% and Australia 25%, our statistics show that Singaporeans are getting fatter. Obesity in Singapore rose from 6.9% in 2004 to close to 11% in 2010. Coupled with a global obesity pandemic, more food choices and affluence in Singaporeans, we face an uphill task.

In our fight against obesity, would MOH or HPB consider strengthening food advertising? This would follow international norms where many countries, like the UK and South Korea, have already regulated the food advertising market. Countries like Finland, Denmark and Malaysia have also set out government guidelines on food advertising. Children, in particular, are of concern as, most of the time, they are easily influenced by temptations in persuasive advertisements.

The health of the individual is very much affected by the consumption of the type of food. Many of our school children consume meals sold in the canteens. In order to minimise the consumption of unhealthy and junk food, can the Ministry consider mandating that only healthy diet are served in school canteens? To encourage Singaporeans to eat healthily, the Government can consider making healthier choice products sold in supermarkets cheaper and more affordable.

While the Government has imposed controls on harmful products like cigarettes, it is worrying that the prevalence of smokers amongst the young and the ladies are increasing. The recent extension of the smoking ban is also a step in the right direction. Non-smokers will have more reprieve from second-hand smoke and avoid the harmful effects of second-hand smoke. While we have banned smokers from lighting up in public places, it would not eradicate the harmful habit of smoking.

Smoking has been linked to many medical conditions including ischemic heart disease, chronic obstructive lung diseases and cancers. We can do more to eradicate this harmful habit among Singaporeans. One radical suggestion would be to gradually introduce a ban on smoking on certain segments of the population. Would the Ministry consider totally banning the sale of tobacco-related products to cohorts of citizens born after a certain year? While it is often difficult to make smokers change their habits and quit smoking, this would gradually eradicate the habit in the next generation of Singaporeans as they would not be exposed to the bad habit of smoking?

While looking after one's health and well-being is an individual choice and responsibility, the Government can facilitate and encourage Singaporeans to do so. Can the Ministry consider working with the insurance industry, or even MediShield to incentivise Singaporeans to lead a healthy lifestyle? This can be in the form of insurance rebates or further premium reduction.

Last but not least, will the Minister consider allowing MediSave to be used for medical screenings of some common medical conditions? This would enable diseases to be detected and treated early, enhancing the prognosis and minimising preventable complications.

Affordability, Scope and Capability

Mr Patrick Tay Teck Guan (Nee Soon): Madam, I would first like to thank MOH for responding to my call during COS last year, and joining hands with NTUC, our healthcare cluster of unions and institutions to form a tripartite workgroup looking at progressive wages and productivity for the healthcare cluster. The Progressive Wage Model implemented has started to raise the salaries and productivity of the lower wage earners in our public healthcare institutions.

Next, the increasing cost of dental treatment in Singapore is putting people off regular dental check-ups until such time they get a throbbing pain. This is especially so with our senior citizens who need it the most.

I recently had to embark on a dental treatment at the National Dental Centre because of a chipped molar and the entire treatment cost me almost $3,000 because of root canal, gum surgery plus a crown.

I, therefore, urge MOH in its review of the healthcare financing framework to address this issue of affordability of dental care and treatment, the use of MediSave for certain dental procedures, including for crowns – which, in my case – was not for cosmetic purposes.

I further submit that with the increasing number of elderly suffering from mental illnesses, there is an urgent need to increase the number of nursing homes for the elderly with dementia and other psychiatric illnesses. Currently, Singapore has 60 nursing homes with about 9,300 over beds, and only a few of these are catered to the elderly with psychiatric conditions.

By the same token, I am equally concerned and thus am requesting for MOH to look into setting clear and specific standards and quality of care across our nursing homes, daycare centres and the intermediate- and long-term care sector as a whole.

With a rapidly greying population and a stressful living environment, I would also like to ask the Minister to look at expanding the scope of MediSave usage, be it for inpatient or outpatient care and treatment. The maximum amount of MediSave to be withdrawn with respect to different treatments should also be reviewed with increasing healthcare costs.

We need to have an integrated approach between different Ministries to take care of the needs of those in this silver tsunami. One example is that with age, there are more orthopaedic conditions requiring the use of MRI scans. MediSave usage is currently allowed only for inpatient MRI, but not outpatient. In the same vein, can MOH look into re-classifying non-standard drugs used for chronic disease management such as diabetes, hypertension, asthma, stroke and so on to standard drugs so that thousands of Singaporeans will benefit. Also, can MOH share, on average, based on all CPF MediSave account holders, how much MediSave monies are left behind after they have passed on?

By the same token, I also hope to hear from the Ministry sharing more on the Seniors Mobility and Enabling Fund to subvention of assistive devices, aids, transportation and consumables?

MediSave

Ms Lee Li Lian (Punggol East): Madam, I would like to ask the Ministry to look into expanding the scope of outpatient treatment which can be covered by MediSave. Last year, MOH announced an increase in the withdrawal of MediSave for outpatient treatment for approved chronic diseases, raising it to $400 a year. However, the list of approved chronic conditions did not change.

1.45 pm

Currently there are 10 approved chronic conditions that one must suffer from in order to be entitled to use MediSave for outpatient treatment. Many elderly suffer from other common ailments, which though not approved chronic conditions, are health problems that are persistent and require continual medication to control or manage.

These health problems may include things like cataract, osteoporosis, or Parkinson's disease, to name a few. Some of these age-related health problems may be controlled or managed with long-term medication, while other problems may require further tests or health screenings in order to detect them. A more flexible use of MediSave would greatly benefit the elderly since many of them may not suffer from an approved chronic condition but have other illnesses that require costly long-term care and constant medical attention.

The cost of healthcare for elderly Singaporeans is a real concern. Many elderly I have spoken to during the course of my Meet-the-People Sessions (MPS) in both Eunos and Punggol East, and also in the course of my recent election campaign, tell me that they struggle with high medical costs and wish they could use their MediSave to cover age-related illnesses that are currently not on the approved chronic condition list.

I urge the Minister to consider expanding the scope of treatment as it not just chronic illnesses that are problematic and costly. And our elderly have a peace of mind knowing that they have the ability to cover any illnesses that plague them today.

Comprehensive Healthcare

Mrs Lina Chiam (Non-Constituency Member): Mdm Chairperson, the Minister for Health stated in Parliament on 21 October 2011 that out of the total amount of MediSave withdrawn for healthcare expenses for the elderly in 2010, about 45% was from their children's MediSave accounts. We cannot keep expecting those with insufficient MediSave to ask their children or family members to top up from their own MediSave accounts. This is not a sustainable plan. What if they require money in their own MediSave accounts when they themselves are old and sick? Are they expected to withdraw from their own children's MediSave account? This is simply kicking the can down the road. This will have the effect of deepening inequality. It will also aggravate the plight of lower income families.

Similarly for MediShield, the Ministry urges children to apply for MediShield coverage on behalf of their elderly parents. It expects all children with elderly parents to be able to pay such premiums.

Late last year, the Ministry noted that 35% elderly Singaporeans aged 76 to 85 are not issued under MediShield. That figure for the general population is 8%. Current payouts from ElderShield are insufficient. What happens when the bills of some patients are twice the amount, as is sometimes the case?

The 3M accounts for less than 10% of total healthcare expenditure which itself is currently at 1.6% of GDP. At last year's Budget, the Minister for Finance said that he would increase that figure to 3.5% GDP by 2030. Let us not wait that long. Other countries and economies in the region like South Korea, Taiwan and Hong Kong have already achieved this level of healthcare spending at 3% to 4% of GDP some years ago.

Prof Phua Kai Hong, an academic on healthcare policy, has characterised the standard of Singapore's long-term care as third world. If I may ask the Minister, what is holding us back from spending a little more of our GDP on healthcare?

The Minister for Health (Mr Gan Kim Yong): Mdm Chairperson, I would like to thank Members for their comments and their questions. As Mr Sitoh Yih Pin and Mr Cedric Foo have reminded us – 10 years ago, Singapore faced our first major health crisis as an independent nation when SARS broke out in March 2003. The outbreak dealt a significant blow to our economy and severely affected our community and our social life. Singaporeans rallied together during this trying time and emerged stronger from the experience.

Madam, with your permission, I would like to share a video clip with the House on SARS [ A video clip was shown to hon Members ]. Madam, we will be holding a series of commemorative events later in the year.

Mr Cedric Foo asked about the Courage Fund. We will also be reviewing the use of Courage Fund to make it more effective in helping our healthcare workers. I would like to take this opportunity to pay tribute and to recognise the contributions and sacrifices of everyone who was involved, in particular, my colleagues in the healthcare sector, some of whom fell ill and some who lost their lives as they cared for their patients. We will and we must remember them.

Madam, over the years, our healthcare system has grown from strength to strength, achieving good outcomes and delivering good care for our people. The global Burden of Disease Study 2010 ranked Singaporean men and women as having the second and fourth highest healthy life expectancy at birth in the world. We were also very happy to find out last year that Bloomberg ranked Singapore as the world's healthiest country. Premature deaths from cancer, heart disease and stroke have also steadily fallen over the years. However, it is not time to celebrate yet as there remain key challenges ahead of us, which my colleagues and I will be talking about.

Our National Health Expenditure in 2011 amounted to 4% of GDP. It is lower than the OECD's average of 9.5% but we must bear in mind that several OECD countries have older populations than we do, and our expenditure on healthcare is likely to grow as our population ages. Ageing will be a key driver of demand for healthcare services. An older population means a higher incidence of admission to hospitals and, for each admission, a longer stay. Lifestyle changes are another driver. Many of us have sedentary lifestyles and do not exercise enough. More young people are taking up smoking and becoming obese. Non-communicable diseases, especially cancer, heart disease and stroke, account for 60% of deaths in Singapore each year. Therefore, I agree with Mr Laurence Lien that we need to do more and be more innovative to keep Singaporeans healthy.

Last year, I announced my Ministry's Healthcare 2020 Master plan to build an inclusive healthcare system for the future – one that will provide Singaporeans with affordable, effective and good quality healthcare. Dr Lam Pin Min asked about the progress of Healthcare 2020.

First, on capacity to meet the needs of our patients. Over the past five years, resident bed days rose by about 4% each year from roughly 1.5 million to 1.8 million bed days in total. A significant proportion of this increase was contributed by an ageing population. Over the years, foreign visitors have remained at about 2% of the public sector's total patient load – a question that Mr Low asked. Our hospitals adopt various strategies to actively manage the increasing patient load. For instance, they deploy inpatient medical teams to the emergency department to ensure that prompt medical assessment and definitive care can be provided at the emergency department (ED) even before patients are warded.

In the short term, we will increase our capacity by adding beds in existing facilities. NUH current renovation project will make available an additional 79 beds by December. Ang Mo Kio Thye Hua Kwan Community Hospital has just added 50 beds and St Luke's will add a similar number by year end.

We will also be opening two new facilities this year. The new medical centre at the NUH will open by July 2013. This will allow NUH to expand its specialist outpatient clinics and day surgery operating theatres. The building will also house the National University Cancer Institute. The new National Heart Centre, on the other hand, will allow for expansion in our cardiac services. We are on track with our infrastructure plans for the medium term. The Ng Teng Fong General Hospital will begin to serve patients from end-2014. Let me show you how the hospital looks like [ A video clip was shown to hon Members ].

Madam, I wish I could build the hospital as fast as the video shows. This is our next upcoming acute hospital. Jurong and Yishun Community Hospitals will be ready by end-2015. Sengkang General and Community Hospitals are scheduled for completion by 2018. In the central region, Outram Community Hospital will be ready by 2020. Altogether, we will add 4,100 more acute and community hospital beds. This is 400 more than what we announced in Healthcare 2020.

Dr Lily Neo talked about planning for our future healthcare needs. Beyond 2020, we are planning for new hospitals in new population centres and in areas where demand is likely to grow. We anticipate that we may need to build four more new acute hospitals between 2020 and 2030. We currently studying regional demographic profiles to identify potential locations for these new hospitals and we will review our infrastructure plans nearer 2020.

Madam, we are also improving our delivery of primary care to Singaporeans which Dr Lam Pin Min asked about. As more Singaporeans develop chronic diseases, a good GP in the neighbourhood, who is familiar with our family's medical history, will be well placed to advise us on how to manage our health. This is also a point raised by Mr Lien. We have taken steps to make primary care more accessible and affordable for patients. We introduced CHAS to help lower- to middle-income patients receive subsidised treatments at GP clinics as well as for dental care, which Mr Patrick Tay asked about.

Last year, we enhanced CHAS significantly. More Singaporeans have benefited as a result. The number of CHAS cardholders has grown from 35,000 to about 250,000 since we made these changes – more than a seven-fold increase. We will monitor the scheme for a while more before reviewing it again, but I note Dr Lam's appeal to review the age criteria. Participating GPs can already refer CHAS patients to public sector's specialist outpatient clinics at subsidised rates, as Ms Tin Pei Ling and Mr Low Thia Khiang had asked about. They do not need to visit a polyclinic anymore as long as they are a CHAS patient.

During the Budget debate, Dr Fatimah Lateef asked about progress on community health centres (CHCs) and the family medicine centres (FMCs). There is growing support from the GP community for the idea of CHCs which provide allied health and other support services to GPs and patients. To provide more patients with convenient access to such support services, we will be setting up three more CHCs this year, in addition to Tampines. The next CHC will be opened in mid-2013 in the Bedok area while centres in Jurong East and Tiong Bahru will open by year end.

We will pilot four family medicine clinics (FMCs) this year. This is a group practice managed by private GPs in collaboration with other healthcare professionals with the support of ancillary services. Here, patients will be looked after by a regular care team and receive comprehensive care. Our first four FMCs in Clementi, Lakeside, Ang Mo Kio and Bedok will come on-stream later this year. We will continue to work with GPs to explore different models that will best suit their needs and those of their patients.

We will also need to build more polyclinic capacity to meet the growing needs of our population. We have refurbished Geylang polyclinic to increase its capacity and incorporate age-friendly features such as barrier-free access throughout its premises. Similar improvements are being made to Tampines polyclinic, and we will also be redeveloping Ang Mo Kio and Bedok polyclinics.

In regions where there may be gaps in coverage, building a new polyclinic will be necessary. I am happy to let Mr Cedric Foo know that we will be constructing a new polyclinic in the Jurong West area near Pioneer. This new polyclinic, along with the new Punggol polyclinic, which Miss Penny Low asked about, will open by 2017.

I anticipate that we will need another four new polyclinics by 2020 and another six to eight more polyclinics by 2030. All our polyclinics are equipped to handle basic emergencies, a point which Dr Teo Ho Pin raised. However, for serious emergencies, patients will be triaged and referred to the emergency departments of our public hospitals.

Polyclinics continue to play an important role in our primary care sector. Our polyclinics, together with a wide network of GPs and CHAS, provide the public with good access to primary healthcare services.

2.00 pm

Mr Low Thia Khiang asked for an update on the Regional Health Systems (RHS). Developing the RHS is an ongoing effort. I can share with Members the example of the Eastern Health Alliance, which Mr Low mentioned. It is collaborating with HPB on the Eastern Community Health Outreach (ECHO) programme . This combines community-based screening with appropriate follow-up care, as well as lifestyle advice such as diet plans and workshops to help patients control their chronic conditions, such as diabetes and high blood pressure.

Strong and lasting RHS partnerships will take time to build. One of the lessons that we have learned from this Eastern Health Alliance is that trust and understanding among providers from the various sectors – public, private, as well as the community sector – are critical to forge strong partnership and deliver coordinated, holistic care to our patients. While each region has its own unique needs, and will therefore develop quite differently, I am confident that we can share lessons from our experience in Eastern Health Alliance, and forge strong partnerships in these other regions as well.

Mr Low also asked about the progress of the National Electronic Health Records (NEHR). This is a multi-year, long-term project, which aims to facilitate information flow to improve care delivery. The system has been rolled out to almost 5,000 clinical users in the public healthcare sector, including eight hospitals, six specialty centres, and all our polyclinics. Access to NEHR has also been provided to the Agency for Integrated Care (AIC), some GPs and long-term care providers, with more nursing homes to follow.

To help our healthcare providers understand how to use the system, our teams conduct on-site training, and provide comprehensive information packages to all clinical users. Providers can share information such as patient diagnosis, lab results, medications, and discharge summaries. We will next work towards enriching the system's functionalities, including case management and shared care plans. With information shared across providers, we will have a system that is better connected, better coordinated, and better able to provide good care to each and every patient.

