Committee of Supply – Head O (Ministry of Health)

Head O (cont) −

ElderShield

Dr Lam Pin Min (Sengkang West): Mr Chairman, Sir, ElderShield is an insurance scheme introduced in 2002 to provide financial help to those who are unable to take care of themselves because of severe disabilities. Since the last revision in 2007, the basic ElderShield payout stands at $400 per month for 72 months. With medical inflation and the high cost of nursing care, this quantum is insufficient to cover the basic medical needs of most low- and middle-income families. Will the Ministry consider revising this amount in view of the escalating medical cost? Can the Ministry also give an update on the take-up rate for this scheme?

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MediShield for the Elderly

Mr David Ong (Jurong): Mr Chairman, Sir, in our many helping hands approach supported by the 3Ms of healthcare financing and our family as the cornerstone of elderly care, the presence of MediShield has been a source of much comfort and support for Singaporeans. In the area of caring for our elderly sick, the financial strains can be debilitating. The strains almost nearly cut across all social classes particularly more acute for the low income and sandwich class. A person with stroke and in a comatose condition lying in an intensive care ward for 30 days can easily chalk up $30,000 on hospitalisation cost alone. Thus, even with the 3Ms and subsidised assistance, the financial strains can be crippling. Although I applaud the extension of the MediShield coverage to 90 years in this year's Budget, I believe we can do more.

The twilight years of a person's life are the period when they utilise the most healthcare. A person living long beyond the age of 80 would probably have stopped working for at least 15 years. Thus, it may be the case that they would have used up most of their savings accumulated in their working life. Their children may also have progressed to become senior citizens themselves. Hence, the burden of caring for them may cascade down to their grandchildren.

Presently, there are 11,100 Singaporeans aged 90 and above whom I shall call "Elite Seniors". It will be a benevolent gesture to honour our Elite Seniors for their contribution and sacrifices made for the country. Would it not make good sense to go that extra distance and complete the MediShield coverage for our Elite Seniors till the end of life? This will give our honourable Seniors the added peace of mind as they live to a ripe old age, knowing that they can be less of a financial burden to their children or grandchildren.

Can the Government work with its MediShield's private insurers to make extending MediShield coverage to end of life a reality? Can an assistance scheme for premiums be looked into for co-payment of a higher premium?

Sir, I would also like to ask the MOH to help promote and encourage MediShield coverage for women aged 65 and above. The number of working women in Singapore lags behind many countries. We have about 65% women working here versus about 80% in Norway. Hence, the number of women having little or no CPF is estimated to be easily about 30%. Correspondingly, a majority of the 170,000 women aged 65 and above will have no MediShield coverage. Sir, I would like to ask MOH if our current MediShield coverage is adequate, given the rise in medical and healthcare costs. Can the Ministry do more with its MediShield coverage for our Elite Seniors and senior women?

Increasing the MediShield Coverage

Mr Gerald Giam Yean Song (Non-Constituency Member): Mr Chairman, MediShield is a Government-administered insurance scheme. It is meant to help cover the cost of major hospital bills. Unfortunately, some of those who need MediShield coverage the most, like babies with congenital problems and the very old, are often denied coverage. MediShield currently covers 92% of Singaporeans. Those who are not covered include some of the elderly, homemakers and others who have voluntarily opted out of MediShield. Some are not able to obtain MediShield coverage due to pre-existing conditions. I would like to ask what the Ministry is doing to help achieve a higher level of MediShield coverage for all Singaporeans. What is the Ministry's targeted level of MediShield coverage?

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Currently, newborns with congenital conditions are either denied MediShield coverage completely or have their conditions excluded from coverage. This does nothing to relieve the financial hardship that parents of these children may face. In order to ensure that these children are adequately covered under the MediShield, will the Ministry consider providing pregnant women an option to buy a MediShield rider to cover for any congenital problems or prematurity-related complications? This should naturally be done before any problems are diagnosed. It would be a one-off payment for the rider and it could actuarially be adjusted upwards for older women as they are at a higher risk of having babies with congenital problems or prematurity-related complications. This will provide the insurance coverage if the baby is later diagnosed with a problem, yet it would ensure a large enough risk pool to cover the potential payouts. Overall, this change should not require any increases in premiums.

As proposed during my Budget debate speech, will the Ministry consider doing away with the age cap of 90 years old for MediShield altogether? There are currently only about 11,000 Singaporeans aged above 90. We should be doing all we can to help this small group of seniors who have made it this far, instead of denying them the insurance coverage when they need it the most. Beyond age 90, many of them may have outlived their own children or siblings and have no direct relatives to support them.

I note some enhancements to MediShield coverage may require premium increases. However, based on the Minister's reply to my Parliamentary Question (PQ), between 2006 and 2010 MediShield collected an average of $131 million more in premiums each year than it paid out in claims. While I appreciate the need to set aside a portion of the premiums as reserves, can the Ministry relook at whether the premiums collected can be used to cover at least part of the increased coverage, instead of passing the additional cost entirely to policyholders? Currently MediShield premiums vary widely according to the members' age from $30 a year for those aged below 30, to $1,123 for those in their 80s. This imposes a heavier burden on older members, many of whom may be retired or have exhausted their Medisave. If premiums can be increased to cover the additional claims, can they be increased for working adults, instead of the elderly?

Medisave and MediShield

Assoc Prof Fatimah Lateef (Marine Parade): Mr Chairman, our 3M scheme is a good one. Medisave has since its inception been expanded to cover beyond hospitalisation expenses. These include its use in Chronic Disease Management Programme (CDMP), payment for certain chemotherapy and radiotherapy, dialysis, and so on. MediShield, on the other hand, is a medical insurance scheme.

I would like to ask MOH to consider increasing the Medisave from $400 to $500 per annum for the CDMP in view that (i) Singaporeans are having more chronic illnesses these days, especially with the rapidly ageing population; (ii) the push towards more ambulatory and outpatient care, which would mean patients may have to make more out-of-pocket payments; (iii) the use of new generation and non standard drugs for treatment may end up with a slightly higher cost for patients; and (iv) the increasing healthcare cost from market forces. There has been much feedback on the payment of the administrative fees for CDMP. Can this be waived, absorbed or reviewed?

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On MediShield, Sir, I have the following suggestions: first, can the upper age limit be extended considering that Singaporeans are living longer? On the average, for every eight-hour shift I do at the Emergency Department, there would be at least two patients who are aged 90 years or more. Can we also expand the repertoire of riders and companies available for choice, and, finally, similar to my call at last year's Committee of Supply (COS), can we extend MediShield for use in congenital diseases, as well as related familial screening, in a regulated way. Those affected need regular follow up with multiple procedures and aggressive interventions. For those with congenital problems that end up living into adulthood, multiple complications will surface again requiring intervention. Also, can we do more roadshows to encourage women to come forward and sign up for MediShield?

Free MediShield Coverage

Mr Gan Thiam Poh (Pasir Ris-Punggol): Mr Chairman, I would like to request that the Ministry considers providing free MediShield coverage to the lowest 20th percentile of Singapore citizens whose per capita income is about $750 and below, and to all homemakers looking after children up to the age of 17. A serious illness can wipe out one's Medisave and cash savings. Yet many poor families do not have any catastrophic medical insurance as they are struggling to meet more urgent daily expenses. Homemakers, children and the elderly are particularly vulnerable as they do not have incomes. Housewives sacrifice their earning opportunities to care for their children and the elderly at home. Yet, day in day out, they are doing work which, if monetised, is worth thousands of dollars a year. In many single-income families, housewives tend to scrimp and save and overlook their own medical insurance. Senior citizens in the lowest income groups have to face many issues. If they are working, their pay may have already been cut as their job responsibilities are reduced. If they are already retired, they worry about making their savings stretch. Either way, insurance premiums would be higher and less affordable to them. Currently, the annual premiums for MediShield start from $33. I hope the Ministry would consider assisting them by helping to pay for their coverage.

Medisave of Elderly

Ms Tin Pei Ling (Marine Parade): Mr Chairman, Sir, many, if not all, in this House understand the principle behind imposing a minimum sum criteria for Medisave is to ensure that we set aside enough savings to meet our future healthcare expenses. Imposing an annual cap on the amount that we can withdraw from Medisave is in line with this principle as well. It has also been emphasised to us that we ought to rely on our Medisave, then MediShield and, when all else fails, do we then rely on Medifund. However, seniors who have retired therefore no longer have the income to co-pay for their health expenses and those who are without family members are unable to tap on another person's Medisave Account and can only rely on their Medisave for their healthcare expenditure. However, some of these elderly persons have apparently been compelled to tap on Medifund while they still have sufficient monies in their Medisave.

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I have met one such elderly gentleman at my Meet-The-People Session (MPS) and he has been asking to use his Medisave for his medical expenses. He is in his 70s, has a heart condition and regularly needs medical attention. He believes he has sufficient savings in his Medisave for his medical bills. He strongly believes that he should be self-reliant and cannot understand why his request has been repeatedly rejected. Understandably, his is a rare case. But his request stems from his belief in personal responsibility which is a worthwhile value to support. Hence, would the Ministry consider allowing seniors to have more autonomy such as allowing them to exhaust their Medisave before offering Medifund to them?

MediShield for Congenital Diseases

Dr Janil Puthucheary (Pasir Ris-Punggol): Mr Chairman, I declare my interest as a paediatrician working in a restructured hospital. The issue of MediShield for children with congenital diseases has been brought up in this House in previous Parliaments as well as in this debate. I would just like to add my voice to the chorus. Sir, the problems faced by these children and their families are significant. But many of the diseases can be treated such that these children can lead long, healthy and normal lives.

The current regulatory framework lumps together all congenital diseases, when in truth there are a significant number of conditions that can be treated in a straightforward manner with a reasonable prediction of cure and a normal life, and a relatively short hospital stay. If part of the current policy position for excluding these children is that these children are expected to not survive, then the policy has not kept up with advances in medical science.

Let me offer some examples. A ventricular septal defect, a hole-in-the-heart, has about a 95% chance of complete cure and an expectation of a long and healthy life. In contrast, a child born with a hypoplastic left heart has the odds stacked against him. The current policy pushes these two together. Let me move to an alternative example. An adult, however, who suffers a significant heart attack has about a 80% chance of survival. In contrast, another adult who has a ruptured aortic aneurysm has less than 30% chance of getting out of hospital alive. Both of those conditions are currently claimable under MediShield. So, the policy pushes those two conditions together.

This subject has been brought up in the House previously, and from previous replies, the main concern is one of risk-pooling and the effect on premiums. This is true if one treats all congenital diseases as being equal, and I would suggest that the assumptions underlying that position are based on out-dated science and medical knowledge.

I would like to suggest that a couple be allowed to apply for MediShield for their unborn child. And as part of that application, there should be a requirement for high quality antenatal screening, which can detect most of these conditions in time for appropriate preparation and counselling, with the final decision about being allowed to have MediShield being made after the child has been born. These criteria need not be subjective and can be independently verified.

Would the Minister consider extending the use of MediShield to cover children with congenital disorders? Would the Ministry consider examining the position that categorises all congenital diseases together?

11.15 am

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Medisave and Outpatient Charges

Dr Chia Shi-Lu (Tanjong Pagar): Mr Chairman, Sir, I wish to declare my interest as a specialist practising in a Government restructured hospital.

Sir, the Chronic Disease Management Programme is an excellent initiative to improve affordability for patients with chronic diseases requiring long-term outpatient follow-up. It covers many conditions such as diabetes, hypertension, stroke and the like. This has recently been expanded to include dementia and bipolar disorder, and is yet another clear and welcome sign of intent by the Ministry that it will address mental health in the community.

I would like to ask MOH to consider liberalising the use of Medisave for outpatient use in certain other circumstances, notably paediatric, cardiological and cancer specialist care. The reason is that these medical services are typically provided by specialists in hospital-based specialist clinics and they require frequent and sometimes costly investigations, and often involve medications and treatments that are long term and may be expensive. Patients and their families who are already struggling with out-of-pocket medical expenses can be tempted to skimp on certain outpatient treatments to cut down on costs. By further liberalising usage of Medisave in such situations, we can encourage better patient compliance with respect to management of these diseases, thereby improving outcomes and reducing chronicity and disability. Alternatively, I hope that MOH can explore health insurance schemes for outpatient care, perhaps as a variation of the managed care systems that are available in the private medical sector.

I also wish to end by raising an additional point that has been frequently brought up by members of the public, my patients, residents and also, very recently, by Assoc Prof Fatimah Lateef. As noted, patients with chronic diseases are required to pay a processing fee to settle each outpatient treatment at the public hospitals when using their Medisave Accounts. Many patients have given feedback that they are unhappy with this surcharge. While they can understand that there is an administrative cost involved, they also feel deep down that they are essentially being charged to use their own savings. The point is this: if these patients were more comfortable financially in the first instance, they would have preferred not to dip into their Medisave in the first place. Hence, I would like to respectfully request that MOH, perhaps, discuss this with its partners, the CPF Board and the National Computer Systems, to see whether there are ways that they can maybe reduce or even waive this processing fee, considering that in today's society, a lot of payments are made electronically as well, and I suppose this can be done fairly cost-efficiently.

The Chairman: Mr Ramasamy Dhinakaran is not in the House. Assoc Prof Dr Muhammad Faishal Ibrahim.

Accessible and Affordable Primary Care

Assoc Prof Dr Muhammad Faishal Ibrahim (Nee Soon): Sir, as one grows older, it is reasonable to expect one to have multiple illnesses. I have met a few elderly constituents and their children who shared with me that they have to go to the different hospitals and specialist clinics in the management of their different illnesses. In doing so, they have to pay the different charges and spend more time travelling as they go for their appointments at these hospitals and clinics. A few have shared with me that at times, they receive repeated referrals in between the polyclinics and hospitals, making them confused and having to pay more. All these create a lot of inconvenience to the patients and their family members. The families feel that they end up paying more in the management of their illnesses. In addition, the children of these elders shared with me that they usually need to take many days of leave to accompany their parents to the different appointments at the different hospitals and clinics. They hope that the Health Ministry will be able to bring a few of these services closer to their homes, where they are able to manage their illnesses better. This will result in convenience and possibly more affordable healthcare.

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Sir, as we increase the expenditure on healthcare, I feel that it is important that we also look at making primary care more accessible and affordable to Singaporeans. Wherever possible, we should model the processes to be as accessible and affordable as possible to Singaporeans. I would like to ask the Minister on his plans in providing more accessible and affordable primary care for Singaporeans.

Community Health for Older Estates

The Senior Minister of State, Prime Minister's Office (Mr Heng Chee How): Mr Chairman, Sir, Singapore's population is ageing rapidly as more of our elderly live longer. In estates with a higher and fast-rising proportion of the elderly, one of the concerns is easy and affordable access to quality basic medical care, including the management of chronic diseases. Many elderly therefore ask for polyclinics to be built near their homes. I think that is a short form way of requesting for accessible, quality and affordable healthcare near their homes. Whampoa is one such estate.

The Ministry has improved the coverage of the former PCPS, now called the CHAS scheme, to tap the local GP network and to provide affordable care for the community. I understand that the Ministry is also examining the idea of building community health centres to complement the work of GP network. I would like to ask for an update on these initiatives and to what extent have they increased the effective availability of accessible, affordable basic medical care in the older estates. I would also like to ask what has been the ground experience of setting up such GP network and what difficulties have surfaced, and what will the Ministry do to intensify and scale up this capability building.

Strengthening of Primary Healthcare

Assoc Prof Fatimah Lateef: Mr Chairman, with our ageing population and increasing incidence of chronic diseases, GPs are well positioned in our healthcare system to provide accessible, holistic and continuing care. The GPs' overall share of primary care patients is 81% compared to their share of chronic disease follow-ups which is only 55%. The GPs may be under-utilised in this aspect as patients attend polyclinics, emergency departments in hospitals and specialist outpatient clinics. These institutions thus tend to get overloaded. There is a need to strengthen and enhance the public's perception of GPs and primary care.

This can be done with: (1) MOH's call for every family to have one family physician or a GP; (2) setting up of community health centres (CHCs) in a common vicinity, tagged with support services such as radiology, laboratory and allied health services. There could even be visiting consultants from tertiary institutions who can do this but they, of course, need to be given dedicated time so that they can work with the CHCs' personnel; (3) enhancing GPs' qualifications, knowledge and training, with postgraduate degree and diploma as well as working closely with the College of General Practitioners; and (4) frequent interactions between GPs and specialists in tertiary care and even perhaps using video-conferencing to manage some of the more complex and difficult cases. This can certainly help to cut down the number of referrals to the emergency departments and tertiary hospitals to a minimum and keep it to real emergent problems, thus offloading the tertiary system and improving waiting times.

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All this requires a changed mindset amongst GPs and also the public. The GPs must take the lead and take ownership of these changes as it is planned in the Primary Care MasterPlan.

Can I ask MOH to update us on the number of proposed CHCs and their potential locations? Are we on track with the recruitment of healthcare personnel to man these CHCs? And how are we doing on the recruitment of more GPs and dental practitioners onto the CHAS Scheme, because I think that this is an important scheme that will have an impact towards strengthening our primary care.

Palliative Care

Ms Ellen Lee (Sembawang): Mr Chairman, the World Health Organization defines "palliative care" as "an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychological and spiritual".

However, as a young nation, very few Singaporeans know what palliative care is, what hospice does and how its services can be enhanced to cope with the silver tsunami in Singapore. It is no longer a matter of providing end-of-life care but how to enhance the quality of life of a dying person, to maintain it, improve it through nursing, psychological support and supporting the family members on this journey.

Death should not be stigmatised as taboo or inauspicious as all of us will die eventually. Children should be taught about death, not to instil fear in them but to let them accept it as a natural process of living. End-of-life care is not the prerogative of the old or the sick or people with cancer. Young children and youths need end-of-life care too, although their needs are very different from people who are, say, 70 or 80 years old.

How can the needs of the patients and their family members be met? Do we have the manpower to provide for such a service? What is the current state of palliative care and how accepting is the public of having such a service provided in their midst? What is the Ministry's projection of the need for palliative care in the short and long term and what is being done to cater to this growing need? Will there be community outreach programmes?

Enabling Silver Enterprises

Ms Tin Pei Ling: The following cut has got nothing to do with health but I think it was redirected because it is under "ageing".

Sir, in this year's Budget, the Finance Minister has introduced several measures for the elderly. These measures are appropriate and timely. Our seniors have enabled Singapore to progress to where we are today and we owe a debt of gratitude to them and we should do our upmost best to help them age with comfort and dignity.

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Singapore also needs to prepare for an ageing population by putting in place the support framework and services for senior to live in our community. Besides national schemes, the Government is also fostering services from the ground-up. The community has also initiated projects aimed at enabling a better understanding of the needs of all elderly and developing new services to meet these needs. Notwithstanding these moves, the Government will do well to harness the private and people's sectors to help. In this way, we can broaden the search for new ideas and enlist entrepreneurs to speed up the process of discovering seniors' needs and coming up with ways to meet them.

Can we do more to foster silver enterprises that can provide new services to the elderly? The need for some of such services may not be that obvious today. But as our population ages, this will become increasingly critical. How do we help silver enterprises build up in time for the future?

The Finance Minister has also introduced the Special Employment Credit (SEC) for companies which employ workers who are older than 50 years old. I think this will help older workers to secure and hold on to jobs. Nevertheless, not all seniors want to work as employees in firms. Some may decide to become entrepreneurs to try to do something in their silver years. I know of some seniors who have already embarked on such an entrepreneurship journey. For instance, I know of a Miss Helen Lim who started Silver Spring. She is a passionate lady who wished to remain active and contribute meaningfully to the economy and the society. Just like we have the SEC, might we consider setting up a framework to support seniors who want to be self-employed or who still have aspirations to fulfil? This might suit a minority of seniors but can be a useful complement to SEC.

Other countries have ventured into this area of silver entrepreneurship. For example, there is an organisation in the United Kingdom called the Prince's Initiative for Mature Enterprise (PRIME), founded by Prince Charles, which helps people over the age of 50 set up business for themselves. PRIME offers free information, workshops and business networking events. It can also refer people to accredited advisers for free business advice and, in some parts of the country, can also offer free mentoring and advisory services. Would the Ministry therefore explore similar initiatives to encourage silver entrepreneurship in Singapore, to help our seniors also achieve their aspirations despite being in their silver years?

Integrated Eldercare

Mr Chen Show Mao (Aljunied): Sir, the importance of delivering integrated care to our seniors is well known. This applies not just to integrating the delivery of healthcare − medical, nursing, rehabilitative, mental health − but also integrating the delivery of healthcare and social and other care services, including home help, day care, counselling and other services.

The objectives of delivering integrated care are, of course, to make the care elder-centric, that is, to meet their needs for multiple types of care, in view of the chronic nature of many of their conditions, with as little fragmentation and duplication as possible. With this in view, could the Government actively investigate ways to integrate, coordinate or link the relevant functions or administration of AIC under MOH, which coordinates the delivery of healthcare to our seniors, and CEL under MCYS, which coordinates the delivery of social care support services?

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11.30 am

The Minister for Health (Mr Gan Kim Yong): Sir, I would like to thank Members for their thoughts and their feedback on our healthcare policies. Yesterday, I spoke about the challenges facing us, and our efforts to expand healthcare infrastructure and the healthcare workforce to support the expansion of services under our Healthcare 2020 plan. I will now talk about how we will provide Singaporeans with quality and affordable care.

Over the years, we have invested heavily in building up our acute hospitals. They have attained high standards of care, with some achieving peaks of excellence and earning themselves a global reputation. At the individual level, our healthcare professionals have also attained high levels of proficiency. But there is room for improvement, especially in building up the intermediate and long-term care sector and outpatient sector as well as providing more integrated, patient-centric care. Sir, first, let me share our efforts to facilitate holistic management of patients to improve the care outcomes for them.

One of the key strategies to raise quality of care is to better integrate across different settings by re-organising the healthcare system into a more hassle-free, integrated and patient-centric Regional Health Systems. Each regional system would have an acute general hospital working in close partnership with community hospitals, nursing homes, home care and day rehab providers as well as polyclinics and general practitioners (GPs) within the geographical region to provide seamless and holistic care to patients.

This way, patients can be better cared for and supported across different stages of their healthcare journey from diagnosis and treatment to post-discharge follow-ups. It will also help patients navigate across providers more easily, enabling and empowering them to manage their own needs more effectively. This is a point made by Assoc Prof Muhammad Faishal yesterday. The Eastern Health Alliance, for example, launched in November last year, was the first such multi-party collaboration.

The Regional Health Systems need to be supported by enablers, such as the Agency for Integrated Care (AIC) which helps patients navigate the system and refers them to the most appropriate care provider. They also need strong case management capabilities, to ensure that patients follow up after their discharge as well as National Electronic Health Records to facilitate information flow.

Mr Low Thia Khiang asked for a progress update on the National Electronic Health Records (NEHR). We are on track to rolling it out to all the public health institutions and six community hospitals by June this year as well as the two nursing homes, selected GPs and users of the AIC. Mr Low also raised concerns about patient confidentiality. Patient confidentiality is important and it is protected in two ways. First, we have built the security framework in accordance with international standards to protect sensitive data. Secondly, an audit system is put in place for us to identify unauthorised entry. And as a deterrent, stiff penalties are in place for those who violate IT security. We will continue to enhance our IT security in a practical way, striking a balance between regulation and operational flexibility.

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As our population ages and the prevalence of chronic diseases increases, we can do more to support our GPs and tap on them to better care for residents in their community in a more cost-effective way. Assoc Prof Fatimah Lateef and Mr Heng Chee How asked how the new models of care that we have shared would increase accessibility. The new models of care involve four key features. First, encourage GPs to set up Family Medicine Clinics (FMCs) to provide team-based care for patients. Second, set up Community Health Centres (CHCs) to support GPs and provide allied health services for their patients. Thirdly, develop Medical Centres (MCs) to provide community-based services for patients who require day surgery and less complex specialist services. And, fourth, provide portable subsidy to patients under the Community Health Assist Scheme (CHAS) so that they can enjoy subsidised services at private GPs and FMCs.

With these new models of care, more patients can be cared for outside of the hospitals' specialist outpatient clinics by GPs in the community. At the same time, through team-based care, we can help patients slow down their disease progression, reduce complication rates and, in turn, minimise referrals to hospitals. We also hope to grow the capabilities to manage mental health conditions within the community and primary care, which Minister of State Dr Amy Khor will be speaking on later.

We have been engaging interested parties to set up the first FMCs and CHCs. We plan to pilot four FMCs this year to test out the model, with more in coming years if it proves effective in managing patients with chronic diseases in the community. We are also engaging potential providers to set up three CHCs this year. Our hospitals are now studying the setting up of new MCs. These are more complex set-ups and it will take a bit longer. I will update on our plans when the details are firmed up.

Assoc Prof Fatimah Lateef asked how the Ministry was going to upgrade the skills, knowledge and attitudes of our GPs. Sir, we recently improved the training of Family Physicians under the Family Medicine residency programme. We also have other training pathways for GPs to upgrade themselves. To recognise doctors who have the necessary skills needed for family medicine, the Register of Family Physicians was set up in 2011, and made publicly available earlier this year. After eight months, we have 509, or 25% of GPs accredited. We aim to double this by the end of next year.

Besides caring for the sick, we also need to ensure that those who are at life's last stage die well. Ms Ellen Lee asked how the Government will support this. Most people wish to die in the presence of their loved ones and with dignity. They prefer to die at home. We will help patients achieve this through good home palliative care.

MOH currently funds five home palliative providers, serving 3,800 patients each year. We are seeing how we can expand this. Part of dying well involves having one's care preferences honoured at the end of life. Through Advanced Care Planning (ACP), we encourage patients, families and healthcare professionals to come together to engage in discussions on care and treatment preferences. We are scaling up existing ACP programmes in the various Regional Health Systems.

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Let me now turn to the issue of healthcare costs and affordability, which many Members have spoken on. We have so far built a strong healthcare financing system. First, Government subsidies help to significantly reduce the cost to patients. Next, the 3Ms, that is, Medisave, MediShield and Medifund as well as ElderShield, come in to help the patients pay their share of the bill.

In the past, our financing framework focused more on inpatient care. As an ageing population requires more frequent care in the outpatient, intermediate and long-term care settings, our financing framework must also evolve to help Singaporeans meet the new realities. We have thus increased the subsidies for chronic outpatient treatment at GPs and for intermediate and long-term care services to benefit not just low-income families but also the middle income by raising the income criteria. Let me elaborate.

Last August, we announced significant changes to the Primary Care Partnership Scheme – now you know why I need to change the name – it is now known as the Community Health Assist Scheme (CHAS), which enables patients to receive subsidised care at GP and dental clinics. In January, the per capita household income criteria was raised from $800 to $1,500, and the minimum age lowered from 65 to 40. Middle income households can now benefit from this scheme. These enhancements to CHAS have been well received. We have doubled the number of Singaporeans on this scheme, from 38,000 two months ago to 77,000 now. I expect applications for the scheme to grow further as we step up our outreach efforts. Mdm Foo Mee Har suggested simplifying the application process. We will keep the process simple and extend the access points for applications to include polyclinics and GPs who are now in the scheme. We will explore what more we can practically do to further simplify the process. Together with the higher Medisave withdrawal limit for chronic disease treatment of $400, we have reduced patients' cash outlay when they see GPs for their chronic illnesses.

Assoc Prof Fatimah Lateef asked how we can attract more clinics into CHAS. Sir, we now have 460 CHAS GP clinics compared to 420 in December. This is about one-third of all GP clinics here. We are targeting to reach out to about 1,000, or 70% of all clinics. We are exploring IT solutions to ease the administrative load on clinics to make it easier for them to join in the scheme.

Assoc Prof Fatimah Lateef also highlighted the transaction costs incurred by patients when they make Medisave claims. I think Dr Chia Shi-Lu also mentioned that. This fee is imposed to recover CPF Board's operational cost of administering the scheme. We are very mindful and we will ensure that it does not affect patients' affordability. We recognise that outpatient care is not the only source of concern for Singaporeans. Many are worried about the cost of intermediate and long-term care, especially for those from middle income families who receive little to no subsidies. As their parents age and need more care and support, they too shoulder a heavy emotional and financial burden.

As announced by Deputy Prime Minister Tharman earlier, we are significantly expanding subsidies in the intermediate and long-term care (ILTC) sector, that is, for community hospitals, for residential long-term care services such as nursing homes, and for non-residential long-term care services such as home care and day rehabilitation centres. The Government will help patients afford these services.

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We are raising subsidy rates for long-term care services and extending the coverage from $1,400 to $2,200 per capita household income. Patients from a household of four with $8,800 total household income will still be eligible for this scheme. Details have been announced earlier. And with the changes, up to two-thirds of the households in Singapore will qualify for the subsidies, benefiting not only the lower income but also many middle-income families. As for the community hospitals, all patients regardless of income will be eligible for subsidies of at least 20%, higher for lower-income families.

To encourage and enable our elderly to age at home as far as possible, families who take care of their frail parents at home will receive greater Government support as well as a grant for the employment of a foreign domestic worker.

As part of these changes, we are also simplifying the means-test criteria in the ILTC sector from per capita family income, which includes all immediate family members, to per capita household income, which includes only those family members that the elderly is living with. This reflects the elderly's extent of financial support. We hope this will also simplify the process and reduce the hassle for patients and their family members as well as the institutions.

These changes will come into effect in the third quarter of this year, and overall Government spending on ILTC subsidies is expected to more than double by 2016.