Let me update the House on our progress on initiatives under the Ministerial Committee on Ageing to take care of our seniors. We have moved decisively to enhance the access and affordability of aged care. Last year, we announced that the Government will invest $500 million to build 10 new nursing homes, 39 senior care centres, and 56 seniors' activity centres by 2016.

Some of the new capacity is already on stream. This year, three existing nursing home providers will begin their operations at their new sites. Bright Hill Evergreen and Singapore Christian Home are slated to start within the first quarter of FY2013, followed by Villa Francis. By the end of 2013, we will add more than 500 new beds to our nursing home capacity. Three senior care centres providing day rehab and day care will also open this year.

We have raised the subsidies for community hospitals, nursing homes, centre-based care, and home care last year. Let me also clarify a point raised by Mr Gerald Giam. We have simplified the means-testing process and criteria in the intermediate and long-term care (ILTC) sector to reduce hassle to patients and their families. They only need to give consent for us to access their CPF or IRAS data to carry out the means-testing, as Mr Giam suggested in his speech. In fact, we are already doing so. This has been implemented, in fact, since last year.

One beneficiary of our subsidy enhancements was Mr Tan Cheng Lim, who needed rehabilitation for his spinal cord injury. Mr Tan also has other chronic conditions, including high blood pressure. With the changes to our subsidies, Mr Tan now receives an 80% subsidy, as compared to 50% previously, at St Andrew's Community Hospital's Day Rehabilitation Centre. Mr Tan is happy to have his total healthcare bill reduced.

This year, we will pay greater attention on two areas. First, enhancing the quality of aged care. We have started workgroups comprising service providers as well as relevant agencies to look at care standards in nursing homes and centre-based care. The nursing home workgroup has proposed a new set of guidelines and standards, and we will be launching an industry consultation on this shortly. Dr Amy Khor will provide more details later.

Second, we will enhance the access and affordability of services to help the elderly to be cared for in their own homes and in the community. We are making significant efforts to expand home nursing, home medical and en suite home personal care services. MOH will convene an industry-led committee comprising professionals and home care providers to develop the home care sector, to chart new directions, new strategies, and set new standards to develop the home care sector so that home care can provide a viable alternative to nursing homes.

To make care more affordable, the Deputy Prime Minister has announced that the Seniors' Mobility and Enabling Fund will be expanded from $10 million to $50 million to subsidise more devices and consumables needed by frail seniors. We will also provide transport subsidies to a wider population of wheelchair ambulant seniors who need to travel to day centres to receive care. Dr Amy Khor will provide more details on this in her speech.

Mdm Chairman, seniors who need care often have complex care needs spanning social, medical and sometimes financial needs. In order to provide more holistic and person-centred care to our seniors, we will merge the aged care functions of the Centre for Enabled Living with those of AIC, under one roof at AIC.

Let me now move on to talk about how we are developing our healthcare workforce. In the past year, our healthcare professional workforce grew by 3,700, or about 8%. We are on track to growing our professional workforce to meet the healthcare needs of our population, as outlined in Healthcare 2020. Our priority continues to be to grow our local healthcare manpower supply.

We will continue to invest in the training of our healthcare professionals. In addition to classroom training within educational institutions, healthcare professionals also undergo supervised training in the public healthcare institutions. MOH will provide an additional $50 million to our institutions in FY2013, to enhance their capacity to deliver good quality clinical training, in view of the increasing number of students.

We also aim to raise the attractiveness of careers in healthcare. Last year, we increased the salaries for all healthcare staff in both the public and VWO long-term care sectors. This includes specialists, which Mr Low Thia Khiang asked about. The salaries of our specialists take into account their contributions in all areas – patient care, education, research and leadership. Their skills are especially valuable in our public hospitals where patients are cared for by a team. We need experienced specialists to supervise and lead the team, and ensure that we deliver good quality care. We allow our specialists to see private patients – but within certain guidelines – as this helps to retain them within the public sector. We will be introducing a new remuneration framework in 2014 and we intend to pool part of the professional fees, a point that was made by Mr Low.

MOH has also started a campaign to increase the awareness of the diverse and fulfilling work that nurses and allied health professionals do, to attract more Singaporeans to join healthcare. With Mdm Chairman's permission, I would like to show a snippet of our nursing campaign, which by the way is a real story [ A video clip was shown to hon Members ]. This is just one of the campaigns that we will be running, to raise awareness of the work that nurses do and their contribution to our society.

Beyond our local training pipelines, we will continue to supplement our healthcare workforce with overseas-trained professionals, especially overseas-trained Singaporeans. The pre-employment grant for Singaporean medical and dental students studying overseas has proven to be successful, with 189 grants given out since 2010.

Foreign healthcare workers also help us meet our healthcare service needs, add diversity to the sector and help develop our capabilities in various clinical specialities. Public healthcare institutions have put in place various initiatives to help them adapt to our practices and working environment, so that they can be effective members of our teams in serving our patients.

Mdm Chairman, I have outlined MOH's efforts to ensure that our healthcare system provides for the care needs of Singaporeans. But better healthcare is only part of our strategy. More importantly, we should all aim to achieve better health by living healthily. Ageing need not be a burden if we stay healthy. Instead, ageing can be fulfilling and meaningful. If we stay healthy as we age, we can continue to live good quality lives and contribute positively to society and family.

Each of us is responsible for our own health. The first thing we need to tackle is our own behaviour. I agree with Dr Lam that we should start as early as possible, targeting at our youth and young adults, so that healthy habits are inculcated early in life. Let me outline two key ideas.

MOH and HPB are looking into introducing a set of food advertising guidelines for children. There is growing evidence that advertising affects children's food choices and dietary habits. As such, we will strengthen the standards for advertising to children and for food and drink products which are high in fat, sugar or salt.

We conducted a broad-based consultation process on this issue last year. Responses from the public were overwhelmingly supportive for restrictions on food advertising to children to be introduced. MOH and HPB, together with the Advertising Standards Authority of Singapore, an Advisory Council to the Consumer Association of Singapore (CASE), will jointly work out the details for implementation, to be announced later.

Today, our smoking prevalence is relatively low, at 14.3%, compared to about 20% in New Zealand, 21% in the UK, and even higher in some developed countries. But it is on the rise, especially among our young adults. Smoking prevalence among young adults aged 18 to 29 years has risen at a faster pace than that of the general population – from 12.3% in 2004, to 16.3% in 2010.

An effective way of discouraging individuals from smoking or picking up smoking is through a ban on point-of-sale display. This means that when you go to the retail shops, they will not have these products on display. Customers will have to ask for tobacco products specifically. Vendors can store these products in areas that are not visible to the public, such as in closed drawers. In the coming months, MOH will seek the views of the public on the point-of-sale display ban.

Finally, let me share with the House our broader vision for healthy living. We aim to catalyse a whole-of-Singapore effort, in which healthy living becomes a shared vision.

To lead this effort, we have formed a Healthy Living Master Plan Taskforce, chaired by Parliamentary Secretary Assoc Prof Muhammad Faishal Ibrahim. This Taskforce will develop a plan on how we can change our current landscape to encourage healthier living. But such change must come from within. We want this plan to be created and owned by the people, and to enable Singaporeans to make decisions for themselves that favour healthier living. The Taskforce has done a lot of preliminary work and developed a 3P approach: Place, People, and Price, and it will consult extensively before finalising its recommendations. Assoc Prof Faishal will elaborate on this later.

Mdm Chairman, I have outlined the progress on the Healthcare 2020 Masterplan. We are on track to enhancing access to healthcare services. We are also making good headway in building up our capabilities to provide these vital services. I have laid out our vision for a healthier Singapore – one in which individuals, organisations, and the community must work together to change the way we think about health. The conversation on healthy living must go beyond the boundaries of the healthcare sector. We need a whole-of-Singapore approach in order to keep Singaporeans healthy and give them greater peace of mind.

2.15 pm

Outpatient Care Financing

Dr Chia Shi-Lu (Tanjong Pagar): Mdm Chair, inpatient hospital expenses are reasonably covered by the 3Ms framework. But I am going to focus this cut on out-of-pocket expenses for outpatient care. Many Singaporeans are still concerned about these expenses, despite the heavy subsidies already provided for primary and specialist outpatient care by the Government.

The Chronic Disease Management Programme (CDMP) has indeed improved affordability for patients with chronic conditions, covering many conditions such as diabetes, hypertension, stroke and major depression. CHAS, which has been alluded to by many Members in this House and by the Minister, also helps Singaporeans who wish to remain under private care with their family doctors, to still enjoy healthcare subsidies from the Government, and also to be able to be referred for subsidised care in Government's restructured hospitals.

I would like to renew my call along with that of many Members of this House that MOH continues to consider the liberalisation on the use of MediSave for outpatient care, whether for existing schemes such as CDMP and CHAS mentioned earlier, or for intermediate and long-term care, and perhaps for new segments, such as paediatrics, cardiological and cancer specialist care. These medical services, typically provided by specialists in hospital-based specialist clinics, require frequent and sometimes costly investigations, and often involve medications and treatments that are long-term and may be expensive. By further extending the use of MediSave, we can encourage better patient compliance with respect to management of these diseases, thereby improving outcomes and reducing chronicity and disability.

I call upon MOH to review the sacred cow of MediSave adequacy calculations. It may not be prudent to accumulate too much in MediSave, as the power of MediSave to buffer healthcare costs is limited and it should primarily be considered as a supplemental source of healthcare financing in the short-to-middle term, rather than to prepare for expenditures eight to 10 years away, or beyond. This "sinking fund" concept works better for insurance schemes with preloading considerations, but less well for what is essentially a savings scheme which, in real terms, functions mainly to cover smaller costs in the near term of three to five years. I also hope that MOH can explore health insurance schemes for outpatient care.

I also call for MOH to consider calibrating subsidies to inflation, across the entire healthcare delivery chain. Such an inflation peg would help cushion Government-subsidised patients from inflationary pressures. And my final point is to renew the call —

The Chairman: Your time is up, Dr Chia. Assoc Prof Fatimah Lateef is not here. Mr Muhamad Faisal Manap.

Ambulance Subsidy

Mr Muhamad Faisal Bin Abdul Manap (Aljunied): Madam, there are currently two types of ambulance services in Singapore – the Emergency Ambulance Service (EAS) operated by SCDF and the non-emergency ambulance services managed by private entities.

The non-emergency ambulances provide services such as ferrying patients to and fro hospitals, polyclinics and medical centres for their checks, scheduled appointments and follow-ups. The non-emergency ambulance service cost a family between $60 and $120 for a one-way trip; for a two-way trip, the cost of basic transport services is between $70 and $180. Additional surcharges will be imposed in the event that additional medical attention is required.

Madam, I would like to highlight a family of three that I came across recently. The sole breadwinner was previously employed and earns about $1,500 a month. However, due to his wife's medical condition, he left his job to take care of his wife, who is wheelchair-bound and has multiple medical conditions. Her condition requires her to frequent the hospital for her check-up. In order to ensure smooth and safe transfer to and from the hospital, a private ambulance is engaged. I subsequently wrote an appeal letter to AIC but I was informed that there are currently no subsidies in place for families who engage the private ambulance.

For this family and many other families who have to use this service on a regular basis, the cost of hiring a private ambulance constitutes the financial burden for them. As such, I urge the Ministry to introduce a non-emergency ambulance subsidy scheme for families with a monthly household income of $1,700 and below, or per capita income of $550.

Use of MediSave

Ms Tin Pei Ling: Mdm Chair, to many Singaporeans, MediSave is a compulsory savings account to cater specifically to their healthcare needs. They see their MediSave as their hard-earned money and they feel they have the right to use it as and when they need it. Such thinking is understandable.

Madam, the principle behind imposing criteria such as annual withdrawal cap and minimum sum requirement on MediSave is to ensure we set aside enough savings to meet our future healthcare expenses. However, for senior citizens, especially retirees who no longer have an income, they have limited means and they will look to their MediSave to pay for their healthcare needs.

So, firstly, can the Ministry allow greater flexibility in the use of MediSave with a higher annual cap and lower minimum sum? Can the Ministry extend the coverage of MediSave to more areas? For instance, can we have a definition by exclusion? For example, MediSave can be used for all medical needs except aesthetic medicine.

When I raised a cut on the use of MediSave for senior citizens in last year's COS debate, it was suggested that if MediSave and MediShield cannot be tapped on, or tapped on further, the elderly can turn to MediFund. However, some elderly feel extremely uncomfortable with having to apply for MediFund, especially if there is still money in their own MediSave account, but which they are unable to use. They also fear they will have to incur out-of-pocket expenses if they fail to secure financial assistance.

Furthermore, there is an administrative fee chargeable on MediSave deduction transactions. While the fee may appear modest, it can add up to quite a sum if a senior has to go for several medical appointments or treatments and thereby, has to make several MediSave deduction transactions. With each fee payment therefore, it means that a senior will have even less money in his or her MediSave to pay for subsequent treatments. This is as a result of their admin fee charged. This will adversely affect Singaporeans who are needy and without family support, and particularly our elderly.

Moreover, with the advancement of technology, better process design and economies of scale achieved, would there not be cost savings gained over the past years? Therefore, can the Ministry waive off the administrative fee for MediSave transactions so that Singaporeans' hard earned money can be fully utilised for their healthcare needs?

Support for Chronic Patients

Mr Yeo Guat Kwang (Ang Mo Kio): ( In Mandarin ) : [Please refer to Vernacular Speech on Pg xx.] It is best to stay healthy; falling sick is no fun. Chronic illness will take an even higher toll on the patients. I would like to ask MOH about its plans and efforts to support Singaporeans who are chronically ill patients, particularly those who need expensive and long-term care. I am concerned especially with those suffering from kidney failure and needing dialysis. Is the Ministry doing enough to support them and the organisations that help them live a better quality of life?

Take kidney failure, for example, I understand that about 750 people are diagnosed with end-stage kidney failure every year and this figure is rising. In Singapore, NKF is the biggest and only provider of dialysis treatment in Singapore and cares for about 60% of the kidney failure patients. The increased demand means organisations such as NKF are struggling to build enough centres and are facing cost pressures associated with caring for their patients. How would the organisation invest in building its capacity to meet the increasing demand? I would also like to ask the Ministry about the current demand for dialysis and how many private service providers are starting up? What is the ratio of this private-to-public supply of dialysis? The Government must step up its effort in providing citizens with such services.

Currently, breakdown of dialysis funding for an average patient is that NKF foots 40% of the cost, paid for by donor contributions. Insurance or MediShield makes up about 38%, employers pay 2% and the patient pays about 8% of the bill. Government assistance comes up to about 9%. Can the Government look into reviewing its quantum of assistance for NKF and other VWO dialysis organisations? If organisations such as NKF fail, the consequences would be dire.

In the USA, the support is more comprehensive with concerted efforts from the Government, insurance companies, the community and dialysis centres.

With an ageing population, I hope the Government will go more into preventive healthcare and provide more support to Singaporeans who are chronically ill.

ElderShield and Active Ageing

The Senior Minister of State, Prime Minister's Office (Mr Heng Chee How): The health of the population has a direct impact on that population's spirit, morale and strength, therefore, its ability to have a better future. With a rapidly ageing population in Singapore, the upkeep of our health, individually and for the entire population, is even more important. Hence, I fully support the Health Minister's two-pronged approach, both to look after the healthcare cost as well as to promote health.

I believe that the two need not be done in a separate or silo manner, but could be integrated. So, if you take the case of the ElderShield for example, as it is currently structured, it is a straight bet. That is at age 40, you enter ElderShield. At any subsequent point, if you are unable to perform, say three or more activities of daily living, that is beyond a certain level of disability, there is a cash payout for an X number of months according to the policy.

I feel that it is not only about how much money it is being paid out under the policy. I think we can do more to use such kinds of insurance programmes to motivate the current kind of behaviours towards healthy living and active ageing. For example, I hear that in some other developed countries, such as in the US, places like Kaiser Permanente for example, they have programmes which integrate the wellness practices and participation in wellness programmes of insured persons together with the insurance programmes. In this way, through premium differentiation for example, they motivate the right kinds of behaviour amongst more of the insured, and there are other examples. I believe this is one area in which the eldercare programme could be reviewed.