Even as Government subsidies are expanded, we also need to help Singaporeans better afford their share of the costs. Dr Lam Pin Min and Ms Sylvia Lim suggested that ElderShield payouts be revised to help Singaporeans with the increasing cost of long-term care. There has been increasing support from Singaporeans for ElderShield, with the opt-out rate at 8% for the cohort who turned 40 in 2011. With higher subsidies, a significant portion of a VWO nursing home bill can now be covered by the basic ElderShield payout of $400. But this may not be sufficient for the elderly in future. We will have to revise ElderShield payouts in line with the increasing costs. But I am sure Dr Lam and Ms Lim are mindful that better ElderShield benefits will necessitate higher premiums, so it requires careful study. We plan to review ElderShield next year to ensure that it remains relevant.

For those low-income elderly and disabled who were unable to join ElderShield when it was introduced, they can apply for the Interim Disability Assistance Programme for the Elderly (IDAPE) instead to receive disability payouts. We are increasing the monthly payout to provide more help and raising the per capita household income cut-off also to $2,200 per month as well.

The changes to subsidies in the outpatient care and the ILTC settings will help the low income significantly but they also signal a major shift towards providing some help for the middle income. By raising the income cut-offs, we are extending the healthcare safety net to better support the sandwiched class, who are supporting both children and elderly parents.

11.45 am

Sir, even as we increase subsidies in the ILTC sector for Singaporeans, we will widen the differential between the subsidy levels for citizens and PRs. Permanent Residents will receive a lower subsidy rate than Singapore citizens in the same income tier. The same principle will apply to subsidies at the restructured hospitals. However, we will be mindful of the impact on the affordability of low-income Permanent Residents, many of whom are close family members of Singapore citizens. My Ministry will release more details shortly.

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I know many Singaporeans remain concerned about the cost of drugs, especially those required for chronic conditions, as their cumulative costs can be high over time. Ms Sylvia Lim asked about drug subsidies. The Government provides drug subsidies to improve the affordability of commonly used medications. The list of subsidised medications, known as the Standard Drug List (SDL), contains drugs that have been assessed to be cost-effective and essential. Most SDL drugs are capped at a price of $1.40 per week for subsidised patients in the public sector, while the rest are subsidised at 50% of the retail price.

We recently raised the subsidy for some SDL drugs used in the treatment of chronic conditions to 75%, for patients with per capita household income of $1,500 or less, halving the cost for them. The previous subsidy was 50%. Now we have raised it to 75%. In addition, the Medication Assistance Fund (MAF) assists Singaporeans who need selective but expensive drugs that are not on the SDL with up to 75% subsidy, also up from 50% previously. MAF has also been expanded to include other non-standard drugs that are not in the list, if they are assessed to be clinically necessary and appropriate for the patients.

Together, SDL and MAF help to keep drugs affordable for subsidised patients, often significantly below their cost. We also constantly review the SDL to include more drugs to help patients. In fact, we will be adding about 20 new drugs into the SDL and MAF this year. This will include drugs such as Olanzapine and Quetiapine for the treatment of bipolar disorders, as well as the antibiotic co-amoxiclav, better known as Augmentin.

Ms Sylvia Lim also asked about the pricing policy of drugs. Currently, our clusters purchase drugs through a centralised Group Procurement Office (GPO) where possible. However, some drugs are better purchased at the individual cluster or hospital-level for various reasons. For example, where quantities are small, or if the drugs are specific to that institution, it is better for them to purchase the drugs directly. Price differences could still arise, even for drugs purchased via the GPO. For example, same drugs purchased in different batches may have different prices because different tenders carry different pricing. So, some hospitals may be using drugs from an earlier batch or a later batch so their base price will be different, their costs will be different. Also, institutions have different cost structures and therefore we have to take into account giving institutions some flexibility so that they can take into account their different clinical setups and cost structures, but they are all subject to general subsidy guidelines. Some drugs are sold at a higher margin in order to cross-subsidise other drugs which may be very expensive and therefore need a much higher discount to keep them affordable. In this way, we ensure that, overall, drugs are affordable for patients.

I would like to stress that contrary to what Ms Lim has said, our healthcare institutions are not-for-profit organisations. Whatever revenue that is generated from operations, be it from the pharmacy or be it from drugs, or charges from consultations, is taken in as overall revenue to the institution and used to partially defray the costs of operations, including overheads. These revenues are, however, insufficient to fully cover their costs. In FY2010, the public healthcare institutions incurred operating deficits of over $2 billion, before subvention from the Government. And I would just like to inform Ms Lim, who mentioned a number of drugs yesterday, that I took the opportunity to clarify with our hospital last night and Changi General Hospital told me that their price for Epoetin-beta 4000 IU had been reduced in June 2011. So, Ms Lim may be referring to earlier prices and the earlier more expensive prices were because the hospital was purchasing the drugs on their own as the quantities were small and now they have joined the GPO scheme and, therefore, the prices have come down.

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Mr Desmond Lee asked whether patients could fill their prescriptions at subsidised prices outside of the public institutions. Today, subsidised patients can obtain their medication at subsidised prices from the public institutions where they are being treated. A stable subsidised patient who just needs to fill his prescription without visiting the specialist may take advantage of the home delivery service introduced by our institutions. My Ministry will be reviewing alternative, more convenient options for our subsidised patients to fill their prescriptions of commonly available drugs easier, nearer their homes.

Let me now turn to MediShield. As an insurance scheme, MediShield works on the basis of risk-pooling and helps patients pay for their hospital bills, providing peace of mind for many Singaporeans. Several Members have called for better coverage and benefits for MediShield. We agree and, indeed, we are reviewing the scheme. But additional coverage and benefits will need to be supported by higher premiums paid by policyholders. Hence, we need to weigh the costs and benefits very carefully.

One area is the coverage for congenital and neonatal conditions mentioned by many Members. Today, conditions, such as hole in the heart and cleft palate, and medical treatment for newborns, such as jaundice or infection, are not covered under MediShield in order to keep the present premiums low. But parents have given feedback that this is an area of worry for them and Members have also surfaced the issue.

By covering congenital and neonatal conditions under MediShield, we would be able to reduce parents' financial burden and give them greater peace of mind. But doing so will also impact the MediShield premiums they would have to pay for their children at the younger ages. We hope to avoid the situation where some parents who expect their children to be well, to be healthy, choose to opt out of the scheme and apply for insurance coverage for them only later to avoid the higher charges during the earlier ages. This could undermine the scheme over time. I also note Dr Janil's suggestion to extend MediShield coverage only to some congenital conditions, but not all, which we will study further with medical experts and actuaries.

I am encouraged to hear the support from Members in this House for the extension of MediShield coverage to congenital conditions. We will be consulting the public shortly on this, and hope to receive strong public support for this pro-family measure.

We will also explore if there is strong public support for MediShield to cover inpatient psychiatric treatment. Such an extension will be in line with our efforts to enhance the affordability of mental health treatment. Finally, we are also reviewing the policy year limit and lifetime claim limit, to help the small number of Singaporeans who exceed these limits today.

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As part of the MediShield changes, we will have to update our premiums in line with the claims experiences to keep the scheme solvent. As MediShield premiums are set to be sustainable for a five-year period and the last increase was in 2008, we are due for the next update soon. The premiums need to be adequate to sustain MediShield members' claims and to fund future liabilities under the scheme. On the whole, MediShield has paid out 21% more in claims each year between 2008 and 2011, which benefits policyholders, while the premiums collected grew by only 10% per annum.

Based on our preliminary estimates, to keep MediShield sustainable and support the extension in benefits, a 45-year-old may see a premium increase of $7 per month, with the younger age groups seeing a smaller increase. On the other hand, an older policyholder at 75 could see an increase of $20 per month because of the higher risk profile. To offset these increases, Deputy Prime Minister Tharman has announced a one-time Medisave top-up of up to $400, or $33 per month, for all Singaporean policyholders, to help cushion the impact of the premium adjustment. We are still doing consultation and we are still finalising the premium numbers, so these numbers are just estimates at the moment.

In addition, most older policyholders who are beyond the re-employment age of 65 will receive direct and long-term assistance via Medisave top-ups under the GST Voucher scheme, of up to $450 a year or $37.50 per month which can offset the premium increases in full. Those aged 50 to 60 will also see a higher contribution to their Medisave accounts due to the higher CPF contribution rates which we have just announced.

Mr Gerald Giam asked if some of the MediShield reserves can help to offset these premium increases. Sir, these reserves are crucial in ensuring the long-term sustainability and viability of the MediShield Fund. Their main purpose is to provide an adequate capital buffer in accordance with MAS guidelines, and to fund other liabilities, such as future treatment costs and premium rebates for policyholders when they age. I will talk about the premium rebates shortly. Ultimately, MediShield operates on a not-for-profit basis, with premiums actuarially are calculated to cover expected payouts and meet the MAS risk and reserve requirements. The reserves ensure that MediShield will be able to honour policyholders' future claims. We have instead addressed potential affordability concerns through targeted Medisave top-ups.

Several Members highlighted the challenges faced by the elderly and vulnerable in particular in paying for their healthcare expenses. We have paid special attention to ensuring that the elderly can afford healthcare services. First, to strengthen protection for the elderly, we will be extending MediShield coverage from 85 to 90, given the longer life expectancy today. This will ensure that Singaporeans will be covered by MediShield for most, if not all, of their lives.

Some Members have asked whether we can extend beyond 90 and maybe provide lifetime coverage. Sir, it is something that is very attractive, but we must be very cautious about doing so, as there is really limited risk-pooling at ages far beyond the life expectancy, which currently stands at 82. Although Assoc Prof Fatimah Lateef mentioned that she had met quite a number of elderly above 90 in her clinics, the total number in Singapore remains rather small. With the small number of people with a higher risk profile, the premiums can be very expensive and they may become unaffordable for some and they will drop out of the scheme. Nonetheless, we will study how we can help those above 90 in other ways.

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Mr Gerald Giam asked if MediShield premiums can be increased for working adults to offset the increases for the elderly. I hope I understand what he meant. I presume that he is talking about this: as a person when you are younger, you accumulate more, you pay more and when you get older you pay less. In fact, MediShield was designed to have an element of this, where policyholders "pre-pay" a bit more when they are young, and this amount is then held within the MediShield Fund to support premium rebates in their old-age. This is the premium rebate that I talked about earlier. This forms part of the reserves. By paying more today, younger policyholders will pay less in premiums when they are no longer working, when they are older.

If Mr Giam is suggesting that we ask the younger generation to support the older generation, I think that could be problematic. Increasing premiums for the younger generation to cross-subsidise claims by the elderly, if this is what Mr Giam is suggesting, may not be viable in the long term. With an ageing population, each young policyholder will face increasingly higher premiums in order to support the growing number of elderly policyholders. This may not be acceptable to the younger generation and the younger people may choose to opt out, affecting not only the older generation but also their own insurance. With the GST Voucher for Medisave and the one-off top up just announced in this Budget, the Government is stepping in in a big way to help older Singaporeans afford healthcare costs, without adversely affecting the younger ones.

Through the MediShield review, we hope to address the needs of a few vulnerable groups, be it the elderly, those with congenital conditions, or those who require inpatient psychiatric care.

12.00 pm

Let me now turn to the low income, which is another vulnerable group in our population. Mr Gan Thiam Poh suggested that we extend free MediShield coverage to them. I am not sure that is the best approach. Low-wage workers, who qualify for the Workfare Income Supplement Scheme (WIS), can get an average of $1,000 in payouts, which is paid partly in cash and partly into their CPF accounts, including Medisave. The total of the WIS payout into Medisave and the worker's own Medisave contribution from his salary, is more than sufficient to pay for the MediShield premiums for himself, his non-working spouse and two children. For a 51-year old earning $1,500 per month, he would have a total Medisave contribution of $1,700 per year, compared to the total premiums of $516 for his whole family. This approach encourages self-sufficiency while supporting their basic healthcare needs, including premium payments for MediShield.

For those who are really in the low-income group, those who really cannot afford, or those who are on public assistance, we will look for other means to help them including Medifund. With the various support measures through Medisave, we have achieved 92% MediShield coverage of the population, surpassing the target of 90% that we set in 2008. We will continue to reach out to as many Singaporeans as possible. However, there will always be some who opt out of MediShield because of various reasons and some of which are valid reasons, sensible reasons. For example, some of them may have other benefits, other medical benefits provided by their employers, therefore they see no need to continue to be in MediShield. Some of them may have applied and purchased their own medical insurance as well.

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Dr Chia Shi-Lu asked the Government to liberalise the use of Medisave, especially for more outpatient treatments, while Assoc Prof Fatimah Lateef asked to raise the Medisave $400 limit to $500. Both Medisave and MediShield are primarily designed to assist with larger healthcare bills, for inpatient care and selected expensive outpatient treatments such as chemotherapy. We recently raised the annual Medisave withdrawal limit for chronic diseases to $400. We must be mindful not to deplete Singaporeans' Medisave balances prematurely and affect their ability to meet their post-retirement needs.

It is also important for the elderly to maintain sufficient balance in their Medisave to pay for their MediShield premiums, and stay insured for as long as possible. Hence, while we understand Ms Tin Pei Ling's concern that some elderly prefer to use their own Medisave monies first before asking for financial assistance, we must maintain safeguards on Medisave usage to prevent exhausting the Medisave. I would prefer to see how we can help them directly through Medifund or other ways. But on a case-by-case basis, if there are specific cases, like the one that Ms Tin has come across, I would invite her to write to me. I will take a look, on a case-by-case basis.

As Singaporeans build up more Medisave balances, we can study how Medisave can be gradually extended to cover other healthcare expenses. For those who still face difficulties with their healthcare bills despite Medisave, MediShield and subsidies, Medifund will be available for them. Deputy Prime Minister Tharman announced a $600 million top-up to Medifund which will increase the total annual quantum of grants available from $80 million to about $100 million. This will allow us to help more needy Singaporeans, including the middle income, with larger bills.

One such patient whom we helped was a middle-aged mother of one with leukaemia. She eventually needed a bone marrow transplant last year, and accumulated more than $130,000 in hospital bills over two years as she also developed complications. Post-transplant, she had to take a powerful and costly cocktail of immune-suppressants to avoid rejection of the donated bone marrow. Insurance and Medisave covered $100,000 for the inpatient bills, and the patient received $13,000 in Medifund assistance to help with the remaining bill. This is despite the husband earning above the median income. We do so because of the large expenses she encounters. To date, the patient has received further Medifund assistance of more than $10,000 for her outpatient treatment.

Sir, Mr Sam Tan spoke about how patients need to be better educated so that they make good decisions – both in terms of the treatment outcomes and finances. I agree that we need to find ways to better empower patients to make informed decisions concerning their care. Ministry of Health will work with the community to step up our public education efforts and improve Singaporeans' financial literacy about healthcare.

Mr Sam Tan asked whether we can reintroduce fee guidelines and improve financial counselling for patients. Sir, we agree that greater transparency on fees is essential. This empowers patients and allows market forces to work more efficiently. MOH currently requires clinics to display their charges, and also provide bill size comparisons on the MOH website. All hospitals are required to provide financial counselling upfront to help patients estimate their bills.