Secondly, when the money is paid out upon the claim, there is no question of how the money is being spent. In other words, it is not necessarily spent on better eldercare or disability care. I believe that if it is a programme meant for ElderShield – the claim is to do with the elderly and meeting disability requirements – then I think more could be done so that the payout is also used to support better eldercare and disability care.

The Chairman: Dr Chia Shi-Lu, you have two cuts. Please take them together.

ElderShield Enhancements

Dr Chia Shi-Lu: Mdm Chair, let me begin by saying that I believe ElderShield to be an excellent safety net to maintain the livelihoods of our senior citizens should they have the misfortune to become significantly disabled.

There are concerns about the scheme though. Even with supplemental policies, many have questioned whether ElderShield can adequately support them should they become permanently disabled, particularly since it is unsure whether future payouts will be corrected for inflation. Hence, there are many who have opted out of the system. I hope that MOH can address these concerns and strengthen ElderShield in future reforms, such that it becomes more robust and universal, so that it will achieve its stated aims as a social insurance policy.

In 2007 and 2012, as claims were not as high as feared, rebates were returned to policyholders. I hope that consideration may be given to use future surpluses instead, either to adjust for inflation for future payouts, or to extend the payouts for claimants who only have basic coverage. The basic ElderShield coverage is for 60 months or 72 months, but most disabilities in seniors are permanent, and it would not be unreasonable to extend the payout period with these surpluses.

I have constituents who are reaching the end of their ElderShield payout after six years, and they are understandably very concerned. I would like to ask what alternative means of support such claimants can turn to, following the end of the payout period under ElderShield.

Treatment of Rare Diseases

For my second cut, I welcome the introduction of MediShield and MediFund Junior for children, as having a severely ill or chronically sick child presents a great emotional and financial burden on the parents. We, as a nation, should provide these families with all the assistance we can.

This issue concerns the treatment of rare childhood diseases, most of which fall under the classification of inborn errors of metabolism, and this has been brought up in this House before. However, I feel it is important to bring this again to the attention of the Ministry. Some of these diseases, such as Pompe's and Gaucher's disease, can be effectively treated by medication, such that the children can grow up to lead normal productive lives. But the treatment is lifelong, and due to the rarity of such conditions, the medications required are prohibitively expensive and may cost several hundred thousand dollars a year.

Presently, these costs are borne to a large extent by the Government and various charitable organisations, and parents contribute what they can. I understand that MediFund Silver can also be used in these situations.

However, parents of these children are understandably concerned about whether these costs will continue to be covered, and I seek assurances from the Minister that we will continue to support the costs of such medications for this small group of patients. These children also typically require other treatments and considerations that incur extra costs to the family, and I hope that the Ministry will take these special needs into consideration and extend the necessary financial assistance.

2.30 pm

National Vaccination Programme

Dr Lam Pin Min: Mdm Chair, Singapore's National Childhood Immunisation Programme (NCIP) has been in place for several decades and has been effective in protecting against the targeted diseases. Its schedule has been revised regularly, with the last amendment in 2008. In many ways, vaccination works on the old adage "Prevention is better than cure". By protecting children against certain infectious diseases, vaccination can reduce mortality and morbidity of preventable diseases.

Today, NCIP covers over 10 different diseases, but only two, measles and diphtheria, are compulsory. Moreover, some vaccinations are provided free while some, such as Hepatitis, though listed in the national programme, are charged at cost with the option of paying through MediSave.

I would like to seek clarification from the Minister on the following:

(a) How does MOH determine which diseases are compulsory for vaccination? Should MOH not make more diseases compulsory under the NCIP to offer a better and more comprehensive coverage?

(b) Can the Minister consider including more preventable diseases, such as chickenpox, Hemophilus influenza and human papillomavirus (HPV) in the national immunisation programme?

With higher air, land and sea connectivity and the large influx of immigrants from countries without comprehensive immunisation programme and coverage, the risk of localised outbreaks of infectious diseases is enhanced. How would the Ministry mitigate this risk and prevent the resurgence of infectious diseases, such as tuberculosis (TB) and poliomyelitis?

Mr Gan Kim Yong: Mdm Chair, several Members – Dr Lam Pin Min, Mr Lim Biow Chuan, Ms Jessica Tan, Ms Janice Koh, Mrs Lina Chiam – have raised a concern shared by many Singaporeans and, that is, how to keep healthcare affordable.

How do we help Singaporeans pay for their healthcare costs? Today, we have a financing framework comprising four pillars – subsidies, MediSave, MediShield and MediFund, or what we usually call subsidies and "3Ms". In 2002, we introduced ElderShield. Let me now explain briefly how all these work together to help our Singaporean patients.

First, Government subsidies. All Singaporeans can enjoy significant subsidies at our public healthcare institutions – up to 80% for inpatient care and 50% for specialist outpatient care, as well as up to 75% in our polyclinics. Let me give an illustration. Take, for example, the median bill size for C Class wards at SGH which is about $4,300 before subsidy. After subsidy, this is brought down to about $1,100.

Patients can then use MediSave to cover up to the full amount of the balance, while MediShield helps Singaporeans cope with the larger bills. With MediShield and MediSave, for eight out of 10 subsidised hospitalisation bills, patients only need to pay $100 or less in cash. Those who still have difficulties after MediShield and MediSave subsidies, can tap on our MediFund. While our framework has served us well, we need to plan forward as our needs change in years to come.

I, therefore, initiated a major review of our financing framework last year. We have also held two sessions of "Our Singapore Conversation" and engaged many Singaporeans, including patients, to hear their views. Let me elaborate on four areas of feedback that we have received.

First, Singaporeans are concerned about rising healthcare costs. Today, we spend about 4% of our GDP on healthcare, or about US$1,700 per person. This is similar to what Hong Kong spends. Over time, we can expect National Healthcare Expenditure to continue to rise as our population ages.

So, what drives healthcare costs? First, cost of the same treatment goes up over time due to rising cost of manpower, supplies and so on. This is inflation. Next, as we age and our health deteriorates, we will spend more on healthcare. On average, annual expenditure on hospitalisation, after subsidy, for a 65-year old is three times that of a 45-year old.

The third reason, and a key one, is that healthcare is getting significantly better and more accessible. We have adopted more advanced medical treatments and technologies that achieve better outcomes for patients, and these have become more common than before. However, they are also more costly. For example, 10 years ago, a heart attack patient would have been given an injection to dissolve the clot in the heart arteries. Nowadays, it is standard practice for a similar patient to be treated with ballooning or angioplasty, which improves patient survival rates and long-term outcomes, but at twice the cost or more.

A second concern of Singaporeans is with how much out-of-pocket cash they have to pay. Dr Lily Neo and Dr Lam Pin Min have highlighted this. Expenses for outpatient care, including diagnostic tests, such as MRI, ongoing medication and long-term care, can become large cumulatively over time.

Ms Tin Pei Ling, Ms Lee Li Lian and Mr Patrick Tay have asked for more flexibility in the use of MediSave in the outpatient care setting, or for long-term care. Some Singaporeans have asked for more subsidies, especially in these areas, to further reduce their out-of-pocket bills. I will discuss our thinking on these areas later.

A third area of concern arises when we hear stories of Singaporeans who incur exceptionally large healthcare bills and wonder – "what if this happens to me?" While such large bills may be rare in the subsidised public institutions, it is natural for us to worry about them. We need to provide Singaporeans with more assurance on this. We will carefully explore how we can provide Singaporeans with greater assurance against very large out-of-pocket payments and we will take into consideration the various suggestions made by Members.

Finally, many Singaporeans have told us that while there are many help schemes, they do not know how to get the help they need. As Ms Tan Su Shan mentioned in the Budget debate, we need better outreach and communication to the public, to reassure Singaporeans that help is available, and that everyone will have access to good healthcare.

I should add that it is not just the elderly who are concerned about the cost of healthcare, but also the sandwiched generation, who are helping to pay for their elderly parents' healthcare and retirement needs, while raising young families. While we want to encourage family support, there are limits to this approach. Mrs Lina Chiam raised this point. We need to calibrate our policies to ensure that reliance on future generations is within reasonable limits.

We also want to help the middle-income with the cost of healthcare, as Mr Vikram Nair suggested in the Budget debate. This is why many of our schemes, such as the CHAS for GP care, the Medication Assistance Fund (MAF) for drugs, and subsidies for long-term care have been extended to the middle-income. We will do more for this group.

Madam, there is a strong desire among Singaporeans for greater peace of mind – the assurance that I will be able to afford healthcare when my family and I need it, whether now or when I grow old. We take these concerns to heart. We want Singaporeans to be confident that they can always afford the care they need.

Part of this involves managing costs in our system. We work with our hospitals to identify and introduce clinically proven and cost-effective treatments, and provide sound advice to patients on the choice of treatment. This ensures good outcomes for patients, at the most reasonable cost possible. To enhance productivity, we are making strong efforts to upskill our workers, leverage on technology and automation, and redesign jobs and work processes. Right-siting of care is also crucial in keeping our healthcare costs low.

While we manage costs and ensure that we are effective in the way we deliver care, we also need to enable patients to pay for their portion of the cost. The subsidies and 3M framework have served us well so far. But we need to further strengthen this, as the healthcare needs of our population evolve over time. The review of our healthcare financing system will be extensive, and will involve fundamental shifts. Therefore, it will take more than a year to complete. Let me take this opportunity to share some of our initial thinking.

Even as we seek to give Singaporeans greater assurance today, we must not inadvertently create a problem for future generations of Singaporeans. If we get it wrong, we leave a heavy burden of debt for our children and grandchildren. This is why it is important to retain some key principles that have served us well.

The starting point is for every Singaporean to take ownership of his health, to live healthily, seek treatment early and make informed choices in seeking treatment. I was heartened that in our dialogues, including the Our Singapore Conversation (OSC) sessions, participants understood this well.

For this reason, it is important to preserve the principle of co-payment, but we will also have to ensure that co-payment is affordable. With this in mind, let me elaborate on how we intend to shift the balance of the way we pay for healthcare.

The first major shift is to increase Government's share of national spending to provide Singaporeans with greater assurance that care will remain affordable and accessible. Government spending will not only rise in tandem with the increase in national healthcare spending. We will, in fact, take on a greater share of national spending, from the current one-third to about 40% and possibly even further, depending on various factors such as demographics and our ability to manage healthcare costs and target our subsidies. This will help to reduce the impact of rising healthcare costs on Singaporeans, especially the lower- and middle-income Singaporeans.

However, how we spend the additional money is also crucial. Today, the bulk of our subsidies go towards hospitals, where the cost per episode is high. As our population ages, delivery of healthcare will increasingly extend beyond hospitals.

Many Singaporeans, including Dr Chia Shi-Lu, have given feedback on the cost of outpatient care. We have enhanced CHAS to make primary care at GP clinics more affordable, and raised subsidies for drugs to help lower- and middle-income patients.

In our review, we will explore how we can provide more financial support in a targeted way for specialist outpatient care, primary care, preventive healthcare, dialysis and long-term care, to reduce the share that patients have to pay.

The second major shift is on MediSave. We have been expanding MediSave use progressively since 2006, to include outpatient treatments for chronic diseases as well as selected vaccinations and screening. Now, Singaporeans can use up to $400 per MediSave account to pay for these each year.

MediSave has been sized primarily to pay for subsidised care in the inpatient setting. As we grow old, we are more likely to require hospitalisation and each hospital stay is longer. If we allow unrestricted use of MediSave, many of our elderly may not have sufficient MediSave for their needs in the future.

But I hear the concerns expressed by several Members and we do exercise flexibility on the ground for cases with exceptional circumstances. I believe if we calibrate carefully and put in place some safeguards, we can allow greater flexibility in the use of MediSave to reduce out-of-pocket costs, without jeopardising our future. We will review MediSave policies to see how to have greater flexibility in the use of MediSave. We raised the cap on use of MediSave for chronic diseases from $300 to $400 last year. Can we raise it further? Should we expand the Chronic Disease Management Programme (CDMP) to include more diseases, as some Members have suggested? Should we allow MediSave to be used for outpatient treatments beyond the CDMP? How do we prioritise the different needs, to ensure that MediSave will not be depleted prematurely? How do we ensure that providers focus on necessary and cost-effective treatments, so that each MediSave dollar is well spent? These are issues that need to be addressed in the review.

The Government will continue to provide additional help for the lower-income and the elderly to save more through MediSave top-ups under the Workfare Income Supplement (WIS) and the GST Voucher for MediSave. In the Budget, Deputy Prime Minister Tharman announced higher WIS payouts for lower-income workers and doubled the GST Voucher MediSave payout this year for eligible elderly. In addition, $200 will be provided to all citizens 45 years old and above. We will study what else we can do to help Singaporeans build up their MediSave balances, so that we can allow more MediSave to be used.

The third shift is on the role of insurance. As Dr Chia Shi-Lu mentioned, we need to calibrate the balance between personal savings through MediSave and the role of MediShield by risk pooling.

For us to stretch the health dollar and to give Singaporeans a greater peace of mind, we need to enhance the role of insurance schemes such as MediShield and ElderShield. But we need to do this carefully to guard against over-servicing and over-consumption, both of which will lead to rising costs and higher premiums for us all.

2.45 pm

We will study how we can shift the balance towards greater insurance coverage, without driving up demand and consumption, and allow insurance to carry a larger share of healthcare funding. Together with an enhanced Government share I mentioned earlier, this can help to reduce the need for individuals to pay more from MediSave or cash.

We recently enhanced MediShield to include congenital and neonatal conditions and gave each Singaporean baby a hongbao of $3,000 in his own MediSave account. This is a significant step towards making MediShield coverage universal for the younger generation. We will next need to look into how to help the older Singaporeans stay insured under MediShield, a point which Dr Lily Neo raised.

MediShield is designed to be a catastrophic insurance primarily for larger inpatient bills. As we review how we can strengthen insurance coverage, we will also examine whether it should remain so, or if we can expand it so that it can offset a higher proportion of costs, while keeping premiums affordable. We will also have to address Singaporeans' concerns about exceptionally large bills that go beyond the current cap on MediShield claims.

Let me now turn to address the specific concerns of our elderly today. Budget 2013 will deliver an additional package of one-off MediSave top-ups for the elderly. But in addition to these ad hoc top-ups, we will need to review how best to support the healthcare needs of our elderly, especially the very old today. Many of these are our pioneers and they may not have accumulated enough MediSave by the time they retired. We need to take care of their healthcare needs. And this is a priority area that we will be looking into in the review.

Dr Chia and Mr Heng Chee How raised the issue of ElderShield. As the care needs of our seniors expand and become more complex over time, there is a need to revisit the coverage of ElderShield. We have started the review of ElderShield but rather than to review ElderShield on its own, we really need a more fundamental review of the roles of Government subsidies, insurance and individual share of healthcare costs and how aged care fits into this big picture. We will review ElderShield as part of the overall review of our financing framework.

While we carry out this review which will take some time, we will make a few immediate changes to strengthen our safety nets, to keep healthcare affordable.

First, on MediFund. MediFund plays an important role as a safety net, to help provide peace of mind for both lower-income patients, as well as middle-income patients with larger bills.

We introduced MediFund Silver in 2007 to take care of our needy seniors, and we recently announced the establishment of MediFund Junior to help needy children.

MOF will be topping up the MediFund capital sum by $1 billion. This will increase the annual MediFund assistance by about 20% to $120 million, to help more needy patients with their healthcare bills.

We will use some of the additional MediFund monies to close existing gaps in MediFund coverage. Mr Patrick Tay expressed concern about the high cost of dental treatment. From 1 April 2013, we will extend MediFund assistance to patients at the National Dental Centre. In addition, Singaporean mothers who face difficulty paying for their antenatal care and delivery can also be assisted by MediFund. By June 2013, we will also extend MediFund to the polyclinics, including dental services there. This will provide some relief for needy patients. We will continue to see how we can make our safety net more effective in giving Singaporeans greater assurance. Dr Chia Shi-Lu mentioned rare diseases. We will also explore how we can help this group.