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We are exploring how we can do more, through various means. One possibility is to publish more information on the professional fees that our public sector doctors have charged for their services. Another possibility is to require hospitals to give their patients a comparison of their estimated charges against the published fees in the MOH website, as part of the financial counselling process. We are studying the various options.

Even as we expand the healthcare safety net for Singaporeans to bring about a more affordable and equitable healthcare system, it is important not to lose sight of the fundamentals that will keep healthcare affordable in a sustainable way over the long term, and yet produce good outcomes in terms of accessibility and quality of care. Mrs Lina Chiam suggested cost benchmarking to compare ourselves with other countries. We will study the suggestion but we must be aware that there are difficulties and limitations as different countries will have vastly different structure and costs and, hence, we have to be very careful when comparing costs across countries.

Mr Sam Tan rightly stressed that it is not how much healthcare spending is raised, but how it is spent. Dr Teo Ho Pin urged the Government to manage overall healthcare costs for Singaporeans more efficiently. Mr Gerald Giam also asked us how we intend to be more efficient and better optimise our existing manpower resources. Underlying all these questions is this – how do we make sure that we make the best use of the resources that we have, and that whatever we spend now is sustainable in the long term?

A key driver for the increase in healthcare costs is improvements in medical care – technology, new and improved drugs, better treatments, breakthroughs in surgical techniques – that improve quality of life and extend life. This is good for patients and their families. However, as a society, we cannot afford to support and subsidise all new treatments "at all costs". New does not necessarily mean better. We need to consider what appropriate and cost-effective treatment is.

As a system, we need to do our best to bend the cost curve – to reduce inefficiencies and discourage over-consumption. Let me share two key fundamental principles that will serve us well. First, we must always strive to innovate, increase productivity and develop new and more cost-effective models of care. Wherever we can, do more with less. One of the ways we achieve this is through technology. Take tele-ophthalmology, for example, which allows ophthalmologists, located in the hospitals, to "look into" the eyes and the retina of patients in the polyclinics. The optometrists in the polyclinic prepare the images which are transmitted to the hospital ophthalmologists for assessment. Those with minor conditions such as dry eyes can receive the medication that they need at the polyclinic, and only those with more serious conditions will need to be referred to the eye specialist clinic for further assessment. This brings care to the community level, and cuts down unnecessary visits to specialists, saving costs for patients and freeing up resources of the hospitals.

To improve efficiency and productivity in our healthcare system, we will set aside $20 million for a fund called Healthcare Productivity in Acute Services Scheme (Health-PASS). The hospitals can make use of this fund to pilot and implement projects that improve productivity and efficiency. A similar scheme will be introduced in the ILTC sector.

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Co-payment by patients is another fundamental principle to prevent unnecessary over-consumption of healthcare services which will drive up costs. Through co-payment, the patient shares part of the responsibility of spending his healthcare dollar smartly. He is more likely to weigh the treatment options or choices of drugs and choose a more cost-effective option. It will also ensure that healthcare providers are more cautious in prescribing treatment to ensure patients can afford the co-payment. We want to avoid the pitfall of countries where healthcare is virtually free, resulting in an insatiable demand from patients for healthcare services, runaway healthcare spending and an increased fiscal burden that is eventually borne by all taxpayers.

Sir, I have shared with Members the key strategies of Healthcare 2020. How we will build capacity to improve access, how we will introduce new models of care to improve the quality and outcome of healthcare services, and how we will enhance our financing framework to keep healthcare affordable for all. Singaporeans, not just for the low income but also the middle income families, will be able to afford healthcare.

Ultimately, for Healthcare 2020 to succeed, we need to move upstream to help Singaporeans stay healthy and prevent illnesses from setting in or progressing. To do so, we must re-emphasise personal responsibility for health and well-being: to lead a healthy lifestyle, get screened, and comply with medical treatment. We must continue with public education to help Singaporeans make informed choices and spend their healthcare dollars smartly. With the Government enhancing the healthcare system and each Singaporean taking personal responsibility, I am confident that Singapore will continue to have a good healthcare system into the future. Healthcare 2020 will ensure that Singaporeans always have access to good quality and affordable healthcare. After all, this is integral to an inclusive society.

The Chairman: Dr Chia Shi-Lu, please take your two cuts together.

Inclusive Environment for Seniors

Dr Chia Shi-Lu: Mr Chairman, Singapore's population will age rapidly over the next two decades, a result of startling gains in longevity coupled with declining childbirths. We have here all seen the statistics and we all recognise that it is imperative that we plan for our ageing population today and start putting in place the infrastructure, services and programmes to support the needs of the growing number of elderly.

The Ministerial Committee on Ageing (MCA) was formed to coordinate a national strategy on managing an ageing population and so I would like to take this opportunity to ask for an update of the strategies and priorities being considered, and to what extent they will be supported by the Budget.

The preference of seniors is to age in place, in the environment and community that they are familiar with, and not in nursing homes, where they can remain close to their friends and families. And while I applaud MOH's announced efforts to promote community-based services and ageing-in-place initiatives for seniors, I would like to seek clarifications about the plans to build an inclusive and responsive environment for the elderly, both in terms of the physical infrastructure as well as social outreach programmes, bearing in mind that many of our seniors may be both physically and/or socially isolated.

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Recent incidents in Toh Yi estate, where two groups of residents opposed where a block of 130 studio apartments for elderly residents was supposed to be sited, and also in Woodlands, where residents protested against the building of an elder day-care centre at their void decks, highlight the difficulties that planners are going to face as we try to integrate facilities for the elderly into highly built-up and, in particular, more mature estates. I would like to ask if the Ministry and MCA have any strategies in place to counter these problems.

To provide more choices for the elderly, I would like to propose another option for MOH and MCA to consider and that is to build retirement villages. In land-scarce Singapore, we can have elder-friendly condominiums with comprehensive onsite medical services, with round-the-clock emergency response systems, recreational and sports facilities and services which provide transport to and from the nearest bus stops and MRT stations or even to hospitals.

12.15 pm

Retirement villages provide an attractive combination of elder-friendly housing, professional management, and care and community engagement services. This will allow more seniors to live on their own. These seniors may not have children, or if they have, these children may be living overseas, or they simply may not want to depend on their children. Retirement villages will offer them a safe and secure environment in which to spend their golden years. A village can offer different wards to cater to different budgets as well. There are already many such retirement villages in both Europe and the US. I hope this is an option that MCA and the Ministry will consider.

Finally, I would like to just put on record my gentle objection to the term "Silver Tsunami" because I feel that the connotation here may not be entirely complimentary to our seniors − comparing them to a natural disaster. I think that we should rather be celebrating and cherishing our "Super Seniors" or "Supreme Silvers" instead. The point is this, a key part of building inclusivity is encouraging and demanding respect, and we would do well as a society to strenuously reject any moral panic of ageing and the aged.

Enhancing Quality of Eldercare

Let me now move on to my second cut which is on enhancing the quality of eldercare. Mr Chairman, while many measures have been announced to ramp up the capacity of elder care, I request that the Ministry of Health and the Ministerial Committee on Ageing (MCA) also provide us with an update on how they are addressing the quality of elderly care services, beyond just infrastructure and capacity improvements alone.

The first point I wish to raise is that the quality of healthcare, as many have already pointed out, is highly dependent on the quality of the healthcare workers. The Ministry 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 about 8,000 and 10,000 and under home social care, from 2,000 to 7,500. I would also like to ask how MOH intends to achieve the target recruitment numbers. What are the plans to attract, train, motivate and retain these personnel? Will there be a cap on the number of foreigners?

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I appreciate the Minister sharing with us the emphasis on productivity initiatives. But I would submit to this House and the Ministry that based on the complexion of healthcare delivery and the unique demands of quality patient care, standards or typical discussions on estimates on productivity can be quite difficult.

Currently, many of our elderly care services are already running at full capacity and face manpower shortages. We have been quite reliant on foreign manpower as not many Singaporeans are attracted to this sector because the pay may not be very high and the conditions are also quite challenging.

How do we plan to maintain the quality of services under these trying conditions and also prevent cases of abuse? According to reports, since June last year, MOH had received nine complaints of abuse in the nursing homes. MOH has taken firm steps to address this, but I wish to ask how MOH plans to continue to ensure that homes comply with the guidelines on handling patients and safeguard against abuse and lapse of care.

My second and final point is this: a critical facet of quality care is a genuine and steadfast respect for the rights of the person being cared for. I hope that MOH and MCA will ensure that in all their deliberations, with all their best intentions, the right of the individual to decide on his care arrangements, including end-of-life issues, will be safeguarded at all costs.

Mental Health

Dr Lam Pin Min: Mr Chairman, Sir, with the impending "Silver Tsunami", or "Silver Supremacy" as Dr Chia prefers to call it, more people are living longer, the incidence of age-related degenerative disease of the brain such as Alzheimer and senile dementia is expected to rise. Other mental illnesses such as schizophrenia, depression and addiction are also on the rise.

Unfortunately, the stigma attached to mental illnesses is still very apparent and people tend to shun mental patients due to the lack of knowledge and understanding of mental conditions. In addition, globalisation and the pursuit of economic success have also resulted in tremendous mental stress amongst many Singaporeans. Will the Ministry update the House on the progress of the National Mental Health blueprint and the workplace health promotion programme? What is the Ministry doing to educate the public on mental health and mental diseases so as to help de-stigmatise the problem?

Mental Illness

Mr Low Thia Khiang (Aljunied): Mr Chairman, Sir, mental illness is a condition that not only affects the individual or the public but also the community. I believe that mental illness will increasingly become an issue for Singapore in our highly competitive environment. Because of the strong stigma against mental illness, it may be difficult to observe the actual prevalence of mental illness in Singapore. The Government should conduct a study to get a better understanding. We need to look at how we can manage mental illness in the community, for example, what support is needed for the patient and their family and how to ensure that those with mental illness will not become a problem and affect life in the community, such as throwing things out of the windows, shouting at neighbours and having unacceptable social behaviour.

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The treatment of most mental illness often requires counselling, social intervention as well as medication. As such, there is a need for an integrated and holistic approach between the social service sector and the medical sector. However, at the moment, MOH and MCYS which provide different services to patients with mental illness operate separately. Can the services be centralised so that we have a one-stop service to provide better integrated care for the patients?

In developed countries like Australia, US and UK, they have 10 to 15 psychiatrists per 100,000 in the population. I understand that there are less than 200 registered psychiatrists in Singapore with a population of five million people. We would certainly need to increase the number of our mental healthcare professionals. Importing foreign doctors in this area is not a solution. They will not be able to function well if they cannot speak the language or understand our culture. I would like to know what MOH can do to increase the number of our mental health professionals.

Mental Health and Suicides

Mrs Lina Chiam (Non-Constituency Member): Sir, the recent Singapore Mental Health Study revealed that more than one in 10 people in Singapore will be stricken by mental illness in their lifetime. The top three mental disorders have a grave impact on families and caregivers – depression, obsessive compulsive disorder (OCD), and alcohol related disorders. Most sufferers do not seek help and, hence, their ailment goes undetected.

Our youths are particularly vulnerable to suicide, given the enormous stress they now face during their schooling years and after. Mental illness strikes most people when they are in their 20s.

In a reply in Parliament, Dr Ng Eng Hen revealed that suicide rates for residents aged between 10 and 24 increased from 5.8 youth suicides per 100,000 residents in 2004, to 6.1 in 2005, and reached a high of 6.7 in 2007. In 2010, the figure increased to 7.85. Elderly and the sick are another group that is susceptible. The next step after the study should be a systematic review of the problems that it unearthed, so that appropriate help may be given to make a real improvement in the overall mental health of Singaporeans.

Public education on mental illness must be stepped up, to remove the social stigma associated with it, and to alert vulnerable persons as to how they can seek help. Recovered psychiatric patients and their families would benefit greatly from a similar project like the Yellow Ribbon.

The media should be careful not to sensationalise suicide cases, as that may risk a copy-cat syndrome, but instead highlight suicide prevention and successful stories of people who have overcome such tendencies. Counsellors are very much needed in every strata of society, whether in schools or the workplaces or at the grassroots level.

The Chairman: Mrs Chiam, please finish your speech.

Mrs Lina Chiam: Okay. Perhaps Medisave could be adjusted for it to be used to pay for counselling services, which will be effective in reducing suicide rates. It could also be made compulsory for people who have attempted suicide or have expressed serious suicide intentions. Right now, Medisave can only be used for major depression, like schizophrenia and bipolar disorder. In closing, may I ask the Minister how he intends to act on the findings of the Singapore Mental Health Study?

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Mental Healthcare

Ms Tin Pei Ling: Sir, I would like to urge MOH to do more to support those with mental health issues. The World Health Organization estimated that, globally, one in four people develop some form of mental illness at some stage in life. This is a significant statistical figure by any account. However, despite the prevalent of mental illness around the world, this category of illness continues to be plagued by stigma that prevents social acceptance and discourages those who need help to step forth and seek help.

Therefore, as I have mentioned in the Budget Speech debate last week, I hope more can be done to de-stigmatise mental illness, promote greater social acceptance, enhance accessibility and affordability to professional mental healthcare and to strengthen the community support framework. First, we should combat stigma in order to promote greater social acceptance and self-acceptance as well as encourage treatment. In fact, I hesitate to use the label "mental illness" and would much prefer the use of the phrase "mental health conditions" or "mental health issues". But for the purpose of simplicity and familiarity, I would use the former phrase for now.

Studies have shown how information and understanding of various mental illnesses reduce stigma. Studies have also shown how the media plays a critical role in propagating and reinforcing negative stereotypes of mental illnesses. Therefore, would the Ministry share what are the ongoing efforts to address this issue of stigma and social acceptance? And would the Ministry consider: (i) working with the mass media to provide a more objective and balanced coverage of mental illnesses by avoiding linking crimes of bad behaviours through mental illness, and instead highlighting and celebrating inspiring models such as successful individuals who have overcome their mental conditions as well as showcasing great works by famous persons who have been known to have mental illnesses, for example, Sylvia Plath, Van Gogh, Beethoven, Abraham Lincoln and John Nash; (ii) organising a national campaign to promote deeper understanding of a range of mental illnesses, from depression to eating disorders to sleep disorders, to generalised anxiety disorders, to personality disorders to OCDs to bipolar to psychosis, and re-image mental illness as being no different than any other illnesses that any person could have at any point in time.

Second, we should strengthen community care and support framework. A recent study done by a group of Ngee Ann Polytechnic students showed that when one suspects oneself to have mental illness, one would most likely turn to friends, relatives, family doctors or even the polyclinics for help and these are very much part of the community setting. Therefore, I hope the Ministry will consider making mental healthcare in the community more accessible, establishing a more structured mechanism to enable referrals and working with the community groups and organisations in identifying people with such vulnerabilities or exhibiting mental illness symptoms.