Next, on cost of drugs. The cost of drugs is also a concern for many Singaporeans. We provide subsidies through the Standard Drugs List (SDL) and the Medication Assistance Fund (MAF) to ensure that drugs are kept affordable for our subsidised patients. From 1 April this year, we will add 17 new drugs onto the SDL and MAF. These drugs include second generation insulin products and insulin penfills, to help lower the cost to diabetic patients. I previously mentioned that Atorvastatin, which is a drug for high cholesterol, was being reviewed. This drug will now be placed on the MAF. A patient who requires this drug to treat chronic high cholesterol can enjoy potential savings of up to $375 a year, and pay just $125 instead of about $500 a year for this drug, depending on his dosage and subsidy level. These enhancements are estimated to cost the Government $5 million per year.

Finally, let me address a topic that many Members have raised over the years, which was also raised by Ms Tin Pei Ling and Dr Lam Pin Min recently, or at this debate. Dr Chia Shi-Lu also asked about this just now. This refers to transaction charges for MediSave claims. This is a fee of about $3 for each MediSave claim that patients make. As I explained last year in a PQ reply to Mr Ong Teng Koon, this charge goes towards the costs of operating the MediSave scheme. However, I understand that this fee may pose a burden on patients, especially the lower income, or those who need to use their MediSave frequently to pay for chronic disease treatment. My Ministry has reviewed this and I am happy to let Members know that with effect from 1 April, MOH will absorb the transaction fees fully.

Madam, let me sum up. Over the years, we have established a healthcare financing system that has served us well. We have made changes to our financing policies and revised them regularly to respond to the needs of our patients and their families.

Looking ahead, the landscape is shifting rapidly, demographics are changing and there is a need to strengthen our framework, to give Singaporeans better peace of mind. There will be key shifts in Government subsidies and the 3M framework. The review will take more than a year to complete, but I hope to be able to give the House an update and introduce some of the changes by the next COS.

While everyone has to play his part to live a healthy life and to save ahead for his own future needs, the Government will increase its funding share, and put more money in prevention, primary care and aged care. Insurance will be further expanded, to enhance risk-pooling across the population. The MediFund safety net will be strengthened and made more accessible. Ultimately, the purpose of this review is to give Singaporeans better health and greater peace of mind.

The Chairman: Dr Chia Shi-Lu.

Nursing Home Standards and All-ages Living

Dr Chia Shi-Lu: Mdm Chair, MOH has announced that by 2020, it will be adding 6,600 nursing home beds and tripling the number of rehabilitative care places from the current 2,100 to 6,200. Correspondingly, we will have to increase the number of staff under home healthcare from 4,000 to between 8,000 and 10,000 and under home social care, from 2,000 to 7,500. I would like to request an update on how MOH is achieving these target recruitment numbers.

Currently, many of our elderly care services are running at full capacity and also face manpower shortages. We have been quite reliant on foreign manpower as not many Singaporeans are attracted to the sector due to the challenging working conditions. Can the Ministry provide an update on the Healthcare Professionals Conversion Program which is designed to encourage and facilitate locals to consider a career switch to the healthcare sector?

I also asked last year what are the steps the Ministry is taking to maintain the quality of services under these conditions and prevent cases of abuse. Could MOH provide an update of their efforts to ensure that homes comply with the guidelines on handling patients and safeguard against abuse and lapses of care?

As we build a City for All Ages and encourage aging-in-place, I also request the Ministerial Committee on Aging to provide an update on efforts to promote community-based services and ageing-in-place initiatives for seniors. One issue in particular is the monitoring of the elderly who live alone or with other elderly. I hope that efforts will continue to explore effective but yet minimally intrusive ways of monitoring the well-being of these seniors in their homes.

Finally, I welcome the enhancements to the Seniors' Mobility and Enabling Fund because mobility is a critical element for building a City of All Ages. And the Seniors' Mobility Fund has been a great success since its launch. However, many Singaporeans may also look at mobility as not just about devices. Some patients, for example, may require taxis or special vehicles to transport them from their homes to healthcare institutions and back and such transport is costly. I hope that the Mobility Fund can be expanded to help defray these transport costs.

The Chairman: Assoc Prof Fatimah Lateef is not here. Mrs Lina Chiam.

The Elderly, Disabled and Caregivers

Mrs Lina Chiam: Madam, the labour force participation rate of women is lower than that of men usually because women are expected to be caregivers for the elderly or for the young children. Figures from MOM show that a large percentage of women are not in the workforce. Much more has to be done to recognise their work in financial terms. How else can they retire one day in security if they do not have CPF? We cannot assume they can rely on their spouses as a breadwinner as the current system does. What if they are not married in the first place?

Perhaps hospitals and homes could initiate a programme for nurses and social workers doing part-time and flexi-hours to visit caregivers to offer basic nursing care and training. Retired nurses should be encouraged to come back to join the workforce.

Another plight of caregivers is single parents who do not get the same childcare subsidies like fatherhood benefits and housing benefits. The Government has to adopt a different mindset to accept children born out of wedlock. Every child is a gift from God and should be counted as only to caregivers and their parents, whether single or married so that we can nurture them.

I want to stress the importance of diapers for elderly, particularly important because I believe they are being rationed in nursing homes and they are costly. Perhaps the Minister could look into giving more subsidies for this item.

The Public Assistance (PA) scheme is designed for those who are either disabled through illness or with physical disability with no dependents to get support from the Government. Currently, adults on the PA scheme living alone receive $100 a month while those with dependent child receive $50.

Could I ask the Acting Minister for Social and Family Development: how many PA recipients in Singapore currently have a dependent child and whether the cash component for a PA recipient with a child can increase to allow better development for the child, as a growing child would need more money than an adult?

Promoting Mental Wellness

Ms Ellen Lee (Sembawang): Mdm Chair, Singapore has become a very stressful society where people often demand for instantaneous results. This has to a large extent impacted our physical health, personal well-being, family and inter-personal relationships. For people who can cope or are open to seeking help, they can safely claim to be sane, save perhaps for some idiosyncrasies that may raise eyebrows but cannot be called "insane". But for people who cannot realise their own abilities or cope with the daily stresses of family, work, neighbours and relationships, they may act strangely and be unkindly labelled as "insane"! As they bottle up their anger, frustrations and hurt, they become even more distanced from their family, friends and community.

For many years, counselling has become prevalent in Singapore. However, there are still people who view counselling with suspicion as they think it pries into their privacy. Many people still resist counselling as it is perceived to be for people who have done wrong or who are emotionally or mentally weak.

In some developed countries, mental health and substance abuse go hand-in-hand. They have affected people from all walks of life, intensify personal suffering and interfere with family and life goals.

I would like to ask the Minister if substance abuse is common among the patients who encounter mental health issues. What more can the Ministry do to promote mental wellness and what are the plans the Ministry has to encourage Singaporeans not to stigmatise or discriminate against victims of mental wellness and their caregivers or family members?

Mental Healthcare

Ms Tin Pei Ling: Mdm Chair, over the past year, the MOH has put in commendable efforts on the front of mental health. However, I urge the MOH to continue paying attention to this area. There are four points that I would like to raise.

First, on capacity for public mental healthcare sector. The Institute of Mental Health (IMH) is the authority in the mental health sector in Singapore. Many look to the IMH when encountering mental health issues. It is commendable that there are satellite wellness centres, which are under the purview of IMH, in some neighbourhoods, and there are also community health teams that go into the community to assess and provide support to those with mental health. However, more can be done.

Firstly, there are those who suffer from moderate to severe mental health problems. They may not be violent but do require constant attention and care. They may also not have caregivers or their caregivers are no longer able to provide care. The IMH is currently operating at near full capacity. Hence, would the MOH consider increasing bed space at IMH or setting up more homes that can permanently care for those suffering from serious mental illnesses or whose families can no longer care for them?

3.00 pm

Second, there are those who exhibit certain anti-social behaviours but who are not violent, which is typically the barometer for the Police to intervene. However, they do not seek treatment either because they have no insight to their conditions or they fear being stigmatised. Those who were once IMH patients or with family members who can persuade them to get help and treatment are more likely to get help with their conditions. However, there are also cases not known to IMH and without family or friends available or willing to approach them. In such cases, what other levers do the MOH have in getting them to seek treatment?

Third, can the MOH consider a mechanism to ensure that people who have mental health issues but not yet known to IMH will be treated? For example, having a community health assessment officer to conduct preliminary assessment at the person's residence and then make the necessary recommendations to the IMH. If the person is assessed to suffer from moderate to severe mental illnesses, the person is required to seek treatment.

This may sound intrusive, but the main aim, really, is to make sure that those who have mental health issues can receive help and treatment and recover as soon as possible. This will no doubt enable the well-being of the individuals and those who are around them in the family or community.

Clearly, what I have just shared will require more space and manpower and, hence, will the MOH look into increasing the capacity and capabilities in the public mental healthcare sector?

Perhaps MOH can also leverage on NGOs or VWOs more to achieve better outcomes. For instance, can MOH work with and give funding support to these organisations to outreach to the community and do early detection work? Currently, I know that organisations such as the Silver Ribbon Singapore are often tapped on by Government agencies to visit, befriend and conduct preliminary assessment – more in terms of detection work and not intervention – of residents who are suspected to require mental healthcare. Can more be done to support such organisations which play a complementary role within the public mental healthcare sector?

The second area is to give more support for caregivers. We should give more support to them. They play the main role in caring for those with mental health issues. They also play a role in helping those with mental health issues to rehabilitate and integrate well into the community.

MOH has set up a fund for caregiver training. This is useful, but apart from equipping them with the needed skills and knowledge, their welfare is also important. As caregivers, they make many sacrifices – in terms of jobs, which impact their financial capability, and personal time, which, in turn, impacts their own personal well-being. Thus, could the MOH consider providing more financial support? For instance, for those who need foreign domestic helper, can the levy be reduced further?

Could more respite care services be provided so that caregivers can catch a breather while comforted in the knowledge that their care recipients will continue to be well cared for? Caregivers are often assumed to be strong and resilient and I believe they are. However, they, too, need to catch a breather at times to refresh, recharge and then soldier on.

The third area is to combat stigma. Public and self-stigma hinder early detection and intervention of mental illnesses. Public stigma makes fund-raising to help those with mental health problems more difficult, and makes it much harder to find meaningful employment for those with low or moderate mental health issues. The latter could have been due to misconceptions and scary portrayal of people with mental illnesses portrayed in the media.

Following my call on the Government during last year's COS debate to do more in combating stigma, can the Ministry provide an update on what has been done to address this issue?

Would the Ministry also consider:

(a) working with the mass media to provide a more objective and balanced coverage of mental illness by avoiding linking crimes or "bad" behaviours to mental illness and instead, highlighting and celebrating inspiring models, such as successful individuals who have overcome mental illnesses or showcasing great works by famous persons known to have mental illness, for instance, Sylvia Plath, Van Gogh, Isaac Newton, Beethoven, Abraham Lincoln and John Nash.

(b) organising a national campaign to promote deeper understanding of the range of mental illnesses – from depression, eating disorders, sleep disorders, general anxiety disorders (GADs), personality disorders, bipolar, OCD and psychosis – and to re-image mental illnesses as being no different from any other illnesses any person may have at some point in life.

(c) working with and give financial support to NGOs in destigmatising efforts. These organisations can help share the agencies' load in mental health efforts and destigmatising mental health ought to be a national effort in a society aspiring to be inclusive.

The fourth area is enabling confidence and meaningful employment. I applaud the launch of the handbook for employers and employees, which aims to help raise awareness and promote greater understanding amongst employers and colleagues of those with mental health issues. This is a good initiative and definitely a step forward in the right direction.

However, the readiness of employers to hire or continue to hire those with mental health issues needs to be addressed too. For instance, I have heard of some employees not daring to present MCs issued by the IMH, or to inform bosses that they need to go to IMH for appointments and, hence, have to take no-pay leave or miss the appointments altogether.

One reason for such behaviours could be due to the stigma and inaccurate stereotypes of those with mental health issues. Unfortunately, the more people try to shun stigma and do the "normal" thing, the more it reinforces stigma. Hence, efforts to combat stigma need to continue and be reinforced.

I believe that giving help to those with mental health needs is an important signal of our priority and governing philosophy. Singaporeans with mental health issues need help but are not in a position to advocate for themselves. In many cases, giving more help might improve their lives and will not generate immediate tangible returns to the society. But in adding this as a focus area, we are sending an important message that we, as a people, believe in carrying everyone together with us, even those who cannot ask for help, and that we help not for gains but to share, as a society, the burdens of those less fortunate. It shows that Singapore is a nation with a strong, pulsating heart.

Women's Health Screening Programme

Ms Ellen Lee: Mdm Chair, MOH has consistently been promoting health screening for women. At ground level, I have led a few organisations, including the HPB and the Singapore Cancer Society, to hold at least eight roadshows called "Celebrate Wellness" since 2010 till now to promote healthy lifestyle and wellness in general and breast screening for women aged 50 to 69 years old, in particular.

However, despite sending personal invitations to eligible women who need to pay only $25 for a mammogram and another $25 for follow-up screening two years later, the response was disappointing. It seems to me that it may not be an affordability issue but other root causes that have still eluded us.

I wonder if a holistic whole-life approach to women's health is to be preferred than a disease, specific intervention approach. Perhaps, it is not affordability of the tests but the changing of health behaviour, lifestyle, addressing risk factors, although the presence of risk factors does not mean the happening of the risk. Would it be more effective or efficient to focus on vulnerable groups, such as those from lower income or low educational level?

Can the Minister please share with us the success rate of the screening at national level? Are there new plans in relation to women's health screening programmes? Are there new preventive measures targeted at women?

The Minister of State for Health (Dr Amy Khor Lean Suan): Madam, I will first address Members' questions on ageing and mental health before updating Members on the issue of women's health.

Let me start with ageing. Our population is ageing rapidly. We need to make sure that Singapore is ready to support our ageing population in every way. Our goal is simple: for our seniors to live happy and fulfilling lives, and to age gracefully.

Last year, the Government introduced a suite of initiatives to make Singapore "ageing ready". We raised the subsidies for intermediate and long term care (ILTC) substantially; and we announced that we will build more than 100 aged care facilities over the next five years to meet both the social and healthcare needs of our seniors.

To support the expanding aged care sector, we project a need to increase manpower from 4,000 in 2010 to 15,000 in 2020. Dr Chia Shi-Lu asked about our manpower efforts. Last year, we provided additional funding to support the sector to raise salaries and to enhance staffing ratios.

With these initiatives, we grew the workforce in the aged care sector by about 30% over the last two years to about 5,600 in 2012. As mentioned by Deputy Prime Minister and Minister for Finance in his Budget Speech, even as we expand our local supply of healthcare manpower, we will still need a significant pool of foreign healthcare staff. We will, therefore, continue to ensure flexibility in terms of our foreign worker policy so that healthcare institutions are able to fulfil their staffing needs.

Separately, Dr Chia also asked for an update on the Healthcare Professional Conversion Programme. In 2012, we enhanced training allowances to encourage mid-career professionals to make the switch to nursing and allied health professions under WDA's Healthcare Professional Conversion and Place-and-Train Programmes. This has led to an increase in enrolment from about 30 in 2011 to more than 50 this year.

This year, we will place emphasis in two more areas: one, enhancing the quality of aged care; and, two, developing more options for seniors to be cared for at home and in the community. Let me start with enhancing the quality of care, an issue raised by Dr Chia.

First, we want to remake our nursing homes. We are actively engaging Singaporeans and tapping on the creativity of architects to build nursing homes that are not just clinical care facilities, but welcoming, serene and modern homes for our seniors to recuperate.

For the new nursing homes that we are planning, we give careful thought to the design to make them aesthetically pleasing yet functional. An example is the future nursing home in Jurong East. Instead of a squarish residential block, the architect "breaks up" the massing to create a more interesting form. Green balconies are injected in between the towers, making the whole development more visually pleasing to the surrounding community. This will not look out of place within a residential area.

Another example is the new Lions Home in Bishan East. As you can see, lush greenery features prominently to enhance natural cooling and to be aesthetically pleasing. From the outside, the effect is one of a waterfall of greenery. On the inside, there is also a garden and communal spaces on the ground floor where people living in the surrounding estate can enjoy.

Beyond the hardware, we are evolving our nursing homes to be eldercare hubs that can benefit a wider community of seniors and their caregivers. Where space allows, we will expand their suite of services beyond nursing home care to include day care and other services for caregivers.

The Man Fut Tong Nursing Home in Woodlands, for instance, offers day care, day rehab and home therapy services to seniors in the community. Sixty-nine-year-old Mdm Ahesah Bte Abdullah is one of those who have benefited from Man Fut Tong's expanded services. In 2011, she suffered a stroke that rendered her wheelchair-bound and she needed to undergo physiotherapy. Because she lives near Man Fut Tong, her caregiver can wheel her to the Home three times a week for her therapy sessions. Mdm Ahesah's condition has improved vastly and she is now able to walk again, as shown in the slide.

Second, we want to set clearer standards for different aged care services. Dr Chia asked about nursing home standards. I am pleased to inform him that MOH intends to introduce an enhanced set of nursing home licensing standards by 2015. Last year, we set up an industry-driven committee, comprising nursing home operators and healthcare professionals, to review our existing licensing standards and identify areas that can be enhanced. The committee has since drafted an enhanced set of standards for the nursing home sector. These enhanced standards differ from the current licensing conditions in a few areas.

First, there is more specific articulation of standards in various aspects of clinical care, such as oral hygiene, continence management and falls prevention. Currently, these areas are implied but not specifically articulated in the licensing conditions.

Second, the committee has enhanced standards in the social aspects of nursing home care, such as respecting residents' dignity and caring for their emotional well-being.

Third, the committee has added new standards in organisational excellence, covering the areas of human resource and financial management. This stems from the committee's belief that good care must be underpinned by good governance.

The set of standards is a first draft for consultation. We will engage the nursing home sector in the months ahead, to discuss these enhanced standards. These standards largely reflect the good practices existing in the sector today, so we do not expect a significant increase in costs. Nevertheless, MOH will continue to invest to develop the capability of the sector and allow ample time for nursing home operators to achieve these enhanced standards.

3.15 pm

Mr Patrick Tay also asked about setting standards for day rehabilitation, day care and the upcoming senior care centres. I would like to inform him that we have similarly set up an industry-driven committee to review and set standards for the centre-based care sector. The committee started work in September last year and is expected to complete the standards by the end of this year.

Let me now move on to the second area of focus, which is to develop more options for seniors to be cared for at home and in the community. We are stepping up our efforts to develop home care services, to support caregivers who would like to care for their seniors at home rather than in a nursing home. Last year, we added 750 new home healthcare places, bringing the total capacity to more than 4,500.

Take, for example, 94-year-old Mdm Yap Leng Im. Mdm Yap suffered a stroke seven years ago and was wheelchair-bound since. Her family initially considered placing her in a nursing home, but opted to take care of her at home instead. Today, Mdm Yap lives in the comfort of her own home with her daughter-in-law and two grandsons, through the support of home care visits by the Home Nursing Foundation (HNF). HNF also provided training to Mdm Yap's family members and foreign domestic helper so that they can better care for Mdm Yap at home.

After the subsidy framework was enhanced last year, Mdm Yap now receives an increased subsidy of 80% to help cover the costs of her home care visits. And because her foreign domestic helper has been trained in caregiving, Mdm Yap's family is eligible to receive an additional cash grant of $120 per month to offset the cost of hiring the helper. They will also receive a concession on their foreign domestic worker levy and have to pay only $120 instead of the normal rate of $265 per month.

MOH will be going a step further. To encourage and facilitate home care, as my Minister had noted earlier, we will be convening an industry-led committee to review and chart new standards and strategies for the development of the home care sector in Singapore. The committee is tasked to recommend a common system to assess the care needs of home care patients, articulate common standards of home care and identify new home care services that can be developed to meet unfulfilled needs today.

We are also beefing up support for our seniors' caregivers. Mr Christopher de Souza, during the Budget debate, suggested giving an allowance to caregivers. We do want to give families support in caring for their seniors. But we must not inadvertently monetise family ties and filial piety which come from the heart, and they are intangible.

There are practical ways to help caregivers. We can help them relieve the cost of caregiving at home. The Deputy Prime Minister and Minister for Finance announced in his Budget Statement that we will expand the Senior's Mobility Fund (SMF) into the $50 million "Senior's Mobility and Enabling Fund". The SMF will go beyond a fund to promote mobility, to a fund that supports our seniors to live independently in the community. Mr Tay asked how the fund will be enhanced.

First, we will expand subsidies beyond mobility devices to cover other assistive devices. Seniors can receive subsidies for more items, such as motorised wheelchairs, commodes, geriatric chairs and pressure-relief mattresses. The fund will also cover spectacles and hearing aids.

In response to feedback from VWOs and social workers, we will also simplify the application process for subsidies. Any senior living in a 3-room HDB flat or smaller will automatically qualify for 90% subsidy for devices that cost less than $350. There is no need for a detailed household income means test.

Second, for seniors receiving Government-subsidised home nursing or home medical services, and with per capita monthly household income of $1,500 or less, the enhanced SMF will provide between 50% and 80% subsidy for the cost of consumables, such as dressings, diapers and milk feeds.

Third, the enhanced SMF can also be used to subsidise transport costs for more seniors who are community ambulant, to attend day rehabilitation, dementia day care and renal dialysis centres. Dr Chia Shi-Lu and Mr Muhamad Faisal Abdul Manap also asked specifically about transport subsidies to and from hospitals for medical appointments. There are, in fact, already schemes for this. For instance, our Community Development Councils (CDCs) work with a non-profit organisation, Caring Fleet Services, to provide dedicated transportation services to people with mobility difficulties, by giving them vouchers to pay for transportation to hospitals, polyclinics or SOCs. In effect, they use retrofitted vehicles that can accommodate these wheelchair-bound residents. So, they really do not need to use ambulance which, by its nature, is really for emergency cases. In addition, through the "SMRT Gift of Mobility Programme", our CDCs also give out taxi vouchers to needy seniors to travel to hospitals and polyclinics. So wearing my other hat, as a Mayor of Southwest CDC, let me assure Mr Muhamad Faisal Abdul Manap that help is already available for the family of three that he mentioned earlier. In fact, the CDCs have helped such families in similar situations. So, I would like to request Mr Faisal to give either MOH or the Northeast CDC, if the resident is within his Aljunied GRC, details of the case, so that we can follow up on the case and provide help as soon as possible.

Under the enhanced SMF, we will also expand our support to help seniors accessing day services. We will provide transport subsidies for wheelchair-ambulant seniors receiving treatment at day rehabilitation centres and renal dialysis centres funded by MOH, as well as seniors receiving care at MOH-funded dementia day care centres, as I have said.

I thank Members for your positive feedback on the enhanced SMF. When the changes take effect from the third quarter of this year, we believe that the enhanced SMF can benefit caregivers like Ms Masni Bte Jaafar. Ms Masni and her husband not only have to support their six children, but also needs to care for her elderly parents. Her father suffered a stroke a few years back and is now bed-bound; while her mother suffers from diabetes and kidney failure. Both her parents are receiving home nursing services from TOUCH Home Care and require consumables, such as diapers, milk feed and dressings. With the enhanced SMF, they will receive 80% subsidies on the cost of consumables, saving up to $4,000 a year.

Several Members also pointed out that caregiving can be tiring. Indeed, we recognise that caregivers cannot do it for 24 hours a day, 365 days a year. At some point, the caregiver may fall ill or simply need a break, and will need someone else to take over the caregiving temporarily.

To relieve the stress of caregiving, MOH is working to make respite services more accessible and affordable. We are starting a pilot project by working with a few nursing homes to set aside some beds that can cater to respite services. Caregivers who need a temporary reprieve can place their elderly to be cared for in the nursing homes for a short period and enjoy up to 75% subsidy subject to means testing.

This pilot will support caregivers like 63-year-old Mr Koh Kok Heng. Mr Koh has been taking care of his 60-year-old wife, Mdm Choo Ngee Neo, after she suffered a head injury that rendered her bed-bound. Recently, due to a toilet leakage, their flat will need to undergo a week of renovation work next month. The noise and dust from the renovation will make it not conducive for Mdm Choo to be cared for at home. With this new pilot, Mr Koh can admit Mdm Choo into a nursing home for seven days of respite care at a subsidy rate of 75%, while the renovation works are being carried out. The seven-day respite will also give Mr Koh a chance to rest and replenish, so that he can take even better care of Mdm Choo when she returns home.

Mr Sitoh and Mr Patrick Tay asked about the capacity and capability of our long-term care facilities to cater for seniors with dementia. I would like to inform them that our new nursing homes will include wards for dementia patients. Today, we have about 515 nursing home beds dedicated for seniors with dementia. By 2016, we will increase this by more than 400 beds. We will also increase our support to help nursing homes develop the right capabilities to manage these seniors. For instance, CGH and IMH have been providing training to staff from eldercare organisations, including nursing homes, on dementia care and behavioural management.

Besides nursing homes, we also have 12 dementia day care centres which can serve more than 300 seniors per day. In addition, we will be developing more senior care centres by 2016 which will have the capability to provide dementia day care services.

Ms Tin Pei Ling also asked about the capacity of our public mental health sector. Today, the IMH has about 2,000 hospital beds for patients who require inpatient care, with an average occupancy of 84% over the past three years. So far, this is sufficient but we will continue to monitor the situation.

Our objective is, as far as possible, to have persons with mental illness reintegrated with society. But as Ms Tin pointed out, some with more severe illness may need longer term care. Today, there are three psychiatric nursing homes with a capacity of about 650 beds. We will be expanding the capacity to 1,200 beds by 2020. We also have two psychiatric rehabilitation homes with 280 beds for those who need temporary residential care to help them reintegrate into the community. We will be increasing this to about 400 beds by 2016.

I agree with Ms Tin Pei Ling and Ms Ellen Lee about the need to reduce the stigma of mental illness. Because of this stigma, many people who need help do not come forward for treatment. To address this, our strategy is to shift the locus of mental healthcare from institutions into community-based settings that are more accessible and to integrate mental health services with those for physical health.

We piloted two Assessment and Shared Care Teams, or ASCAT in short, last year to provide mental health treatment in the community. One team is located at Ang Mo Kio Polyclinic and the other, which is temporarily sited in Khoo Teck Puat Hospital, will be moving out to a community location later this year. The two teams have helped around 400 patients to date. We intend to set up a total of six ASCAT teams across Singapore by 2016 to support up to 9,500 patients at any point in time.

General Practitioners (GPs), too, play a crucial role in encouraging people to seek treatment for mental health, as they are often the first point of contact. Today, we have about 70 GPs collaborating with IMH to provide mental health care in the community. We hope to recruit a total of 100 GPs by 2016.

To support the GPs, we also worked with VWOs to pilot Community Mental Health Intervention Teams or COMIT teams last year. COMIT teams provide counselling and psychotherapy services to support GPs in managing patients with mental illness. There are two COMIT teams today, in Upper Boon Keng and Yishun, and they have helped over 100 patients to date. By 2016, we intend to set up a total of 10 COMIT teams to serve up to 10,000 patients.

To further combat stigmatisation, we are increasing community outreach and education on mental health. Today, AIC works with a few senior activity centres to start up teams of volunteers in the community who can identify seniors with symptoms of dementia and depression, and refer them for early treatment, which is similar to what Ms Tin had proposed earlier.

HPB is also working with community partners, such as Silver Ribbon (Singapore), Singapore Association of Mental Health and grassroots organisations, to promote awareness of mental well-being. In 2012, over 30 such events were organised, reaching out to about 25,000 people in the community.

3.30 pm

Ms Tin asked for more support for caregivers of patients with mental illness. The enhanced SMF and the residential respite pilot I described earlier will be able to support these caregivers. In addition, we are working with VWOs to provide support targeted at caregivers of dementia patients.

The Alzheimer's Disease Association (ADA), for instance, offers elder-sitting services. Seniors can be brought to ADA's centre or be visited at home, where the elder-sitters will befriend and engage them in simple mind-stimulating activities, giving their caregivers a few hours of respite.

Another example is the "Dusk to Dawn" programme at St Joseph's Home. Some dementia patients have what we call "sundown" syndrome, where they cannot sleep at night, thinking it is day. This is a programme whereby caregivers can leave their loved ones with dementia at the Home at night, so that they can catch up on sleep and bring them home again the next morning. There will be staff and volunteers in the Home to engage these dementia patients in meaningful activities through the night.

Mdm Chair, MOH hopes to engage the community at large, to build an inclusive and caring Singapore for our people. In the past year, reports of "NIMBYism" have made the news. But being an optimist and having confidence in Singaporeans, I think these isolated incidents are hardly representative of the majority of Singaporeans.

Dr Chia asked about the City for All Ages (CFAA) project. I am pleased to inform him that the project is progressing well in its four pilot sites of Marine Parade, Bedok, Whampoa and Taman Jurong. While the project started with the objective of innovating new solutions to create senior-friendly communities, we were pleasantly surprised to see how the project has served as a platform to garner community action for seniors.

The energy I see on the ground is incredible. I see many volunteers, both young and old, walking their towns in the hot sun to identify areas of improvements to the town infrastructure that will make it safer for seniors to move around. In Marine Parade, as a result of volunteers' efforts, the Town Council and the LTA, improvements to the town hardware are being systematically rolled out, such as levelling of void deck aprons and longer traffic light crossings.

On top of that, over 50 new rest stops will be installed across the town so that our seniors can sit down and rest when they feel tired. This rest stop is a suggestion from Marine Parade residents themselves. Even the design is chosen after a vote among the residents!

The software of Marine Parade has also been enhanced. For instance, the local senior activity centre called Goodlife! is now providing one-stop information and referral services for senior-related issues. The centre also links up with the Agency for Integrated Care or AIC to provide outreach and public education on dementia and depression, and works with the Changi General Hospital to provide social support for recently-discharged seniors.

A group of volunteers has also been formed to befriend seniors living alone in Marine Parade. And the oldest volunteer you see here is Uncle Wai Chong and he is all of 83 years old!

We want to continue this positive momentum. I am pleased to inform the House that MOH plans to expand the CFAA project to another five to 10 more constituencies over the next three years, and will provide an award of up to $80,000 for each constituency which wants to start its own CFAA project.

Mdm Chair, our seniors have contributed much to Singapore. Now that they are old, we should create an environment that allows them to age happily and with dignity, in our midst. Our aspiration is to create a people movement across the island in every town, to make our city a senior-friendly one, and the best place for our seniors to grow old in.

Ms Ellen Lee asked about health screening rates among Singaporean women. I agree with Ms Lee that more can be done to improve on our women's cancer screening rates. According to the National Health Survey conducted in 2010, only about 48% of women aged 25 to 69 undergo regular cervical cancer screening and about 40% of women aged 50 to 69 go for regular breast cancer screening.

The Women's Health Advisory Committee (WHAC), which I chair, aims to encourage more women to undergo screening and to promote health among our women. In September last year, we introduced a resource kit called "My Journey to Better Health" to provide women with important health information on issues, such as starting a family, weight management and breast and cervical cancer across various stages of their life. To date, the kit has been distributed to more than 30,000 women. We target to reach 200,000 women by the end of this year.

The Committee and HPB also work closely with healthcare providers and grassroots organisations to increase public awareness of breast and cervical cancer through regular exhibitions and road shows held in the community during the Breast Cancer Awareness Month (BCAM) and the World Cancer Day (WCD).

This year, we aim to make cancer screening more affordable for women, particularly those from lower-income households. The Committee and HPB will, over the next two years, work with VWOs and the private sector to help cover the cost of breast cancer screening for 15,000 women from low-income households. Eligible women will only need to pay up to $2 for a mammogram, compared to the existing subsidised rate of $50 under BreastScreen Singapore. This two-year project will be introduced from 17 March this year. Eligible women will receive an invitation letter to go for screening at a participating polyclinic X-ray centre.

In addition, we are making screening more accessible by expanding the coverage of BreastScreen Singapore's mobile mammogram screening service, the Mammobus, to more estates. As noted by Ms Ellen Lee earlier, it may not just be an issue of affordability. We will also be organising ferry services at selected estates to bring women to the screening centres.

To encourage working women to adopt healthy habits, HPB will expand the existing $15,000 annual Workplace Health Grant by another $5,000 a year for employers to create a supportive work environment to promote health, especially among working women. Employers can use the additional grant to organise health promotion programmes tailored for working women, such as talks on child and maternal health, workshops on managing work and family, and classes on healthy cooking. But, of course, the men would be welcome, too, if they want to join these programmes. The grant can also be used to subsidise costs of breast and cervical cancer screening.