Some sufferers may exhibit certain anti-social behaviours, but they are not violent which is typically the lever which the Police uses to intervene. However, some of them fear of making their conditions known. Others do not even have an insight into their condition and, therefore, refuse treatment. Some of them may not even have family members or even when they have family members, they are unfortunately uncontactable. In such instances, would the Ministry consider new levers or measures to help them help themselves? Would the Ministry also share how mental healthcare will be decentralised to increase accessibility to professional mental healthcare, and how monitoring and follow-ups are done with patients with mental illnesses who are discharged back into the community, and whether there is a support system in place to help these patients adhere to their care plans?

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Third, we should increase manpower by tapping on the local talent pool because having sufficient manpower is vital in supporting mental healthcare. On this point, I am heartened that MOH is already looking into increasing the overall intake of healthcare professionals. Therefore, would the Ministry share what is being undertaken to expand the intake of mental healthcare professionals?

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Every year, NUS, for instance, as I was told, has over 200 students majoring in Psychology. Many are interested in pursuing clinical psychology but had to give up because of high entry barriers involving enormous time and financial investments in pursuing a post-graduate qualification needed to practise mental healthcare. Therefore, in addition to attracting overseas trained Singaporeans back to Singapore to serve in the mental healthcare landscape, would the Ministry also consider: (i) expanding the number or capacity of accredited clinical programmes in Singapore; (ii) providing more financial sponsorship for aspiring young Singaporeans; (iii) ensuring better opportunities in career development for Allied Mental Healthcare professional; and (iv) enhancing the affordability of mental healthcare.

We emphasise a lot on the 3M framework in Singapore. However, mental health patients face particular challenges. Many of them, because of their conditions which are often chronic, are not employable or find it hard to stay in their jobs. The majority of those with mental illness occur by the age of 29 years old − this is according to a local study on mental illness − implying a relatively short, full and active employment period. Hence, their Medisave is limited. Is the coverage of MediShield for such categories of illness? And Medifund would likely be their only eventual helpline. However, patients from the middle income group may not even qualify for Medifund. Hence, could MOH share what kind of financial assistance could they look forward to considering that for some of these patients with mental illness, especially the more severe form of mental illness such as psychosis, eventually when they aged, their caregivers would have passed on, or if not, be so aged and elderly that they are not able to care adequately for them?

One model that we could consider is the state of Illinois. The state made it mandatory for insurers to include mental illness in the group insurances that employers provide for employees. Would the Ministry consider something similar to cover Singaporeans with mental illnesses but perhaps with higher deductibles? I understand from the earlier speech by the Minister that there is already such an expansion for inpatient psychiatric treatment but more could be done in this area.

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In conclusion, there is no place for stigma of the mentally ill in a truly inclusive society. We should do what we can to combat stigma and care for everyone. With timely and proper interventions, mental illnesses can be managed effectively and we can help those with mental conditions to become employable, take care of themselves, rely on themselves and enjoy a better quality of life.

Mr Gan Kim Yong: Sir, Dr Chia Shi-Lu and several Members asked about the strategies to respond to an ageing population. Let me share the Ministerial Committee on Ageing's (MCA) strategies and put in context the various new initiatives that have been announced recently. Our population will age rapidly over the next 20 years. By 2030, the population of seniors above 65 years old will nearly triple to reach over 900,000. How many is 900,000? It is enough to fill nine Toa Payoh towns today. By then, one in five residents will be over 65 years old, compared to fewer than one in 10 today.

Fortunately, the majority of our seniors are expected to remain healthy and functional. However, as rapid ageing sets in, the needs of aged care will increase in tandem. By 2030, 117,000 seniors may be semi or non-ambulant, more than double the number today. We must prepare for this rapid ageing well ahead of time. A key focus of the MCA is ageing-in-place. Our survey shows that our seniors prefer to age in place gracefully and with dignity, within a closely knit community. We aim to achieve this in two ways. First, to build an inclusive environment, and, second, to provide good aged care.

Let me start with Inclusive Environment. We need to make our city "age-friendly" so that our seniors can move around safely and confidently within their homes and also within the community. The Minister for National Development has earlier announced the Enhancement for Active Seniors programme (EASE) to make our HDB flats safer for seniors. In Marine Parade, we are also working with LTA and the town council under the City For All Ages project to improve the environment within the town, so that seniors can move round easily and safely.

In tandem, the MCA will continue to promote active ageing so that seniors can keep their minds active and their bodies healthy, and enjoy their golden years to the fullest. We will promote not just health screening but also follow-up post screening, to minimise the risk of downstream health complications for seniors. We will also promote senior volunteerism and lifelong learning.

We are already achieving some success. The Wellness Programme, which started four years ago, has spread to 42 constituencies touching some 150,000 residents aged 50 years old and above. Two weekends ago, I attended Hougang Wellness Family Day. The seniors had a great time and so did I. Going forward, we want to implement the Wellness Programme work countrywide to all constituencies and eventually reach out to one out of two seniors above 50 years old. Senior Minister of State Heng Chee How will elaborate on our active ageing initiatives during MCYS's COS Debate.

The MCA will also pay special attention to the group of seniors living alone, which is growing. For these elderly, it is all the more important for them to get involved in community activities, build a close network of friends and neighbours, and avoid the problems of isolation or depression. MCYS has decided to expand the Seniors Activity Centres (SACs) to serve seniors beyond those living in rental flats. It will resource the SACs to serve up to 48,000 seniors across different housing types by 2020, a significant increase from the 18,000 seniors served today.

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We have also sought to integrate eldercare services with housing developments. Studio apartments, such as the Golden Jasmine in Bishan, come with eldercare centres at the ground floor that provide social and healthcare services to the residents residing within the block and in the vicinity. I also encourage the private developers to develop the kind of retirement housing that Dr Chia Shi-Lu mentioned. This is a specific area of silver industry that we should promote and I welcome more ideas from Ms Tin Pei Ling and others on what more we can do. Let me now move on to the second area of MCA's focus, that is, to enhance aged care in terms of better accessibility, affordability and quality.

First, we need to ramp up aged care services and facilities significantly to improve access. We have to start now because it takes several years to build the infrastructure and train the manpower. By 2020, we will increase the number of nursing home beds by some 70%, from 9,000 today to 15,600 to meet the needs of severely dependent seniors whose families are unable to care for them at home, as well as those with no family support at all.

We will also develop a range of home- and community-based aged care services to support families in caring for their loved ones at home. We will more than double the capacity of home-based healthcare services from 4,000 patients today to up to 10,000 patients, and more than triple the capacity of home-based social care from 2,000 today to up to 7,500. We will triple the number of day social and rehabilitative care places from 2,100 to about 6,200.

The $120 grant per month for families to hire a foreign domestic helper will help them to care for elderly family members who are unable to care for themselves. Coupled with the expansion of the various centre-based and home-based services, we hope to keep as many seniors ageing-in-place as possible. We will also step up caregiving training so that they are adequately equipped. Mdm Halimah Yacob will elaborate on home-and community-based care as well as caregiver support during MCYS' COS Debate.

We recognise the constraints of voluntary organisations in keeping up with the pace and scale of our expansion. The Government is prepared to take the lead in the hardware development of aged care facilities by bearing the full capital cost of these facilities under a Build-Own-Lease (BOL) model. This will reduce the financial burden on VWOs who wish to expand their aged care services.

In addition to VWOs, we will also be opening up the provision of subsidised nursing home services to private operators, through the use of portable subsidies or inviting the private operator to tender to operate BOL projects. Today, some 700 beds in private nursing homes are occupied by subsidised patients under the portable subsidy scheme.

Second, we will make aged care affordable. We have just announced comprehensive enhancements to the subsidy framework for aged care, which will mean a 30% increase of subsidies amounting to some $250 million this year. Middle income families will now also benefit from Government subsidies for these services, while the lower income will enjoy even higher subsidies. This will ease the financial burden of long-term care for about 30% more patients, or a total of about 40,000 patients.

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Third, we want to enhance the quality of aged care, which Dr Chia Shi-Lu had asked about. Our seniors today had contributed significantly to Singapore's progress and we should care for them well when they age and become frail. We will coordinate and integrate services more effectively so that our seniors can be cared for better. For instance, we will build Integrated Day Facilities in the community which would be "one-stop" facilities providing both health and social care for seniors during the day. I would also like to assure Mr Chen Show Mao that the Agency for Integrated Care (AIC), which focuses on healthcare integration and the Centre for Enabled Living (CEL) which focuses on social care, work very closely together to provide client-centric help to seniors and their caregivers. We will continue to evolve the Government's programmes and organisation structures to facilitate even better coordination for better care of our seniors.

The quality of care in our aged care facilities must also improve. In my visits to the various aged care facilities, I was impressed by the dedication and innovation in this service industry. I have seen how the Wii is used in some day care centres and nursing homes that I have visited, and it has certainly energised and entertained the seniors there! You may find that some of the seniors are very tense in the picture [ a slide was shown to hon Members ]. That is because they take the Wii game very seriously.

But unfortunately, there are also instances of neglect and abuse at the other end of the spectrum as mentioned by Dr Chia Shi-Lu and Mr Patrick Tay. While these are few and far between, when it comes to safe care, we should adopt a zero tolerance policy. One case of abuse is one case too many.

The quality of care is a joint responsibility – the Government must have a robust regulatory and quality framework in place for aged care, while service providers must constantly improve care delivery and put in place a robust framework within their institution to ensure that care professionals uphold the standard of care required. Seniors and their caregivers can also participate by being discerning in choosing aged care providers and providing timely feedback on services. The MCA intends to work with service providers and the public to enhance care standards in a number of ways.

First, reviewing and setting standards. In the MCA's recent dialogue with stakeholders in the aged care sector, there were suggestions that we should have a clearer definition of what constitutes a good standard of care for the sector, and I agree. It is timely now to review existing standards and guidelines for aged care services. My Ministry will involve representatives from the public, as well as providers and clinicians, in doing so, so that there is a strong sense of ownership of these standards. We will start with the nursing homes.

Second, we want to give seniors and caregivers new avenues to provide feedback on care. MOH will set up a Visitors' Programme, where volunteers from across society will be invited to visit nursing homes, chat with patients and give providers suggestions on improvements. This is a voluntary scheme and it is also a useful tool for nursing homes to help identify areas they have done well and areas they can improve upon. To date, 41 nursing homes have signed up for this programme and we have recruited 48 volunteers.

Third, resourcing the aged care sector for better care. We have announced significant enhancements to subsidies for the aged care sector. At the same time, the Government is prepared to help aged care providers recruit staff, enhance the skills level of their workforce and improve processes to deliver better care. Minister of State Dr Amy Khor will elaborate on these manpower initiatives for the immediate and long-term care sector later on.

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The next few years will be challenging but exciting. We must gear up as a society, for the pace and magnitude of ageing that will come. Dr Lam Pin Min passionately argued that Singaporeans had to build a common understanding of what was needed to create an inclusive society where our people can age gracefully and with dignity. I agree with him wholeheartedly and also with Mr Hri Kumar that we need a national plan to address the issue of developing facilities for the elderly. As he has elegantly put it and I quote, "This issue is in everybody's backyard". Caring well for our seniors is a collective responsibility we all share. Many of the aged care facilities will have to be sited within the community for the convenience of the seniors. On our part, the Government will engage advisors, grassroots leaders and residents on our plans for facility development and to strike a careful balance between addressing the needs of the seniors and the needs of the residents in the vicinity. We need the support of grassroots organisations and Singaporeans themselves to make the community inclusive and welcoming for our seniors.

I also agree with Mr Laurence Lien that any national effort to address the issue of an ageing population cannot be a Government-driven one alone. It also has to be community driven. This is indeed what we are doing under the City for All Ages project, where we seek to share the needs of the local community with the local grassroots leaders and non-profit organisations, jointly develop solutions, and empower them to realise their ideas. In Marine Parade, for example, some 70 seniors participated in our town audit by walking around the estate at different times of the day and night, and they surfaced almost 300 suggestions on how the built environment could be improved to help seniors move around more safely and with greater confidence. The Town Council and LTA responded by fixing many of these hardware issues where practical. We also tapped on the many helping hands in Marine Parade. Senior volunteers helped us in conducting functional screening of seniors, aged 70 years old and above, in Marine Parade. The local Seniors Activity Centre, called "Goodlife"!, responded to the needs of vulnerable seniors by visiting those who said they were living alone, and I know that some of the local RC chairpersons personally keep in touch with these seniors living alone in some of the RC zones.

We intend to foster similar partnerships in Whampoa, Bedok and Taman Jurong. I am also heartened to see many ground-up efforts in other constituencies as well, such as the MacPherson CARE fund to help needy elderly residents in MacPherson cover medical costs, and the new MediWheels programme in Ang Mo Kio which will make it easier and cheaper for the frail elderly and disabled to move around the neighbourhood. In fact, I just launched the Nurses' Initiative for Community Engagement (NICE) in Hougang, some two weeks ago, where a group of 100 volunteer nurses commit their own time outside their working hours to visit seniors in the community to conduct health checks and give them advice. Sir, the momentum is rapidly building up and there is great energy on ground. Let me just say a few words in Mandarin.

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( In Mandarin ): [Please refer to Pg 2251 for Vernacular Speeches.] Just as we care for our own old folks, we should also care for other old folks. Our elderly are treasures who have contributed to our country. They are treasures for the family, the community and, even more so, for the country. We should not only respect them, but also cherish them and look after them, so that they can enjoy a warm and comforting living environment, high quality of life and affordable healthcare services. This will enable them to lead an active lifestyle and continue to contribute to their families and to society.

( In English ): Sir, the MCA hopes to continue to work hand in hand with the aged care sector, grassroots organisations, and Singaporeans, to build an inclusive and caring society for our seniors. If we work together with a caring heart, we can turn the challenge of an ageing society into an opportunity to build an outstanding society. Together, we can make this happen.

The Minister of State for Health (Dr Amy Khor Lean Suan): Sir, Minister Gan spoke on the Ministerial Committee on Ageing's efforts to enhance aged care. Just as we have made a big push to significantly enhance the capacity and affordability of aged care, we need a big push on the manpower front too.

Assoc Prof Muhammad Faishal Ibrahim and Dr Chia Shi-Lu asked whether we have adequate manpower to care for our ageing population, and Dr Lam Pin Min spoke about enhancing the manpower and capability development in the intermediate and long-term care (ILTC) sector.

Like the acute sector, the ILTC sector needs to develop a strong base of qualified healthcare workers. Between now and 2020, we need 11,000 more staff across all levels, especially nurses, therapists, social workers and healthcare support workers, to augment the current 4,000-strong workforce. However, ILTC providers find it challenging to attract and retain good staff today, given their more limited resources and smaller scale. The Government will, therefore, support the ILTC sector to build up its capability and capacity in the following ways.

First, we will enhance the funding support to enable the sector to be better staffed. Since last year, the Ministry has provided additional funding to the funded VWO nursing homes to improve their staffing ratios. We will now extend this funding support to the community hospitals, so that they too can increase their staffing to manage more complex cases, ease the staff's workload, and set aside more training time for them. This initiative to enhance manpower staffing in the ILTC sector will cost the MOH up to $20 million in FY2012.