Before I conclude, let me thank Mr Low Thia Khiang for his feedback on the Continuing Traditional Chinese Medicine Education Programme. The objective of the programme is to help TCM practitioners raise their professional standards and acquire new skills to better serve their patients. We believe that continuing education is integral to their professional development, just as it is for doctors, nurses and pharmacists. Let me clarify also that the TCM Practitioners Board has put this in place after discussions and town hall sessions with TCM organisations and practitioners. The Continuing TCM Education Programme is currently on a voluntary basis. I would also like to point out that we are not the first country to introduce Continuing TCM Education Programme. Participation in CTE for TCM practitioners is, in fact, compulsory for the renewal of their licence in countries like Taiwan since 1993; Hong Kong since 2005; China, 2006; and Australia, 2012.

We have received feedback, similar to the ones raised by Mr Low earlier. This is a fairly new pilot, on a voluntary basis, having only started in January this year, just about two months ago. So, I assure Mr Low that the TCM Practitioners Board will carefully consider all the feedback received during this pilot phase when they review the programme.

Mdm Chair, every Singaporean wants to live healthily and age gracefully – to add life to our years as we add years to our lives. As a Government, we must help our people to reach this goal. Besides our aged care services, we must also encourage Singaporeans to lead healthier lifestyles. After all, a healthy lifestyle today is critical for healthy ageing tomorrow.

The Chairman: Order. I propose to take the break now and resume the Chair of the House.

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

Mdm Speaker: Order. I suspend the Sitting and shall take the Chair again at 4.05 pm.

Sitting accordingly suspended

at 3.41 pm until 4.05 pm.

Sitting resumed at 4.05 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) −

Healthcare and Mental Wellness

Ms Faizah Jamal (Nominated Member): Madam, I am happy to hear from Dr Amy Khor's description of the facilities incorporating green spaces as it ties in really nicely with what I have to say.

Madam, apart from intensifying good programmes for fitness, exercise and nutrition, I think it is about time we pay attention to the role that nature-based activities play in healthcare. I would like to suggest just two. The first is gardening. As long ago as the 1800s, American doctor, Benjamin Rush, a mental health pioneer found that "digging in the soil has curative effects on the mentally ill". It is now well documented scientifically that such activities help to counter depression and raise self-esteem. So, I would go so far as to suggest that MOH consider putting aside spaces in facilities for healthcare for what is called "edible gardens" where patients can take part in planting fruits and vegetables. Apart from the fun of growing food and the satisfaction of harvest, it also creates community and celebration, creating positive emotions that support patients to get well faster.

My second suggestion is for the Minister to seriously consider including visits to nature spaces as a major component in providing physical, emotional and mental healthcare and step-up efforts for such activities as a preventive healthcare method for members of the public. Many years ago, the pioneering work of people like Ulrich showed that patients recovered faster from surgery in a room with a view of a natural scene than those without such a view. Now, the most recent work of environment psychologists, Rachel and Stephen Kaplan, showed that experiences in nature have what is called "restorative" ability, turning negative thoughts and emotions to that of positive self-image. This shows increasing scientific evidence of the link between nature and our well-being resulting in hope, resilience and courage to continue to deal with life's challenges constructively.

So, what I would like to suggest is structured programmes where patients are taken on nature walks on a regular basis, not just to the manicured areas like parks and gardens but also to our nature reserves like Bukit Timah and Sungei Buloh wetlands. As NParks already has an established pool of experienced volunteer nature guides at our nature areas, this service can be tapped for the benefit of patients. In this way, patients get a holistic view that they deserve.

The Chairman: Ms Faizah, your time is up. Dr Teo Ho Pin.

Preventive Care Services

Dr Teo Ho Pin (Bukit Panjang): Madam, preventive medicine or preventive care involves taking measures to prevent disease or injuries rather than treating or curing their symptoms. It can save lives and reduce healthcare costs if effectively implemented. In order to work out effective preventive care strategies, we need to understand the causes of preventable deaths or injuries. Research has shown that leading causes of preventable death include hypertension, smoking, high cholesterol, obesity and physical inactivity.

In Singapore, we have an effective preventive care vaccination programme for children, which includes polio, measles or mumps vaccinations. However, we do not have a nationwide programme for vaccination of the elderly against flu or pneumonia. Thus, I would urge the Ministry to consider subsidising a national vaccination programme for the elderly.

Our health screening efforts are also ad hoc and, therefore, not effective in the early detection of diseases or illnesses. There is a general lack of focus on preventive care services to prevent diseases or injuries. As a result, today we are faced with problems of obesity, chronic illnesses, pneumonia and injuries, especially among the children and elderly.

Madam, I would urge the Ministry to consider implementing a comprehensive programme for preventive care services for health screening. We need to set up the infrastructure to provide preventive care services to improve the health of Singaporeans. For instance, health screening can be better organised to ensure that high health-risk Singaporeans are encouraged to go for regular health screening.

Madam, General Practitioners (GPs) or family doctors are in the best position to identify high-risk Singaporeans and advise them to go for health screening, and ensure that they take up action to stay healthy. Thus, I would urge the Ministry to engage the services of the GPs at market rates for health screening.

Another area of preventive care is the promotion of healthy lifestyle among Singaporeans. We need to constantly encourage Singaporeans to exercise regularly to stay healthy. More outreach, education and encouragement are needed to help Singaporeans to lead a healthy lifestyle. We have done a lot in terms of health promotion education. It is about time we start to encourage or incentivise Singaporeans to exercise regularly to keep fit.

Sir, I wish to ask the Minister the following questions:

(a) What are the key preventive care services provided by the Ministry?

(b) What are the key strategies in providing preventive care to promote healthy lifestyle to prevent chronic illnesses and disease infection among Singaporeans?

Workplace Health and Singapore Core

The Senior Minister of State, Prime Minister's Office and Deputy Leader of the House (Mr Heng Chee How): Mdm Chair, in agricultural societies, farm work gave farming families and farm workers the exercise that they need even as they earn a living. But with industrialisation and also post-industrial societies, much of the manual work has been taken out. Whereas people now still spend a lot of time at work, the amount of exercise that they get from work is not like last time in agricultural societies.

When we look at the situation in Singapore and as we have discussed, the implications of an ageing population and an ageing local workforce and the need to strengthen the Singapore Core, then we recognise the importance of making sure that health promotion is a core part of what we do at work. In the community, there is already a more structured programme, such as the wellness programme, that reaches out to members of the community to enable those who are interested, especially those who are older, to take better care of their health and to stay connected and, in that way, enjoy a better quality of life and more years of health.

With the population spending a large amount of time at work and the need to strengthen our Singapore Core, there is a reason for us to pay greater attention to further systematising our workplace health promotion programmes and to see how best to model that after the community wellness programme and customise it to workplace application so that we can keep the Singapore Core, not only numerically, but healthwise.

Incentivising Health Maintenance

Dr Chia Shi-Lu: Mdm Chair, health maintenance and promotion is critical for the continued wellness of Singaporeans while ensuring that healthcare costs do not spiral out of control, in view of the challenges that an ageing population presents us. Now, this may sound like an MTI cut, but healthy workers are also known to be more productive and enjoy a longer and happier working life which would also help with the population and resident workforce difficulties that face us over the next two decades.

Our disease burden is a function of our intrinsic constitutional makeup and extrinsic environmental and behavioural factors. We all know that we cannot choose who our parents are, but our genes do predict a certain propensity to health or disease. However, we can choose how we live our lives and so have a significant say in our own health. There is much that can be done to nudge Singaporeans to take greater ownership of their health. Unhealthy behaviour, such as smoking or poor diet, could be penalised but, by the same token, healthy lifestyle choices can be incentivised.

Some countries have been studying the effects of imposing taxes on unhealthy foods or limiting the portion sizes of unhealthy foods. For example, New York City has recently attempted to curb the unhealthy consumption by limiting the size of soda servings, although just yesterday this move has been blocked by the courts. As I suggested last week, perhaps healthy foods like fresh fruit and vegetables or wholemeal grain can be made cheaper to make them more attractive to cost-conscious consumers. Singaporeans who participate regularly in approved wellness programmes or demonstrate that they adhere to a healthy lifestyle could receive tax rebates or pay discounted rates at public healthcare institutions or pay lower healthcare insurance premiums. We can also consider rewarding companies that support exercise and wellness programmes for their employees, and which also invest in the health of their workers.

4.15 pm

While I appreciate that MOH already has subsidised health screen programmes in place, I would support the use of MediSave for such health screening which further lessens out-of-pocket expenditures.

More effort should also be spent educating the public about healthy living, and how they can improve the health of themselves and their families. Sometimes the approach can be blatant; for example, explicit front-of-label labelling of calorie counts and even health risks on unhealthy foods, similar to what is being done on cigarette packs.

Finally, I would support expanded recognition and benefits for volunteers who help to promote healthy lifestyle; for instance, the Health Ambassadors of the Health Promotion Board. This could be similar to the system for frequent blood donors, so that they can enjoy privileges for care at polyclinics and Government restructured hospitals.

The Parliamentary Secretary to the Minister for Health (Assoc Prof Dr Muhammad Faishal Ibrahim): Madam, Minister Gan had earlier emphasised the importance of health, rather than just healthcare: I fully support Minister's view and this is a motto that I often tell my residents, family and friends. In my experience, I have found that at the heart of every issue or policy, are our people. The success of a policy or programme hinges upon what we make out of it. This is especially true when it comes to health promotion initiatives.

Very often, Singaporeans tell me that they would like to lead a healthier lifestyle. Many have also shared that they appreciate the Government's effort to encourage them to do so. It is heartening that we have made some inroads over the past years.

Dr Teo Ho Pin and Ms Ellen Lee asked about preventive care services for children, elderly, and in relation to mental well-being, respectively.

MOH has a range of preventive care services for Singaporeans of all ages. We want to provide good support, especially in the early years and through childhood. This lays the foundation for good health habits to continue into adulthood. We have various programmes from conception through birth and pre-school. The HPB's School Health Services provides annual medical checkups, vaccinations and oral health services.

For our elderly, there are initiatives, such as the Community Functional Screening Programme, which aim to detect functional decline in older adults. MOH will look into introducing a vaccination schedule for adults and the elderly.

Health is not just about physical health. Indeed, health promotion also needs to address mental well-being. We have mental well-being programmes tailored for the different stages in one's life: There are online Mental Well-being Scales for Children and Youth as well as for adults. For the elderly, there is a Mental First Aid Kit Programme that improves mental well-being through positive experiential activities. Next month, HPB will be working with the National Arts Council to roll out an "Arts for Mental Well-being" programme that makes use of drama and recycling art and craft.

Dr Teo Ho Pin would be happy to hear that we do measure the effectiveness and health outcomes of health promotion programmes at the national level.

The National Immunisation Registry monitors immunisation coverage. For school-going children, the Student Health Survey assesses key health behaviours.

Regular nationwide health surveys monitor the prevalence of chronic diseases, behavioural risk factors, and preventive health behaviour in adults and the elderly.

These surveys show progress in many areas. However, some trends continue to be worrying: more Singaporeans are getting obese, and more young adults are taking up smoking. As we age, our risk of developing chronic diseases, such as diabetes and high blood pressure, increases. Doing things the same way is simply not enough: as individuals, as a Government, and as a society, we need a new approach to healthy living. One way or another, healthy living should be everyone's business; it should not be something we have to think about; it should be second nature to us.

Our purpose is to ensure that no Singaporean is deprived of a healthy lifestyle. To achieve this, it means, first, that the right environment needs to be developed throughout Singapore, so that leading a healthy lifestyle is not just easy, but natural for all of us. Second, everyone is actively engaged and aware of opportunities for leading healthy lifestyles. Last but not least, adopting a healthy lifestyle need not be the more expensive option.

In summary, our vision for healthy living is to be healthy together – anytime and anywhere through the 3Ps: Place, People and Price.

We want to translate this vision into action. Earlier, Minister Gan mentioned the Healthy Living Master Plan Task Force, which I am leading. We aim to develop a national blueprint for healthy living.

The Task Force is studying the factors that motivate Singaporeans to change behaviour and to maintain a healthy lifestyle. In our discussions, we were very heartened to hear that some ideas are already being considered by various agencies for implementation. I will go into more detail later.

The Task Force has also studied innovative practices from other cities. One inspiring example is New York: they reported a successful 5.5% decrease in childhood obesity rates from 2006 to 2011. This is after years of multi-agency efforts to improve nutrition and the built environment to encourage physical activity. For example, New York requires restaurants to post calorie information on their menu boards. They also came up with active design guidelines to create healthier buildings, streets and urban spaces. Learning from such examples, we aim for similar success in Singapore.

Staying healthy concerns every one of us. During a recent Our Singapore Conversation session, one of the participants, Mdm Rohani, provided much inspiration. She told us about how she prepares healthy snacks, such as carrots, cucumber sticks and cherry tomatoes, for her grandchildren. They also exercise together as a family at least once a week. This is a fine example of how we, as individuals, families and as part of society, can encourage one another to live healthily. I was encouraged that there was strong support among participants for a healthier lifestyle.

Therefore, Healthy Living Master Plan is about making connections at three levels: firstly, across Government. Secondly, it is about connections across communities. Thirdly, between communities and the Government. We hope to strengthen these connections so that everyone gets involved in working towards a common goal. This involves initiatives that cover the Place, the People and the Price, or the 3Ps. Let me share with members in more detail.

Firstly, the "Place" element of the Master Plan involves changing the physical environment that we live in, so that we can go about our daily activities in a healthy way without even thinking about it.

Ms Faizah Jamal asked about access to nature spaces as a health promotion measure. We know that Singapore has limited land, yet we have innovatively maximised the use of spaces, whether natural or man-made, for physical activities to promote healthy lifestyles.

We have designed our built environment to promote healthy living. MND, MOT and other infrastructure agencies have also contributed to the health agenda. Our housing estates are designed to encourage residents of all ages and abilities to go outdoors for fresh air, exercise and even gardening. These estates have facilities, such as parks, park connectors, playgrounds and cycling paths.

With the right infrastructure for physical activity in place, the next step is to experiment with programmes and micro-designs, such as innovative signage. As such, we will be working with town planners and Government agencies to create visual cues in public spaces to prompt physical activity. For example, you will see more exercise maps, and appealing visual designs to encourage the use of stairs at workplaces, shopping malls, schools and public places like train stations.

By connecting the dots between the different Ministries and agencies and the community, we are all working together to achieve the common goal of good health for our people, Singaporeans.

One example is the Healthier Hawker Centres initiative. I am pleased to say that the pilot was a resounding success, with up to a 30% increase in sales of wholegrain, and with the hawkers reporting a 20% increase in business. A conducive environment for healthy living also includes food establishments. During the Our Singapore Conversation sessions, some of us were asked, "Why can't you scale up Healthier Hawker centres faster? We want them in our neighbourhoods, too!" I am pleased to say that Healthier Hawker Centres will be extended to 40 more hawker centres, food courts and coffee shops in financial year 2013. For greater impact, we are also reaching out to centralised kitchens that supply workplace canteens, coffee shops and household tingkat meals to use healthier ingredients. The target is to reach out to five centralised kitchens, supplying more than 50,000 meals per day, by end of financial year 2013. Dr Lam Pin Min would be glad to know that we have similar initiatives in our schools. More than 90% of our schools subscribe to healthy eating guidelines under the Healthy Eating in Schools programme.

As Mr Heng Chee How had emphasised, healthy living should also occur in workplaces. Employers are realising more and more now, that health is very much linked to productivity at work. We have a comprehensive health promotion support infrastructure for companies, such as the Workplace Health Promotion Grant, and capability building courses.

The Healthy Living Master Plan Task Force visited an SME called UMW Equipment and Engineering Pte Ltd. We wanted to learn first-hand how an SME can use its limited resources to build a strong health-promoting workplace culture. I found that their philosophy, "a healthy worker is a safe worker", to be a good start. Some of their staff got together to form a workplace health executive committee that plans and drives health promoting initiatives. In order to encourage active participation, many of these programmes are free and held during office hours. They even have a small gym for employees. This is a good example of how a company and its workforce come together to take ownership of their health.

Some industries that employ many low-wage workers, such as the cleaning and security sectors, have limited access to health programmes. We have not forgotten about them. As such, I am pleased to announce that HPB will collaborate with NTUC to reach out to workers from these sectors, to offer health screening and follow-up services.