Apart from helping providers increase their in-house staffing, we will also increase the external pool of healthcare professionals that ILTC providers can tap on, to augment their base of professional staff. We are starting a new scheme to rotate experienced hospital nurses who have completed the Advanced Diploma in Gerontology, to ILTC institutions for six months. The nurses will get to apply their newly-gained knowledge in helping the institutions improve their services and processes. This scheme will kick off with 75 nurses from the next two batches of graduands of the Advanced Diploma course at Nanyang Polytechnic.

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Second, we must ensure that the sector can pay competitively. Healthcare professionals in the ILTC sector play an important role in caring for patients who need longer term rehabilitation and nursing care. But their salaries have traditionally lagged behind that of their peers in the acute hospitals, which makes it challenging for the sector to attract and retain good staff.

Going forward, the Government will set aside up to $12 million in FY2012, to enable the VWO ILTC sector to raise pay. We will take a phased approach to the implementation. In the first phase, we are looking at salary increases of between 10% and 25% for nurses and allied health professionals. Doctors will receive adjustments similar to their peers in the acute sector. The funding to support the pay increases will apply from April this year. This will boost institutions' ability to recruit and retain good professional healthcare staff.

The Ministry will look towards funding the next phase of salary increases, as the sector grows in terms of its capabilities and productivity. Separately, the Ministry and AIC will work closely with ILTC institutions to review the job scopes of healthcare support staff so as to make the work more challenging and meaningful, and to review their pay in tandem with the enhanced job scope.

We will also work closely with the sector to build its capabilities and boost productivity. Assoc Prof Muhammad Faishal Ibrahim asked about the potential to leverage on technology and innovation. We agree that there is room to further optimise manpower use and boost productivity. The Government will, therefore, invest up to $96 million over the next five years to work with ILTC providers on various productivity initiatives, such as bulk procurement, job and process redesign, and leveraging on IT. For example, AIC has embarked on a pilot to redesign processes and jobs in three nursing homes which are relocating to new premises, and will extend this effort to other ILTC institutions.

As part of this effort, AIC will set up a new $20 million Community Health Improvement and Productivity Scheme (CHIPS), to drive quality improvement and productivity in the sector. ILTC operators who have innovative ideas on how to improve work processes and harness technology to increase efficiency and raise quality of care, can seek funding to turn these ideas into real gains on the ground.

Lastly, we will step up our investment in professional development in this sector. Over the last five years, we have supported more than 350 ILTC staff for advanced skills training through the Health Manpower Development Programme-ILTC or HMDP-ILTC in short, which has been instrumental in helping ILTC staff advance their skills and deepen their expertise. One recipient of the HMDP-ILTC Fellowship is Ms Roselind Tan Cheng, a Staff Nurse at St Luke's Hospital. Formerly an architectural designer, she made a career switch to nursing almost eight years ago. Roselind finds nursing in the ILTC sector an immensely fulfilling vocation, and enjoys learning new ways of caring for her patients. Roselind has been awarded an HMDP-ILTC Fellowship to pursue an Advanced Diploma in Palliative nursing, which will enable her to provide better care for the palliative patients at St Luke's.

Through the HMDP-ILTC and new upgrading scholarships for milestone professional training, such as degree upgrading programmes, the Government will invest $11 million over the next five years in advanced skills training for locals working in the ILTC sector. The Government will also invest another close to $10 million over five years to support continuing training programmes in ILTC-specific areas, such as dementia and palliative care. Together, these efforts translate into an investment of more than $3,000 per local per year – to develop core skills in the sector and upgrade capabilities through advanced training, to raise the productivity of the entire sector. Altogether, the Ministry will set aside up to $32 million in FY2012 to support the ILTC sector in staffing and pay enhancements, and another $117 million over the next five years for productivity and skills upgrading. I would like to encourage our ILTC providers to tap on this additional Government support to invest in the development and long-term retention of their staff. We believe that with these initiatives, institutions can attract more and better staff with the skills, aptitude and compassion to care for our seniors.

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Smoking in Youths

Dr Janil Puthucheary: Mr Chairman, I am concerned that tobacco is a problem in Singapore that needs urgent and serious action. There is a disparity between the increasing evidence of the many harms of tobacco, and the fact that many youths are unaware of these harms, and that recent data show an increase in young smokers in Singapore, which is a very worrying trend. Smoking is dangerous at any age but the younger people start, the more likely they are to smoke for a longer period, and to die early as a result of this.

Sir, the fact that smoking kills is well known. What is alarming though is how many lives are at risk and can be saved with appropriate intervention. The Health Promotion Board (HPB) calculates that there are seven tobacco deaths daily in Singapore. Each day, seven people in Singapore die as a result of tobacco-related diseases. The World Health Organization estimates that about 10% of all tobacco deaths are those of non-smokers. A non-smoker is more likely to be killed by tobacco in Singapore than by a road accident.

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The 2003 SARS outbreak is often cited as a defining moment in our recent history. Its effects were felt for some time after and continue to influence our behaviour today. The SARS deaths were tragic and shook all of us deeply. However, in 2003, more non-smokers died from tobacco than from SARS. For children currently in Primary 6, three children per class will eventually be killed by tobacco-related diseases.

These figures suggest that measures put in place to address smoking amongst our youths may be inadequate. This is where we may need a fundamental re-think of how and what we want to do to address this social issue. Do we want to put forward a vision of Singapore as being a tobacco-free society and, if so, what can be done to achieve this? Tobacco contributes significantly to lost productivity and a reduction in productive years of employment. How much of our projected increase in productivity over the next 10 years might be achieved by the reduction in tobacco-related illness?

In a 2008 survey, nearly one in five youths in Singapore thought that smoking was not harmful. About 70% of those surveyed also said they could stop smoking anytime they wanted to. This is worrying as it shows that the sheer addictive properties of smoking and its destructive capabilities are under appreciated. Nicotine has serious, long lasting, deep-seated effects on the brain. Smoking biochemically re-wires our neural circuitry, resulting in profound addiction. Smokers do not exercise the choice that the marketing suggests they have. They are dependent on nicotine and need help to break their habit.

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Sir, recently, activists and members of the public have argued passionately against the selling of shark's fin because of concern of harm to sharks. This has resulted in some retailers no longer selling shark's fin. Perhaps, some retailers might like to consider saving some human lives and remove cigarettes from their shelves? Could we find ways to increase the awareness on the dangers of smoking and work with youth groups that have an interest in keeping the environment smoke-free to spread the message on the ills of smoking? Should we articulate a vision that we hope Singapore will eventually be a tobacco-free nation?

We need to consider significantly lowering the age at which we target the anti-smoking message at school children. The current approach is inadequate as evidenced by the rising number of young smokers and the falling age at which they first start smoking.

I would like to ask if MOH or HPB has plans to embark on a new campaign or other measures to create a further negative connotation of smokers among the youths and improve the understanding of the harms of tobacco, regardless of whether it is cigarette smoking or shisha smoking. Peer pressure is known to be a strong factor in compelling the initiation of smoking and it can also be used in the reverse. The HPB has been addressing this issue in different ways, including using youths to spread the anti-tobacco message. I would like to ask the Minister how are the successes of these different anti-smoking efforts and campaigns being measured. Are there plans to relook at the methods that are less effective? What new outreach and education plans are in store? And would the Minister consider examining anti-smoking efforts and initiatives with a view to drastically improving their effectiveness? Finally, would the Ministry consider articulating a vision of a tobacco-free future for Singapore?

Health Issues on Smoking and Trans Fat

Mr David Ong: Sir, the damage done by smoking on general health is established beyond doubt. We have done much to spread this message. Yet, despite our efforts in curbing smoking, the rate of smoking has increased from 12.6% in 2004 to 14% in 2010. Smoking amongst the young and women has also risen. What can the Health Ministry do to control and arrest this phenomenon?

On the issue of trans fat, health authorities worldwide are recommending the avoidance of trans fat. The consumption of trans fat increases the amount of "bad" cholesterol, thus increasing the chances of coronary heart disease. What are the efforts undertaken by the MOH and HPB in ensuring safe and healthy food in our national food supply? Can buyers and consumers make an informed choice through labelling of transfat on all our food items as well as at places where food is prepared and served? Would the Health Ministry consider banning trans fat in our food?

National Health Screening

Dr Teo Ho Pin (Bukit Panjang): Sir, there are three ways to reduce the healthcare costs of Singaporeans in Singapore. First, keep Singaporeans fit and healthy. Second, conduct health screenings to detect illnesses earlier. And, third, reduce treatment costs at clinics, hospitals and step-down care facilities.

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Sir, the Community Development Councils, Health Promotion Board and People's Association have been reaching out to Singaporeans to keep fit and stay healthy through regular exercises. Various physical activities, such as brisk walking, health qigong , dance feats, swimming and sports, have been promoted in the community. Through these joint efforts, we have seen an increase in the physical activities participation and fitness among Singaporeans, especially the seniors. Thus, I hope the Government will continue to provide funding support to spearhead healthy lifestyle activities.

Sir, private general practitioners (GPs) provide a good network to reach out to Singaporeans for health screening. Although we have been conducting health screenings in the community for many years, the outreach is limited and many old people have phobia going for health screenings. Therefore, I would like to propose a national health screening programme to be conducted by all GPs in Singapore.

Sir, GP clinics are easily accessible to Singaporeans. GPs are also better positioned to provide professional advice and encourage their patients to go for health screening. To further encourage health screening, the Ministry can consider sending health screening vouchers to targeted groups of Singaporeans, such as those holding the Community Health Assist pass.

Sir, I would like to urge the Ministry to consider engaging private GPs to conduct regular health screenings for chronic illnesses, such as diabetes, high blood, dementia and depression. To lower the costs of health screening, we should also allow GPs to send their patients to polyclinics for subsidised x-ray and laboratory tests or blood samples. With the support of GPs and health screening vouchers, I am confident that we will be able to reduce the healthcare costs of Singaporeans and our Government through early detection of illnesses.

Sir, I wish to ask the Ministry the following questions: one, can the Ministry consider implementing a national health screening programme for all Singaporeans? Two, can the Ministry engage the services of private GPs to implement the national health screening programme?

Genetic Testing

Dr Lam Pin Min: Mr Chairman, Sir, genetic testing is a sophisticated technique necessary to test for genetic disorders. Genetic tests are used for several reasons, including carrier screening of a particular inherited disease; pre-natal diagnostic testing; pre-symptomatic testing for the prediction of certain adult-onset diseases; and, screening and assessing the risk of developing certain adult-onset cancers.

Over the last 10 years, there is an increased demand for genetic screening and genome mapping with rising expectations, as well as affordability of such tests. While the physical risks associated with most genetic tests are very small, particularly for those tests that require only a blood sample or buccal smear, many of the risks associated with genetic testing involved the emotional, social and financial consequences of the tests results.

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The probability of genetic discrimination in employment and insurance is also a concern. Some individuals avoid genetic testing out of fear of being discriminated against by employers and insurance companies. In some countries, anti-discriminatory laws present essentially allows such testing to take place without fear of being discriminated against by employers and insurance companies. Will MOH look into the applications of cancer genetic testings and enact appropriate anti-discriminatory laws to protect the patients?

Outreach to Women

Ms Ellen Lee: Mr Chairman, TODAY published, on 29 February 2012, an article by Mr H Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice and author of Overdiagnosed: Making People Sick in the Pursuit of Health when he claims that "Early diagnosis is the sickness, that screening for diseases too often leads to overdiagnosis and overtreatment of those who are well."

He said that "the basic strategy behind early diagnosis is to encourage the well to get examined to determine if they are not, in fact, sick. But is looking hard for things to be wrong, a good way to promote health? The truth is, the fastest way to get heart disease, autism, glaucoma, diabetes, vascular problems, osteoporosis or cancer – is to be screened for it. In other words, the problem is overdiagnosis and overtreatment."

This seems to reflect the mentality of people who refuse to go for screening, which is not cheap. They cannot reconcile with the fact that they have to pay to be told that they are not well or could be dying, or if the screening turns out negative, they will think that they were fools to have wasted money to suffer the indignity of stripping and other discomforts only to confirm that there was nothing wrong with them. This is particularly true in the case of mammogram screening, where there are conflicting views whether it does help to detect breast cancer. The current state of mammography is just too painful for women to bear, even for those who have the highest threshold of pain.

How does the Ministry view this article which seems to throw a spanner in the works as I believe that the Ministry is already having an uphill task persuading women to go for screening for all types of cancer? I ran a heavily subsidised mammogram screening project with eight other organisations for the past two years. The efforts we have put in have also not yielded the desired outcome. Fewer than 20,000 women in the age group of 50 to 69 who had not done screening before or were not screened for three years responded to our roadshows and mailers. Of these, a few were tested positive and sought treatment.

The Ministry has launched the Integrated Screening Programme in 2008 to encourage and support screening for early detection and management of disease. How many women have responded positively to this programme? What were the rates of detection? Was there funding or subsidy for women who took part in this programme? Is the programme ongoing, and how could one enrol for it? If persuasion does not work, can the Ministry consider working out a scheme whereby women who reached 55 and have gone for certain screening would be allowed to buy medical insurance at half the premium payable?

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Healthcare for People with Special Needs

Ms Denise Phua Lay Peng (Moulmein-Kallang): Thank you, Sir. MediShield today still does not cover congenital and pre-existing conditions. In the face of escalating healthcare costs, it is very worrisome to live without healthcare insurance. This is very much so for families with children born with special needs or disabilities.

The situation is even worse in the case of Singaporean children born with more severe conditions, such as rare genetic conditions. I know of some families whose Medisave balances are wiped out.

Sir, we must rise above the response of "it's just too bad" or that "covering them would burden everyone else", "we will have to pay higher premiums for them". Should the decision to extend MediShield to those with congenital or pre-existing conditions be made through public consultation, as suggested by the Minister? Ask everyone to agree to pay higher premiums? Or should the incremental costs be covered by the MOH budget, just like the way we take care of the vulnerable and those more at risk in our country?

And even if we start off with at least the same MediShield coverage – ceiling that is enjoyed by typical Singaporeans – that would assure couples contemplating babies that whatever condition their newborns turn out to be, they still have access to basic healthcare insurance. I, therefore, urge the Ministry to instil a sense of urgency to ensure MediShield includes all Singaporeans, especially those born with special needs.

Lastly, on early detection. One of the critical success factors to improve prognosis of children with special needs is early detection and quality early intervention. Although screenings are now conducted during health checks, and especially when the kids are due for immunisation, outcomes have been mixed. Detection later in pre-school and formal schools is not systemic and dependent very much on the experience, workload and proactivity of the teaching staff. I, therefore, urge the MOH to improve the current system so that the children might have a better head-start and access to intervention earlier.

The Chairman: Assoc Prof Fatimah Lateef, please take both your cuts together.