Next, the "People" element of the Master Plan has two aspects. First, it means to be inclusive of all segments of society, especially the vulnerable groups, such as those with lower income, the youth, and the elderly. Secondly, the "People" element also means improving people's understanding of health, or health literacy, so that we can make informed choices about how we live and how we eat.

As part of reaching out to all segments of society, HPB will ramp up its ground-up movement. One key enabler is getting ordinary citizens – our Health Ambassadors – to champion health promotion within their respective communities. To date, HPB has trained and deployed nearly 5,000 Health Ambassadors since 2011. We target to have 10,000 Health Ambassadors by 2015.

4.30 pm

Some of the stories of how these health ambassadors have made an impact on their loved ones are very encouraging. Mdm Peh Lek King, a 55-year-old senior Health Ambassador, shared that she first became a Health Ambassador because she started to realise the importance of maintaining health as she ages. She then thought about her family, and felt compelled to keep them healthy too. She became healthier too. As she became more active in HPB events, she started encouraging her friends to adopt healthier lifestyles as well. She has also used her persuasive skills to counsel people who come for screening at community screening events to go for medical follow-up. This is the very attitude towards health and the community that we hope will become pervasive through our Health Ambassador network.

The other aspect of the "People" element is about improving health literacy. We can shape food choices by more clearly labelling the nutritional contents of what we are buying. Last month, that is, 7 February, HPB announced that all products with the Healthier Choice Symbol (HCS) will also have to carry the Guideline Daily Amount (GDA) labelling on the front of their packaging. These labels will better guide consumers on the amount of calories, fat, salt and sugar that are contained per serving, hence enabling consumers to make better informed choices.

HPB has garnered the support of major multinational companies in this regard, and will continue to work with the food industry on this initiative. Our goal is that by 2014, all HCS products will carry this GDA labelling to be followed thereafter by non-HCS products.

We will also provide better guidance on how much we eat. Today, HPB's Healthy Diet Pyramid shows us the recommended number of servings of each type of food group. However, more Singaporeans are exceeding their recommended daily intake of fat and carbohydrates as compared to a few years ago. This means that we still need to understand what the right portion size actually looks like. We will, therefore, shift from the current Healthy Diet Pyramid to the Healthy Plate. The Healthy Plate will visually link nutrient requirements to the recommended portions that should be consumed in a meal.

Last but not least, we come to the price element of the Healthy Living Master Plan. We cannot be inclusive of all segments of society if we do not make healthy living affordable.

We agree with Dr Lam Pin Min, Dr Lily Neo, Dr Teo Ho Pin, Mr Heng Chee How and Dr Chia Shi-Lu that we should look at how to better incentivise healthy living. We are open to exploring some good ideas that you have suggested. For example, Dr Chia mentioned tax rebates or discounts for those who participate in wellness programmes. Also, volunteers who help promote healthy lifestyles, such as Health Ambassadors, can be given expanded recognition and benefits. Dr Lam also suggested insurance rebates for those who can demonstrate that they are living out healthy lifestyles. We will study various feasible incentives, including those tied to insurance premiums. It is equally important that, as individuals, we ourselves are motivated to live healthily.

We also agree with Dr Lam on the need for affordable healthier food options. HPB has worked with the ingredient suppliers and stall vendors in the Healthier Hawker Centre programme to make sure the healthier dishes offered are affordable. HPB also partners major supermarket chains to offer regular promotions of healthier products at discounted prices. We are also working with local R&D institutions and the food industry to build capacity to produce affordable and healthier foods and beverages.

Next, we need to address affordability for screening. Screening enables early detection and treatment of diseases. Yet, I appreciate that for many of us, finances are sometimes tight. We have to attend to the basic necessities first and would not even consider spending money on screening, especially if we feel "OK". Others may be worried not so much about the cost of screening, but more about the financial cost and affordability of treating a condition should one be diagnosed. We are, therefore, focusing our screening outreach on the groups of people who need help most.

To this end, the Task Force recently visited the Henderson Seniors Activity Centre (SAC) run by the Thye Hua Kwan Moral Society. We wanted to understand the voluntary welfare organisations' outreach work and the issues that they face on a day-to-day basis. I was struck by how the SAC's programmes helped give the elderly residents a greater purpose in life, and motivated them to enjoy better physical independence and mental well-being. I enjoyed talking to the seniors, and, in fact, I learnt a lot from this engagement and how we can better our engagement with Singaporeans to enhance their lifestyles and towards a healthier life. However, I asked myself, "Can these programmes be even more effective, if different organisations got together to implement them?"

I am, therefore, happy to announce that such public-private connections are already being made. HPB's pilot Senior Holistic Engagement Programme (SHEP) will bring health programmes to low-income seniors through connecting with VWO partners and SAC platforms. It will tap on HPB's expertise and the reach and passion of VWOs, to provide free health promotion programmes and subsidised health screening initiatives.

Lastly, in response to Dr Lam's question on vaccinations, we have an Expert Committee on Immunisation (ECI) which advises MOH on which vaccines to include in the National Childhood Immunisation Schedule (NCIS). This is based on factors, such as how common and serious a disease is, and the availability of safe and effective vaccines. Dr Lam will be happy to hear that we will be adding the vaccine against Haemophilus influenzae type B (Hib) into the NCIS.

We appreciate Dr Lam's concern that increased connectivity and movement of people across borders heightens the risk of local outbreaks of vaccine-preventable diseases. Our strategy is to ensure high local vaccination coverage to protect our residents. Vaccination coverage has been maintained at above 95% in Singapore.

To improve affordability for childhood vaccinations for Singaporeans, I am pleased to announce that the five-in-one combination vaccine will be available for free at the polyclinics. This vaccine covers Hib, diphtheria, tetanus, whooping cough and polio. We will also introduce free Hepatitis B vaccination at the polyclinics. In addition, we will also allow MediSave use for all vaccinations recommended on the NCIS, up to a cap of $400 per MediSave account, be it in the public or private sector.

We will soon provide the public with a schedule of preventive health services that apply from birth till old age that includes screening and immunisation. As part of our commitment to preventive care, we would like to consult the public on how we can make it more accessible and affordable.

I have shared some initial thinking and ideas today. The Master Plan is still under development. We hope to touch the hearts and minds of Singaporeans, and gather ideas on how we can together achieve a healthier lifestyle. As such, the Ministry would be holding a public consultation on the Healthy Living Master Plan in the coming months. Please give us your ideas and feedback.

Madam, most people know the common taglines: we should be active, eat wisely, be happy, not smoke and attend health screening. Saying it is the easy part. Translating it into action requires a radical change in our mindsets. We hope that you will join us in this journey to be healthy together, anytime and anywhere.

The Chairman: We have a bit of time. Any clarifications? Dr Lam Pin Min.

Dr Lam Pin Min: Thank you, Mdm Chair. I have three clarifications for the Minister. One is on Government spending. We know that it is inevitable that healthcare spending will increase. The current Government share of the national healthcare expenditure is only one-third and I am glad that the Minister has announced that they will be increasing the Government's share of this healthcare spending. Whatever this national healthcare expenditure will be eventually, I would like to ask the Minister what this fair and manageable proportion of the overall healthcare expenditure borne by the Government will be, as this will directly affect and will decrease the financial burden on Singaporeans.

Secondly, on polyclinics. I am glad that the Minister has announced that there will be two new polyclinics in Punggol and Pioneer by 2017. However, from now till 2017 is a long four-year wait. What are MOH's plans to alleviate the high demand and long waiting time in Sengkang polyclinic?

Thirdly, the Minister did not reply to my call for a transparent professional fee structure. Can the Minister elaborate and explain what this ethical limit, as announced by the Singapore Medical Council is, and whether there can be some form of updated fees publication to better inform patients as well as to guide doctors?

Mr Gan Kim Yong: Mdm Chairman, let me thank Dr Lam for the clarifications. First, a clarification on the first question about Government's share – what is the proportion? I mentioned in my speech that we expect the Government's share to grow from the current one-third to about 40%, or maybe even more than that eventually, of the overall healthcare expenditure. The remaining part of the expenditure will be borne partly through insurance schemes and partly through savings – MediSave and other schemes. We are still working on the details. As I mentioned, there will be a major review of the financial framework, and I will share more at the next COS when we have made some progress on the review.

On the second issue on Sengkang Polyclinic, I understand many Members have asked for polyclinics. In the meantime, while we are building two new polyclinics at Pioneer and Punggol, we are also looking at expanding existing capacity in some of the polyclinics that have heavier patient loads.

At the same time, we are also looking at the new model of Family Medicine Clinics (FMCs) working with the private sector, tapping on the existing capacity already existing in the private sector. So that instead of building more capacity, we balance the load between public and private sector. Through the FMC model, coupled with CHAS, we will then be able to encourage the private sector to become part of our team to look after our subsidised patients, especially those with chronic diseases.

I will be very happy to work with Dr Lam, if he has an interest in looking at developing further FMCs in Sengkang. We will work with the private GPs in the area and see how we can develop more FMCs in the Sengkang area.

On the third issue on professional fees, yes, during the last COS, I did mention that we are looking at the possibility of publishing some of the professional fees charged, at least within the public hospitals, so as to increase the transparency, and also serve as a reference for patients who want to decide which hospital or doctors to go to. We are working on this, and our intention is to look at the possibility of publishing some of these professional fees, starting first with our public hospitals and maybe, eventually, extend to the private health institutions.

With regard to the ethical limits, I think this is an issue that the industry and the professionals themselves will have to determine what they deem as ethical, and what they deem as appropriate. Generally, there is a sense that there are certain limits, but since there is currently a case in the legal process, so I would refrain from commenting further until the case is resolved.

4.45 pm

Dr Chia Shi-Lu: Thank you, Mdm Chair. I would like to seek two clarifications on two points raised by the Minister of State earlier. The first is that I do welcome the announcement that guidelines for nursing homes will be tightened and I also note that she did mention that the cost will be kept under control despite these new guidelines. But I am sure we all appreciate that cost is one of the major considerations and I would like to seek more clarifications or assurances that MOH is looking at this in terms of cost containment.

The second question refers to the Seniors' Mobility Fund. I think when this was first announced, there were some headlines when my colleague Ms Indranee Rajah was reported in the papers how she and her grassroots leaders made house-to-house visits to increase awareness of this scheme. I think many Members are doing the same. So, I would also like to ask MOH how do they propose to increase awareness of this programme this time round.

Dr Amy Khor Lean Suan: First, I would like to thank Dr Chia for his clarifications. With regard to cost, I think it is a fair and genuine concern that Members would raise this. As mentioned in my speech, the enhanced guidelines are a result of discussions by the nursing home representatives in the Nursing Home Standards Workgroup. In fact, these enhanced guidelines reflect current good practices that exist today among the nursing home operators. We do not expect this to lead to a significant increase in cost.

Secondly, the way we have phrased the enhanced set of guidelines – which will be put out for public consultation with the nursing home operators particularly – it is outcome-based. It does not list specifically input requirements. This is to give flexibility to the nursing home operators so that they can innovate in order to achieve the outcomes. So, it is a set of outcome-based guidelines instead of something that is very, very prescriptive.

Thirdly, we are pacing the change, so we are not implementing it today or at the end of this year. In fact, we hope to finalise the enhanced set of guidelines into a set of licensing standards by the end of this year, after public consultation. And then, we will give the nursing home operators a year to prepare for and to be able to develop their staff to achieve the licensing standards once they come into effect in fiscal year 2015.

Finally, AIC is going to develop an interpretation guide to help the nursing home operators understand the requirements of this enhanced set of guidelines as well as to invest in resources to train and upgrade the skills of the workforce in the nursing home sector so that they will be able to achieve the outcomes. Nonetheless, we share the Member's concerns. What we will do really is to closely monitor the impact once the enhanced guidelines are implemented, to see if there is any impact on cost and to ensure that nursing home fees will continue to be affordable for those who need the services.

With regard to the Seniors' Mobility and Enabling Fund (SMF), yes, the Senior Minister of State Ms Indranee Rajah has been a real champion for the SMF, going door-to-door, and I am sure many of the other Members are doing it to publicise and create awareness amongst the elderly as well as residents who may have elderly relatives or who know of others who would be able to benefit from the SMF.

What we are going to do for the enhanced SMF would be, firstly, to publicise it through the mass media – radio, print advertisements and, of course, on social media. It is not just to reach out to the elderly. It is really to reach out to the public, create awareness and encourage the public to refer potential residents who can benefit from the SMF.

We would also be working through AIC with the grassroots to again do an outreach in the heartlands, through roadshows, through house visits and so on because I think actually, that is really very useful. The grassroots, together with the advisors, understand the residents and may know of residents who actually will benefit from the enhanced SMF, not just in terms of assistive devices but also the transport subsidies as well as consumables if they are very frail elderly who are cared for at home.

AIC will also be working with the eldercare centre operators as well as other VWOs to get them to recommend and sign on eligible clients for the enhanced SMF.

Mr Gerald Giam Yean Song: Madam, I thank the Minister for his responses. I have two lots of clarifications. One is on means-testing and the other is on the NEHR.

Regarding means-testing, I am glad to hear that the intermediate and long-term care institutions now do not require patients in the families to submit their income documents to receive the Government's subsidies. Can I clarify that this applies not just to the basic hospital subsidies but also to the applications for MediFund and the other hospital endowment funds?

The other thing is that, my understanding is that acute care hospitals still require the submission of income documents for these additional subsidy schemes. So, when will this convenient processing be extended to the acute hospitals?

On my clarification on the National Electronic Health Records (NEHR), the Minister said in his speech just now that only some GPs are on the NEHR. Exactly how many private GPs are actually on-board right now? Is cost preventing a higher take-up rate? Can MOH consider reducing the usage fees in view of the wider benefits that will be brought about if GPs are all on this NEHR?

Mr Gan Kim Yong: I would like to thank Mr Giam for the clarifications. First, let me clarify that for means-testing, there may be other schemes that are offered by the various institutions, whether it is an endowment fund or even the VWOs. They may have their own charity schemes. These charity schemes may not be able to tap onto the network but these are from their own welfare funds. We can continue to work with them to see how we can facilitate the application for these special funds beyond the MediFund and beyond our long-term care (LTC) subsidies.

For hospitals and the MediFund, we will look at it and see how we can further improve to facilitate applications. I believe that they are now able to tap into our CPF and IRAS records but patients do need to give their consent so that they can have access to this database.

On NEHR, we are rolling out to a select group of GPs, working with them, pilot with them. We have identified about 50 of them to test out the system. Some of them have already come onboard and some of them are in the process of training and familiarisation. We hope to be able to roll out to more GPs in time to come.

Cost is an issue because it does cost money to develop the system as well as to maintain the system. I am also very much aware that this cost can impose a financial burden on the GPs. We are working with the GPs to find a way that would ensure that it is affordable on an on-going basis. We developed this system and we really want to benefit the whole healthcare sector – not just the public sector but also the private healthcare providers. I am quite aware of the issues and we are working with the GPs to see how we can keep the system functional, beneficial and, at the same time, affordable.

Dr Lily Neo: Mdm Chair, can I seek two clarifications from the Minister, please? On my first clarification, may I ask the Minister whether he will consider my earlier suggestion on reducing the out-of-pocket payments for patients, especially those from the lower-income group and the retirees? For example, will he consider a tiered reducing co-payment system?

On my second clarification, may I ask the Minister whether he will make available better referral systems for psychiatric patients in the community and better care of such patients in the community? The reason is that presently, there are many neurotic cases and psychiatric cases in the community that are under-diagnosed and under-treated. So, could the Minister look into this?

Mr Gan Kim Yong: Mdm Chair, I would let my Minister of State to reply on the question on psychiatric patients. With regard to the tiered reducing co-payment, I am trying to understand how the proposal works. To date, our subsidy is already tiered. Whether in the hospital or the LTC sector, the subsidies are means-tested, which means that if you are lower-income, you get a higher subsidy and, if you are higher-income, you get a lower subsidy. The patient then pays the balance. And, in that sense, the co-payment is already tiered according to your income level. If you are higher-income, the subsidy is lower, so you pay more co-payment. If you are lower-income, then your subsidy is higher, then you have a smaller component of co-payment. In that sense, the co-payment component is already effectively tiered so long as we make sure that the subsidy portion is tiered according to a means-tested basis.

The Chairman: Yes, Minister of State Dr Amy Khor.

Dr Amy Khor Lean Suan: Can I just seek a clarification to the Member's second question about psychiatric patients? The Member is saying that they are under-treated?

Dr Lily Neo: Many cases of the psychiatric patients are being treated less well because when they are in the community, they have less follow-up. And sometimes, they just ignore taking their medications and they do not have good supervision and that is posing a harm to themselves and also causing inconvenience to their family members.

Dr Amy Khor Lean Suan: Madam, I thank the Member for her clarifications. As I have said earlier in my main speech, the focus of mental health now really is to shift the locus of mental healthcare from an institutional setting, that is, hospital setting, to community-based care as far as possible, and that is really to allow them to integrate back into the community and continue to lead meaningful lives because many of them, actually with medications and proper treatment and follow-up, can work and lead meaningful lives.

I think it is a common concern about the lack of supervision or the fact that they may not follow up on their treatment or continue with their medication. What we have done is to set up community-based mental healthcare services through, for instance, the Assessment and Shared Care Teams (ASCAT). As I have shared in the main speech, we have two now, but we will be expanding this to six across the island.

They will work together with the hospitals, particularly IMH, as well as the restructured hospitals that have got psychiatric departments, and with GPs. So, when the patient is discharged, say, from IMH, and they go into the community, the ASCAT teams can follow up with these patients, together with the GPs. The GPs are actually trained – the 70 GPs who are now in partnership with IMH. If these GPs need specialist advice, for instance, they can refer the case to ASCAT.

There is also another level, we call Community Mental Health Intervention Teams (COMIT) which is not physician-led, unlike ASCAT, but they are actually led by allied health professionals and they can also do follow-up as well as the education of the caregivers in order to help them manage the patients in the community.

What we are trying to do really is to have a seamless and integrated care within the community and help them to re-integrate as much as possible.

5.00 pm

Ms Tin Pei Ling: Mdm Chair, I would like to thank the Minister, the Minister of State and the Parliamentary Secretary for the very comprehensive replies, and I am heartened to know that there is a lot of attention given to the mental healthcare sector.

I have got four questions. The first question is: if a person is suspected to have a mental health issue, perhaps somewhat moderate to severe, and is causing disturbances in the community setting which may not be aggressive and violent enough for the Police to come in, and this person may also not be known to IMH yet; therefore, no records with the IMH; may have little or no family support or social network; how shall the community respond to such an instance, and cope with this case, such that this person will be able to come within the radar, and receive the treatment that he or she needs in order to recover as soon as possible, and to regain normalcy in life? That is the first question.

Second question, talking about stigma, will the Ministry consider working more closely with the mass media to provide a more objective and balanced portrayal and coverage of mental health issues? There have been studies which show that media is a very pervasive and very effective medium for propagating certain messages and imaging certain issues.

The third is about meaningful employment. I have also heard of many instances where people who have mental health issues do have reservations as they feel that they cannot come out into the open and tell their bosses that they need to go for medical appointments and so on. That, in a way, hinders them from getting meaningful employment or staying employed —

The Chairman: Ms Tin, please try to keep your clarifications short.

Ms Tin Pei Ling: I am so sorry. Will the Ministry share with us what is being done to address this issue? And, finally, for the respite care services, apart from dementia, does that also extend to other forms of mental illnesses as well?

Dr Amy Khor Lean Suan: Firstly, on the question of someone who might be an ex-mental patient or potential patient who is causing disturbances, I think quite a number of us have experienced this at one time or another. If they are uncontrollable, violent, pose a danger to themselves or to the community, then, you can call the Police. The Police will then bring this particular person into IMH for assessment and follow-up treatment. But in many instances, they are not violent. They cause disturbances and nuisance to neighbours and so on.

For cases like these, the resident or the grassroots or the advisor can link up with the FSC or SAC. By the end of this month, all FSCs and SACs will have staff that have been trained in call protocol as well as linking up with the Institute of Mental Health helpline. The staff can then assess this situation together with the IMH staff, and decide if they need to activate a mobile team from IMH which comprises generally of two nurses who are trained in mental health as well as crisis management to go down to the house for onsite assessment or house visit. And then decide if they need to bring the person for follow-up treatment at IMH or at restructured hospitals.

Now, I need to say that under the Mental Healthcare and Treatment Act, unless the person is violent, pose a danger to himself or the community and so on, the Act does not allow us to compel this person to be brought to IMH for treatment. So, in many instances, the mobile team will have to work perhaps together with the grassroots or people who know the resident or work with the family if there is some form of family support, and conduct sometimes multiple visits to persuade this resident to be brought for follow-up treatment. In that sense, some patience is needed.

I would like to share that within my own constituency, we have helped a case like this. In fact, I just received an email of a case that we have just solved. Some patience is required in order to identify ways where we can actually bring this resident for treatment and follow-up. And sometimes they are ex-mental health patients; all they need really is help to get them back onto their treatment regime, medication and so on, and then they will get well again.

With regard to using mass media to reduce or mitigate stigmatisation, HPB does work very closely with the broadcast media – radio or TV – to try and weave mental health messages into some of their programmes. Recently, for instance, they worked with the Radio DJs to weave some of these messages into their programmes.

I understand that HPB has also recently worked with Channel 8 on a drama serial called "It's a Wonderful Life" and they have worked with them to weave some of these mental health messages into the drama serial. Where possible, we will continue to look at ways to see how we can promote awareness of mental illness, mental well-being, using mass media and other avenues.

For employment, there is a Job Club that IMH has set up to help mental patients who have recovered to find jobs by preparing them for jobs as well as setting up a network for them to get jobs. There are also other services like Temasek Cares-Employment Support Services which also does the same thing. The CDCs also pitch in and help wherever possible, even organising job fairs specifically for this group of people.

And the last question was on respite care. Respite care is not just for caregivers of patients who are mentally ill or suffer from depression or dementia specifically. It is for care-givers who need respite because they need rest, and so it is for all kinds of mental illness as well as other kinds of illness.

Dr Janil Puthucheary (Pasir Ris-Punggol): Mdm Chair, I have one question for the Minister which relates to tobacco control. I welcome the changes to the removal of the retail display. It is a step in the right direction and represents the choice of public health over possible commercial interest. My question relates to the ability of the Government to protect its ability to make these types of decisions. In other jurisdictions, these types of decisions involving retail displays or packaging are being challenged as a result of free trade agreements – multilateral or bilateral free trade agreements.

I am aware that in many of these agreements, health is an exception. And then there is an exception to the exception which does not cover investments in intellectual property, and trade interests use that as a way of challenging these types of regulatory decisions made by governments. Especially as Singapore engages —

The Chairman: Dr Janil, you may wish to keep your clarification short; not a speech, please.

Dr Janil Puthucheary: Yes, Madam. As Singapore engages with the Trans Pacific Partnership negotiations, how would MOH ensure its ability to make these types of decisions in the future?

Mr Gan Kim Yong: Mdm Chair, let me thank Dr Janil for the clarification. We are very mindful of our international obligations with regards to our obligation to WTO as well as our bilateral trade agreements. In crafting these tobacco control measures, we have also been very careful with regard to the legal implications. Even in our negotiations of bilateral agreements, we are mindful of our own internal interests to protect the health of our citizens. These are all taken into account. As we roll out these tobacco controls, we are quite confident that we are on strong grounds, to introduce these measures, particularly in the interest of population health.

Mr Low Thia Khiang: Clarification for the Minister. Madam, I am happy to note that MOH has shifted its focus and changed its mindset from how to avoid healthcare expenditure escalating, to how Singaporeans can have peace of mind in healthcare needs, especially for those who have little MediSave in their account.

Madam, Minister earlier in his speech mentioned that there will be a new salary scheme for specialist doctors in 2014. Could he elaborate further on what would be the changes?

The second clarification is on the National Electronic Health Records. I would like to know if there is any roadmap for the health records to be implemented or to roll out. Where are the stages and the milestones set? I think we have started on this long ago and I think the progress seems to be quite slow.

Madam, on the referral system, the Minister's answer was that GPs under CHAS do refer the patient to the restructured hospitals and the patient will be treated as a subsidised patient. Does it mean that any patient who walks into a GP clinic under CHAS and when the GP refers him to the hospital, he will be considered as a subsidised patient? Or only a patient who is registered under CHAS as a subsidised patient, will be considered as subsidised patient when he is referred to a restructured hospital?

I understand that the recruitment of GPs under CHAS has been quite slow. What is the objection if MOH opens up the system of referral to allow any GP – instead of just GPs under CHAS – to refer patients to the hospitals to be treated as subsidised patients?

Lastly, we have been talking about long waiting time for a long time. My understanding is that currently there is still long waiting time at the polyclinics, long waiting time for patients, especially subsidised patients, to be referred to the specialist clinics in the hospitals, as well as those who are on the waiting list for surgery. What is the strategy of the Ministry to mitigate the situation, both in the long term and in the short term?

Mr Gan Kim Yong: Mdm Chair, if you would allow me, first let me explain that even as we focus on helping Singaporeans cope with their healthcare costs, it is still very important for us to continue to focus on managing overall cost. If overall healthcare cost goes up, even if the Government takes on a greater share, eventually the society will shoulder the cost. It is important, first and foremost, as explained in my main speech, that the starting point is to ensure that we manage overall healthcare costs. We do take many measures to achieve that. One area, for example, is that we want to ensure that we are productive and cost-effective in our treatment. We are very careful in selecting the appropriate treatments to make sure that we do not over-consume medical services.

Right-siting is another area. We want to make sure that we do not keep patients in a high-cost setting. If they are better off to be cared for at home, then we want to care for them at home. If they can be cared for in a step-down care setting, then it is better to send them to step-down care. All these measures come together to manage overall costs to ensure that, as a society, as a nation, we manage overall healthcare costs.

Even as we manage overall healthcare costs, we want to make sure that the Government's share will increase so as to keep the patient's share of the cost affordable to the patient. So, that is the major shift.

Secondly, Mr Low asked about the new salary scheme. As I explained in my speech, the new scheme will be implemented in 2014. The working group is still working through the details of the scheme. The concept is this: first, we want to emphasise that the doctors' focus is always on the interest of the patients. At the same time, we also have to make sure that our remuneration system treats the doctors fairly. We pay them fairly and competitively so that their salaries are competitive versus the private sector.

We probably will not be able to match the pay that the private sector can offer, but we cannot allow the gap to widen too much, otherwise there will be tension. Pay is not everything as far as the doctors are concerned, but it is an important factor. It also reflects our recognition of their contribution. The new pay scheme that is being worked out will take into account feedback from Members of Parliament as well as the professionals on how to balance between appropriate remuneration for the doctors versus interests of the patients so that we can shape the desirable behaviour.

5.15 pm

With regard to the professional fees that I mentioned earlier, the intention is to look at whether we can take a portion of the professional fees, pool them together and then redistribute them to the individual physicians, taking into account their contribution to patient load, their contribution to education, their contribution to the management of the institution – maybe they are in leadership positions; they might not have a lot of time to see patients, but their contributions are equally important. All these factors have to be taken into consideration in the new framework. We will be able to share more once we finalise the framework.

On the National Electronic Health Records (NEHR), Mr Low had asked the question before and, as I have explained, it is a multi-year project and we will move from stage to stage. We are actually in a very advanced stage of our computerisation. Compared to international standards, our level of computerisation has already achieved a certain milestone. Moving forward in the next phase, as I also explained in my speech, we will focus on developing and enhancing the functionalities of the NEHR so as to allow more useful features to be available to the users.

Today, the basic NEHR is in place. It will take time for us to achieve buy-in from the individual physicians because habits are not easy to change. We do need a change management process to encourage our physicians, our nurses, and all our clinical users to change the way they have been working and move on to tap on the rich features that NEHR will provide.

NEHR also serves as a very important tool for us to put together the healthcare data of the nation. Every single patient ought to have a single record so that we can share the data wherever you are, whichever setting that you go to. In addition to taking care of the patients' interest, it is also a tool to give us the ability to analyse national health data to understand the population's health trends so that we will be able to then develop policy instruments to address the key emerging trends.

It is a multi-year project and our next step is to encourage buy-in, to encourage adoption, and this is not an easy task – I will acknowledge that – but it is something that we need to continue to work on. We will also be developing and enhancing the functionalities of the system.

On the referral programme, I explained in my answer that for CHAS patients who go to the CHAS clinics – these CHAS cardholders – when they are referred by CHAS clinics, will be eligible for subsidy in our SOC. The reason we do that is because when the CHAS clinics are accredited under CHAS, they would have a comprehensive system of managing the chronic diseases of these patients. The patients themselves are already means-tested through the CHAS system. To start with, the patient has to be a CHAS cardholder to be eligible for subsidy because they are means-tested. On the other hand, the referring GPs which work very closely with MOH and our tertiary institutions and our polyclinics in managing these patients are able to then assess the suitability of these patients for our specialist clinics.

As a start, we are allowing our CHAS clinics to have access to the subsidised services in our SOC. For CHAS cardholders, they will go to our CHAS registered clinics. When they are referred to SOC, they will then automatically become subsidised patients. At our SOC, if you are referred by any other GPs, we will also look at it on a case-by-case basis, and depending on your income, we may do a means-testing at the SOC before we decide whether or not to allow you to downgrade to a subsidised patient.

There is some flexibility at the SOC but we do encourage our patients to go through the CHAS clinics so that they are managed appropriately because when the SOC discharges these patients back to the community, it is also ideal for them to be discharged to the CHAS clinics so that they can follow up, and better manage the chronic diseases of these patients. We want to encourage a stronger partnership between CHAS clinics and our tertiary institutions as well as our polyclinics.

On the waiting list for the specialist outpatient clinics, we have adopted several strategies. I had made a reply to an earlier PQ on this matter. For example, for urgent referral cases from polyclinics, we have an expedited route, especially for cardiac illnesses or suspected cancer cases, we have an accelerated programme to allow them to see a specialist quite quickly. We also look at the acuity of the conditions. If the patient needs urgent attention, he will be attended to at our SOC.

If it is "urgent-urgent", then they ought to be in the emergency departments of hospitals. Once they are in the emergency department, they will be given immediate attention. If it is sudden cardiac arrest, for example, then they ought to go to the emergency departments. We have a protocol of referrals, depending on the acuity of the patients.

For electives – electives refer to those cases where you decide when you want the operation to be done – time, in many cases, is not critical. We then have more flexibility in scheduling those electives for the various surgeries. We adopt a multi-pronged approach to address the queues in our specialist outpatient clinics.

I also mentioned in my speech that we are developing a medical centre at NUH. With that, we will enhance the capacity for specialist outpatient clinics. So, we take a multi-pronged approach to address the queue issue at our specialist clinics.

The Chairman: Last clarification, Mr Patrick Tay.

Mr Patrick Tay Teck Guan: Mdm Chair, I would like to ask the Minister a question regarding utilisation of MediSave monies. Many workers and residents I speak to lament that they cannot bring their MediSave monies with them to the grave. Perhaps, the Minister can share with us what is the amount of MediSave monies left in the CPF account holders of those who have passed on – on the average.

Mr Gan Kim Yong: I do not have the data at hand but I would like to point out that from statistics – not just in Singapore but globally – the bulk of the medical expenses is incurred towards the end of life, most of the time within the last six months to 12 months. Even if our members today see that there is significant savings in their MediSave account, it is important to preserve these savings because as you grow older, as you become more frail, as you visit hospitals more often, you will need much of these MediSave monies.

For those that are low income, I would encourage them to approach our medical social workers. It is better for us to help through the various help schemes, including MediFund which we have just expanded, and keep the savings for yourself because eventually you may still need it as part of your co-payment when you are hospitalised towards the end of your life. Some may need to also use it for other outpatient chronic disease management. I would, therefore, not take it too lightly in talking about the balances in our MediSave accounts. Again, I am sorry, I do not have the exact number of the MediSave balance of those who have passed away at this point in time.

The Chairman: Dr Lam Pin Min, you may wish to withdraw the amendment.

Dr Lam Pin Min: Mdm Chair, on behalf of the GPC for Health and other health-conscious Members of the House, I would like to thank the Minister, the Minister of State and Parliamentary Secretary for their comprehensive replies and the many early Christmas presents. I believe MOH will continue to work hard to look into all the issues and suggestions raised by Members today and to make healthcare affordable and accessible to all Singaporeans. With that, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

The sum of $4,929,089,000 for Head O ordered to stand part of the Main Estimates.

The sum of $746,558,600 for Head O ordered to stand part of the Development Estimates.