Regulation of Traditional Medications

Assoc Prof Fatimah Lateef: Sir, there have been cases of adverse consequences following the intake of herbal, traditional and Chinese proprietary medications. These effects were serious and, in some, life threatening. Singapore does not possess a national pharmacopoeia or national herbal monograph. Currently, many herbal medications are regulated as over-the-counter drugs, and there are currently no registration requirements for herbal medicines and none are included on the national essential drug lists. However, there may be a listing system for Chinese proprietary products.

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The control mechanisms usually would also include marketing authorisation and licensing of manufacturers. The regulatory requirements for safety include clearance for traditional use without demonstrated harmful effects, toxic heavy metal content, microbial content as well as the absence of prohibited ingredients. How does a herbal product or traditional medicine get licensed to be sold here? Does MOH and HSA have plans to regulate this further?

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Infectious Disease Surveillance

Sir, my second cut. In a highly connected world, spread of infection is a real consideration. Handling emerging and new infectious diseases, such as SARS and Avian Flu, must be planned with exercised protocols familiar to all relevant personnel. WHO has cited syndromic surveillance as an essential component of our public health system. It is also a means for controlling and managing the diseases and their spread. It refers essentially to the ongoing collection and analysis of statistical data on health trends.

It is useful in the early detection of bioterrorism and pandemic events as such. Advanced technology in surveillance is available today and it brings us closer to real-time detection. Some common standard syndromes are regularly tracked by surveillance systems and these include febrile syndrome, respiratory tract syndrome, upper and lower gastrointestinal syndrome and neurological syndrome, to name a few.

How does MOH work with the hospitals and healthcare institutions to track such surveillance data and trends? How can the data and suspicious trend be disseminated to relevant institutions and personnel expeditiously? As these similar trends are also observed in primary care practice and polyclinics, they are also important partners indeed. How are the data from these primary care institutions collated and consolidated for analysis and dissemination?

Dr Amy Khor Lean Suan: Sir, as Minister Gan mentioned earlier, our healthcare landscape needs to transform to meet the challenges of a growing and ageing population. This would include the growing burden of mental disorders. As our population grows, the number of Singaporeans with schizophrenia is expected to increase by about 2% per year. As we age faster, the number of Singaporeans with dementia will increase significantly. We must enhance our mental health capabilities to cope with this increased burden.

Our strategy of keeping people healthy and managing their health conditions well to reduce the need for costly hospitalisations also applies to those with mental conditions. Several Members spoke on the issue of mental health. Since the National Mental Health Blueprint was rolled out in 2007, we have invested some $180 million in strengthening core services for mental health conditions. We enhanced early detection and access to treatment through programmes, such as the Response, Early Assessment and Intervention in Community Mental Health (REACH), (this is different from the one that I chair for Feedback Unit), which helps to provide early detection and intervention to children with mental health issues, and trains school counsellors to better manage such children.

At the other end of the spectrum, the Community Psychogeriatric Programme provides home-based mental health services for the frail elderly, which has improved clinical outcomes and patients' quality of life. Despite the progress that we have made, much remains to be done.

Several Members asked for a holistic approach in caring for persons with mental conditions in the community. This is indeed our intent. Over the next few years, we will be developing a new community-based mental health plan to complement our hospital-based services. Our goal is to build a network of care and support services that are integrated with our primary care and long-term care services.

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To improve access to care for mental health patients, we will site specialist-led multi-disciplinary teams in the community, starting with the north and central regions this year. These Assessment and Shared Care Teams (ASCAT) will be integrated with our primary care services, so that a person with a mental condition can visit a clinic near him to receive the care he needs, instead of having to see the psychiatrist in the hospital. We target to set up six ASCAT teams by 2016 to manage up to 9,500 patients at any point in time. In addition to the ASCAT teams, we will put in place more specialised teams to focus specifically on dementia patients. We will also expand counselling and psychotherapy services in the community to enable GPs to play a larger role in treating patients with mild to moderate mental conditions, such as anxiety and depression.

Caring for someone with a mental condition calls for tremendous family and social support. To this end, community nodes, such as Seniors Activity Centres and grassroots organisations, play an important role in helping residents with mental health conditions. We will be piloting a helpline to provide information to such community organisations, to enable them to assist patients and caregivers to better navigate the range of services available. Mobile teams of mental health professionals will also provide early on-site response for potential crisis situations where intervention or closer assessment is needed. In tandem, we will work with the Alzheimer's Disease Association to expand the reach of its Elder-sit and Home Intervention Services, to help more families care for their loved ones with dementia.

We are developing community case management to ensure that persons with mental illness adhere to their care plans and are connected to the services they need. Overall, we will spend over $100 million more to support such community mental health projects over the next five years.

Concurrent to our efforts to build up community-based mental health services, we will also grow some of the other hospital and institution-based services for those with more severe mental disorders. We will expand the capacity of the specialised outpatient memory clinics in our hospitals by about 60% over the next five years, to serve more dementia patients. Over the next five years, we will also build two new psychiatric nursing homes, one additional psychiatric rehabilitation home and two more psychiatric sheltered homes at a cost of about $70 million.

This will increase the existing capacity of our psychiatric ILTC facilities from 1,000 beds to 1,700 beds.

We are committed to ensure that mental health services are affordable, which was an issue that Ms Tin Pei Ling, Mr Patrick Tay and Mrs Lina Chiam raised. Apart from subsidised treatment at the polyclinics, those who qualify for the Community Health Assist Scheme can also receive subsidised treatment at GPs for schizophrenia, major depression, dementia and bipolar disorder. Medisave can also be used for outpatient treatment of these conditions. Those who need inpatient psychiatric treatment or residential long-term care enjoy the same subsidies as other patients – up to 80% in Class C wards or up to 75% in ILTC facilities - and additional financial assistance via Medifund is also available for needy patients.

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Patients can also withdraw up to $150 per day from their Medisave accounts for in-patient psychiatric treatment, which is generally less intensive than for other medical conditions. As Minister Gan mentioned earlier, we are considering extending MediShield coverage for inpatient psychiatric treatment.

The capacity expansion will require systematic development of mental health professionals. I would like to assure Ms Tin and Mr Low Thia Khiang that the Ministry is actively working on this. We have grown our psychiatry specialist training capacity to produce about 15 psychiatrists a year over the next five years, compared to only five a year currently. We have also increased the local pipeline for clinical psychologists, through NUS and James Cook University Singapore's postgraduate programmes. The total intake will reach more than 20 per year by 2012 and will enable us to meet the projected national demand. In addition, over the past five years, close to 250 allied health professionals and nurses underwent advanced training in mental health-related disciplines under the Ministry's Healthcare Manpower Development Programme. We will continue to support training opportunities for our healthcare professionals to pursue advanced training in areas relating to mental health, to ensure that we have sufficient numbers of adequately trained manpower to support our national mental health plans.

I would also like to assure Mr Low, Mr Chen Show Mao and Dr Lily Neo that there is a whole-of-Government approach to meet the needs of persons with mental illness and their caregivers.

The Ministry works closely with other relevant Ministries and Government agencies, such as MCYS, MOE, the Police and the Health Promotion Board (HPB), to do so, with AIC playing a crucial role on the ground to manage patient referrals and implement different programmes. An important part of their efforts is to help bridge the health and social service agencies in order to deliver more holistic care for patients with mental illness.

Dr Lam Pin Min and Ms Tin also spoke on the de-stigmatisation of mental health patients. This requires a change in mindset, and is not something that can be achieved in a short time. Siting of mental health services in the community, and allowing patients to seek treatment at a clinic near where they live, just like any other chronic disease, is one step in this direction.

In parallel, we will continue with our mental health education and promotion efforts. HPB reached out to some 170,000 people last year, and will continue with its efforts this year. Some notable efforts include empowering peer support networks among youths, and deploying a roving bus to provide integrated physical and mental health screening for the elderly. HPB has a workplace mental health promotion grant to build resilience and well-being of employees and facilitate early detection and support. From April this year, the maximum quantum of the grant will be raised from $2,000 to $5,000 to sustain and augment companies' mental health promotion programmes. The grant is targeted to benefit 100,000 employees over the next three years, at a cost of $2.5 million.

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Beyond working with the community to increase awareness of mental health issues, we will continue to work with the community and for the community in promoting personal responsibility for health.

We have stepped up our efforts to encourage Singaporeans to lead healthier lifestyles. This is not easy, as many work long hours and eat out. In 2010, 60% of Singaporeans ate out at least four times a week, up from 49% in 2004. With changing lifestyle patterns and an ageing population, we are seeing an increase in prevalence of diabetes and obesity.

Dr Teo Ho Pin asked about our health promotion efforts and advocated that we inculcate healthy lifestyle knowledge and habits in our people. I agree that we need to do so, and I would like to thank Dr Teo Ho Pin for being an avid advocate of healthy lifestyle through his brisk walking and other programmes. However, simply arming Singaporeans with the skills and knowledge to lead a healthy lifestyle is not enough. The community and environment are powerful influences on individual behaviour, and we have tapped on these to further our health promotion objectives.

Sir, allow me to elaborate. Within our community, many people are passionate about living a healthy lifestyle, and they are eager to share this with others.

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HPB has brought them together to form a Health Ambassadors Network. We now have 2,000 Health Ambassadors who have been trained and equipped to be mentors to their family and friends, and we plan to nurture up to 10,000 Health Ambassadors by 2015. This means that each constituency will have at least 100 ambassadors to support local health promotion efforts. I am also passionate about living a healthy lifestyle. Hence, having been appointed as Chief Health Ambassador, I will endeavour to lead the way and champion these efforts and I hope Singaporeans will join me.

Our Health Ambassadors have made a positive impact on the lives of their friends and neighbours. One of my residents visited the health corner at the Residents' Committee in Hong Kah North and was found to have a high blood pressure reading. We found out that she had stopped her medication for high blood pressure, and advised her to see her doctor as soon as possible. Mr Tan Kin Teo, one of our Health Ambassadors, visited her the next day and found out that she was not taking her medication due to financial difficulties. Mr Tan got in touch with the Southwest CDC and the resident is now receiving financial assistance. The health corners at Community Clubs and Residents' Committees are just one of many supporting structures that we are co-developing with the community to support healthy living.

We have also sought to improve access to healthier eating in the community and dispel misconceptions that healthier food options do not taste good or are expensive. Following the successful launch of the Healthier Hawker Programme in April 2011, we worked with the Bukit Batok East constituency to set up the first Healthier Coffee Shop last month. Over the next year, we plan to have 20 more Healthier Coffee Shops and 20 more Healthier Hawker Centres in different parts of Singapore. And let me assure you – I have actually gone to the Healthier Hawker Centre, and the food tastes just as good. In working with the community, HPB also actively promotes the use of its Healthier Catering Guidelines to ensure that healthier food choices are available at the events it co-organises. HPB has also worked with shopping malls, community clubs, and MRT stations to create opportunities to remind and encourage people to live healthy lifestyles. We are working to integrate these efforts to form Health Promoting Constituencies.

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Mr David Ong and Dr Janil Puthucheary noted the recent uptrend in smoking rates, including among youth, and asked what we could do to address this. Singapore has successfully combined multi-pronged, cross-agency measures – ranging from education and smoking cessation, to taxes and legislation to bring smoking rates down to under 15%, which is one of the lowest in the world. However, even as the rates decline, it is challenging to maintain our gains with each succeeding cohort of youth, and to push the boundaries. The increase in prevalence of smoking since 2004, as noted by Mr Ong and Dr Janil, is driven by young adults aged between 18 and 29 years taking up smoking.

To bring us to the next stage in tobacco control, beyond top-down legislative measures, we will focus on stronger, ground-up efforts that, together, will de-normalise tobacco use and establish smoke-free living as the default style of living or as the social norm. To this end, HPB launched the Blue Ribbon movement last weekend, to promote a smoke-free environment. Last year, the ground-up "I Quit" movement inspired smokers to quit through real-life testimonies of smokers who have successfully quit smoking.

These new initiatives complement our long-standing educational efforts in partnership with primary and secondary schools. HPB has also tapped on the Youth Advolution for Health (YAH) peer-led advocacy network to champion the "Live it Up without Lighting Up" movement to reach out to teenagers outside school. These youth programmes have shown results; the rates of youths aged 13 to 16 years old, smoking on at least one day in the past month, decreased from 11% in 2000 to 6% in 2009.

As announced two weeks ago, the Ministry is also banning misleading terms on tobacco product packaging and labelling, and lowering cigarette tar and nicotine limits. Graphic Health Warnings will be replaced with a new set to ensure continued impact. These changes will take effect from 1 March 2013.

I would like to assure Members that we will press on with our tobacco control efforts, with a sharpened focus on youth. We will also work with NEA on the long-term goal of banning smoking in all public places other than designated smoking areas, to further de-normalise tobacco use. Later this month, Singapore will host the 15th World Conference on Tobacco or Health. We will exchange ideas with experts on strengthening tobacco control in Singapore.

We share Dr Janil's vision of eliminating tobacco from Singapore one day, but when that day will come, we cannot be sure. But we will work towards it.

Mr Ong also asked how we could limit the consumption of trans fat. I agree with the need to do so, because of the link to heart disease. In Singapore, three in ten adults exceed the World Health Organisation's daily limit of trans fat intake, and two-thirds of these are young adults under the age of 40. HPB has actively engaged food manufacturers to reduce trans fat in their products and voluntarily label trans fat content. Since 2009, foods that have less than 0.5g of trans fat per 100g can carry HPB's enhanced Healthier Choice Symbol. We are now ready to move one step further, to regulate trans fat in our foods.

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In collaboration with AVA, we will limit trans fat to no more than 2g per 100g product for fats and oils supplied to local food service establishments and food manufacturers, as well as fats and oils sold in retail outlets. We will also require labelling of trans fat levels on packaging of retail fats and oils. The amendments to the Food Regulations will be gazetted in May this year by AVA.

Several Members asked about improving our screening programmes and screening coverage. Screening is a key part of our health-promoting ecosystem. Heart diseases, stroke, cancer and diabetes contribute nearly half of the total burden of disease in Singapore, so early detection and management of these conditions and their risk factors are important in keeping our population healthy for longer.

The Integrated Screening Programme (ISP) was launched in 2008 to encourage Singaporeans to be screened for obesity, diabetes, high blood pressure and high blood cholesterol, which are all risk factors for heart disease and stroke. Singaporeans are also encouraged to be screened for selected cancers. Ms Ellen Lee quoted an article from Prof Gilbert Welch about the perils of over-diagnosis – that "there might be screening for diseases too frequently or we might be looking for diseases too hard".

This is a valid concern, but I would like to reassure Singaporeans that the screening tests used in our programmes, as well as the targeted age group of 40 and above, are based on good evidence, guided by recommendations of the Screening Test Review Committee, an independent expert committee under the Academy of Medicine.

When Singaporeans turn 40, HPB sends them invitations to go for the recommended screening tests based on age and gender. The letter indicates eligibility for subsidised screening, and lists GPs in the vicinity of their homes that offer the Integrated Screening Programme. And I think most of us or all of us should have received this letter.

To date, 45,000 people have been screened under this programme, 54% of whom were women and 46% were men. 53% of those who have gone for screening were detected with one or more chronic diseases. We will continue to encourage more people to go for screening, as well as more GPs to support this programme. Under this programme, Singaporeans pay only $8 for screening tests for diabetes, high blood pressure, blood cholesterol and obesity. Low-income Singaporeans do not need to pay for the tests at all.

The Ministry has also worked with HPB on a "one-stop" enhanced integrated screening programme in the community. This programme adds on the screening of seniors for functional decline. GPs and dentists in the local community will also be on hand to provide on-site follow-up where required. This "one-stop" enhanced programme will be launched in Marine Parade this month, and we plan to roll it out to the rest of Singapore within the next three years.

Dr Lily Neo and Ms Lee will be happy to hear that I have asked HPB to convene a Women's Health Advisory Committee, which I will chair, to improve screening and follow-up rates amongst women. This Committee will help HPB plan and implement a holistic Women's Health Programme, which will adopt a life-stage approach and seek to equip women of all ages with the necessary knowledge and skills to improve their health. In addition, we will build up a pool of women Health Ambassadors who focus on women's health issues. We plan to launch this on Mother's Day this year, and we target to reach out to one million women in Singapore, over three years. And since we are on the subject of women and women's health, let me take this opportunity to wish all women in this House, as well as women outside, in advance "Happy International Women's Day".

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Let me address Dr Lam Pin Min's point on the applications of cancer genetic testing. The use of genetic testing in cancer is a complex issue. While genetic testing is established as part of the care of certain individuals who are at hereditary risk for cancers, not all genetic tests are useful or accurate. As Dr Lam alluded to earlier, there are concerns that the results of genetic tests could be used against the individual, for example, by employers or insurance companies. While we acknowledge the potential benefits of cancer genetic testing, there is the potential for misuse.

However, legislation may not be the answer to the problem of discrimination by employers. The underlying mindset needs to be addressed. We will ride on on-going tripartite efforts to encourage employers to adopt fair employment practices. Employees should be recruited on the basis of merit, such as skills or experience; other factors unrelated to the worker's ability to do his job should not be considered. Furthermore, the Singapore Life Insurance Association has, on the recommendation of the Bioethics Advisory Committee, put in place a moratorium on the use of predictive genetic information for life and health insurance products. The Ministry will continue to monitor the evolving evidence for cancer genetic testing and review our policies accordingly.

A health-promoting ecosystem, as I have described, requires both top-down and ground-up initiatives. There are several good examples of ground-up health promotion efforts in our constituencies today. To foster and strengthen such community health promotion initiatives, Members will be pleased to know that we will pilot a new Constituency Health Promotion Grant from April this year. Each constituency will be given up to $10,000 a year for grassroots leaders to co-plan, co-develop and co-implement health promoting activities for their local residents, such as health talks, healthy cooking demonstrations, exercise programmes or other health interest groups. HPB will develop a toolkit with simple guidelines and checklists to help grassroots leaders with planning and implementation. We believe that this will empower the community and energise the ground-up social movement for healthy living.

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Before I conclude, let me address some specific issues raised by Members. Ms Denise Phua spoke on children with special needs. Managing children with special needs is a complex issue requiring close multi-agency coordination across the social, education and healthcare sectors. Early detection touch-points include parents and care-givers, pre-school educators and healthcare professionals.

HPB has worked with clinicians to revise the Health Booklet that is given at birth to every child, to include a more comprehensive checklist of developmental milestones. The latest revised edition now provides development checklists at four to eight weeks, three to five months, six to 12 months, 15 – 18 months, two to three years and four to six years. This will help parents detect potential developmental problems in their child. Parents are encouraged to track their children's milestones and take them to the polyclinics, GPs or paediatricians for the recommended developmental screenings. Our clinicians also train early childhood educators on basic child development issues so that the educators can detect anomalies. This would strengthen the first tier of detection, which are parents and caregivers. Given their close proximity to their children, they would be the most likely "first touch-point" to identify developmental problems.

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We will continue to work with MCYS and MOE on further raising awareness and educating parents, early childhood educators and healthcare professionals to enable better and earlier detection of children who display signs of developmental problems.

Ms Phua also asked about the use of MediShield and Medisave for people with special needs. Today, MediShield and Medisave are primarily designed to cover hospitalisation expenses and expensive outpatient treatments, such as chemotherapy. As Minister Gan had mentioned earlier, we are exploring MediShield coverage for congenital conditions, while keeping premiums affordable. Medisave currently also does not cover hearing aids and other physical aids and health items.

We would need to weigh any further liberalisation of Medisave use against the adequacy of MediSave for one's post-retirement needs. The hospitals also tap on their endowment funds to offer financial assistance to persons with special needs to help them purchase hearing aids and other health equipment.

Dr Lam Pin Min asked about our national disease surveillance system and pandemic preparedness, and Prof Fatimah Lateef asked about syndromic surveillance. The Ministry maintains vigilance against infectious diseases and other public health threats through a comprehensive system of local and global surveillance, in partnership with healthcare providers and other government agencies.

We collate syndromic surveillance information on acute respiratory disease, diarrhoea and conjunctivitis from polyclinics and hospitals on a weekly basis, although this can be done daily if necessary. If a threat has been identified, healthcare providers can be alerted quickly via email and SMS, and the public will be alerted through print and broadcast media as well as the Ministry's online platforms.

Singapore has a National Influenza Pandemic Readiness and Response plan, which has been developed and refined based on experience with SARS and H1N1. We regularly exercise the plan with public and private hospitals, as well as primary and step-down care facilities.

We have also stockpiled sufficient antiviral drugs for the treatment of infected persons during an influenza pandemic, and H5N1 pre-pandemic influenza vaccine for the protection of frontline essential service personnel and high-risk groups, including the elderly.

Prof Fatimah also asked about the regulation of traditional medications. Dealers and manufacturers of Chinese Proprietary Medicines, or CPMs, have to ensure that the safety and quality of their products pass Health Sciences Authority's pre-market approval process, prior to sale and supply in the local market. This includes ensuring the absence of prohibited substances and excessive toxic heavy metal limits, and objectionable or fraudulent claims on the labels.

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Other Traditional Medicines, or TMs, are not currently subject to pre-market approval but dealers and manufacturers are responsible for the safety of such products in the market. This is complemented by ongoing post-market surveillance by HSA, which monitors adverse events and conducts regular sampling and testing of CPMs and TMs to ensure consumer safety. HSA is currently in the process of reviewing the need to implement a risk-based pre-market approval process for Traditional Medicines, taking reference from international best practices of overseas regulatory agencies, including in Canada and Australia.

Sir, we need to work with and through the community to achieve better health outcomes for all. While healthcare providers have a part to play in caring for the vulnerable, we also want to tap on the wider community and build strong social networks and support structures to encourage more Singaporeans to lead healthy lifestyles. We welcome ground-up initiatives to promote healthy living. Together, we can achieve our vision of a health promoting ecosystem which will benefit all residents.

Chairman: Members, we have some time for clarification. Dr Lam.

Dr Lam Pin Min: Mr Chairman, Sir, I have a few clarifications for the Ministry. First of all, I would like to thank the Minister for the very welcome announcement of the pay revision for public-sector healthcare workers. This is really welcome and it gives due recognition to the hard work rendered by these healthcare workers.

With regard to the funding of $200 million for this exercise, I believe it will be paid for by the Government for this fiscal year. Can I ask the Minister whether the Government will continue to bear this additional cost beyond 2012? And if not, will this additional cost be passed back to the patients?

Secondly, with regard to the Pre-employment Grant (PEG), in the Minister's speech he mentioned that only about 89 students were granted since 2010. So, my questions are: how many Singaporeans are currently studying medicine overseas? What is the outreach to these students and how was this done? And, what are the reasons given for not accepting the PEG?

Mr Gan Kim Yong: Sir, yesterday, I told Parliament that the cost of the wage increases will amount to about $200 million. And for the $200 million for this financial year, the Government will fund it in full, mainly because the hospitals and the institutions have not budgeted for it. Therefore, we need to help them with this funding. Going forward, the additional wage increases will be rolled into the normal wages and these normal wages will form the normal costing of the hospitals and our institutions. And the Government funding will be based on the usual funding framework, subvention framework. For hospitals, for example, the funding will be based on the class of wards that you are in, and the patients will share in the cost. The Government will continue to provide the subvention as what we are doing today.

The second question on the PEG: we have recruited 89 students; we have just started in 2010. We are quite encouraged by the results. As to how many students are overseas, we do not have the exact figure because they do not tell us, not all of them will tell us. We estimate maybe between 100 and 150 or thereabouts every year. So we hope to be able to reach out to more of them, including dentists, and hope that we can bring back more of these Singaporeans who are studying overseas. We also have to be mindful that we could only accept students who are in approved institutions. Other institutions may not be able to qualify. And in terms of outreach, we organise promotional trips to these countries where many of our Singapore students are. We organise events to bring them together and explain to them what PEG is about. We also share with them what they can do when they come back. And we appeal to them to consider PEG and come back and serve the Singapore healthcare sector. We will continue to do that and we also look forward to having more Singaporeans who are overseas, not just in the medical studies but for dentistry studies as well, to come back and join us in our healthcare services.

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In fact, so far the results have been quite encouraging; very few of them decline. Some of them wanted to keep their options open; some of them already have offers where they are studying; or some of them are thinking about going into the private sector. So, there were a variety of reasons, but for the students we have engaged, I would say, the vast majority of them are quite encouraged by this option. As for those who did not accept, some of them may also come back to Singapore on their own to serve in time.

Mr Gerald Giam Yean Song: I thank the Minister for his responses and I look forward to working with him to make this Healthcare 2020 Plan work. I have two clarifications, Sir.

I was not asking to draw down from MediShield reserves as I know that would not be sustainable. Instead, what I suggested was that given the very healthy financial position of MediShield, perhaps not all the annual costs increases from the enhanced coverage for the elderly have to be automatically passed to policy holders through premium increases.

My second clarification is the point about the cross-subsidy of MediShield premiums across ages. My main concern is actually the high premiums payable by the elderly who have no other source of income. I am not saying that premiums must be equal across all ages but that the enhanced coverage that I proposed in my cut could come from small premium increases for the many working adults. I do not think many working adults will begrudge paying a bit higher premiums to cover the 11,000 seniors above age 90.

And, Sir, I have three questions: is the Minister saying that MediShield currently has no cross-subsidy across ages? Is this a key principle of our healthcare financing approach, or is it only for MediShield? And, thirdly, how does this gel with the expectation for adult children to use their Medisave to pay for their parents' medical treatment before Medifund assistance is provided? Is this not a subsidy across generations of an even worse kind since many of these are low-income children paying for retired parents who have exhausted their Medisave accounts?

Mr Gan Kim Yong: Sir, I have explained the need for MediShield reserves. And even as we look into the future when we review the MediShield this year, we also need to look at the adequacy of the reserves. As we enhance the benefits and look at the claim experiences of previous years, we will have to decide how much of reserves need to be put aside for the coming five-year period. And therefore for every revision to the premium, we will have to take into account what proportion of it needs to be put aside for reserves, partly for the capital adequacy required by MAS and also partly for the loyalty rebate in future which I explained.

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As an individual when you are younger, when you are able to earn a regular income, there is a loading on your premium. This loading is not for other people but for yourself, so that when you are older, your premium would be lower than what it would have been. As you get older, you would appreciate that the number of people shrinks and the claims go up. And, so, as you get older, for the older cohorts, their premiums are going to be very high and that is why we have this arrangement for pre-funding. So, as an individual, you pre-fund yourself; when you get older, you then draw on this rebate which comes from the reserves. And so in the design of the scheme, as we move forward, you will not want to put aside more than what is necessary; but we need to be advised by the actuaries on what is adequate. So, I would assure Mr Giam that we will be very careful because we do not really want to increase premium unnecessarily. But if it is necessary for reasons of prudence, then I think we ought to do so.

Your second question on premiums across ages: for MediShield, the design of the scheme is such that each cohort will be risk-pooled together, so there is very little cross-subsidy between younger generation and older generation.

But if we start to do that, and as the younger generation begin to shrink, you will have a bigger problem in future for the younger generation to shoulder the insurance premium for the older generation, if it is built into the structure of the MediShield. Because once you go on that structure, that means the older generation is not paying their own premium. And you will find that as the younger generation grows older, they are already not paying their own premium and they are relying on the next generation to pay for them. And this inter-generation subsidy is between people who are unrelated. So, I think it is a lot more difficult to persuade the younger generation to accept this. The risk of that is that some of the younger generation may opt out of the MediShield scheme and join other schemes that do not have this cross-subsidy.

Therefore, we have to be very mindful. Even the loyalty rebate I talked about, we also have to be very careful not to overload a person when he is younger. Because when he compares his own insurance premium versus premiums that are available in the private sector, they may ask, "why is my premium so expensive today?" Because he may or may not be aware that there is a loyalty rebate that will benefit him in future. So some of them may actually decide to drop out, and once they drop out, there will be problem, because they may not be able to rejoin due to pre-existing conditions. So, as we adjust some of these parameters, we have to be mindful and be very careful.

Mr Giam talked about Medisave sharing between generations. I think I have answered that question in a previous Parliamentary Question. The answer - and I also mentioned it in my speech – is that family support remains an important component. But I also said in my speech that we have to recognise that the older generation has a lot more burden and we want to make sure that they too have a sufficient amount to meet their healthcare needs. And that is why, in this Budget, we have provided top-ups for the older generation, and the one-time top-up is specifically to help members pay for the increases in the MediShield premium when we adjust it. We want to strengthen family support for our Singaporeans but, at the same time, we recognise that we have to be very mindful that the older generation would have a higher burden, and we find different ways to help them. So, our top-up is one way.

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Ms Denise Phua Lay Peng: Sir I would like to seek clarification on the MediShield review which does not cover those with congenital and pre-existing conditions. I would like to ask the Minister to clarify when the review for the MediShield coverage for those with congenital and pre-existing conditions be completed. The review has been going on for some years now. I wonder if it can be brought forward, because basic healthcare is not a "nice-to-have" item. It is a basic essential service. And I also worry about the traditional paradigm and the narrative that if we want to include people with congenital or pre-existing conditions, then the fee will have to come out directly from the pockets of other Singaporeans. I find this underlying assumption not acceptable because, for example, in education, we never say that if we want to help the weaker students, then we ask those who are more able to pay higher school fees. Hence, I would like Minister to clarify and consider, in the review, to include people with congenital and pre-existing conditions earlier in the MediShield scheme.

Mr Gan Kim Yong: Sir, I share the sense of anxiety with Ms Denise Phua. We want to finish the review as soon as possible and, in fact, we will be going out for public consultation soon. Public consultation will give us a better sense of what are the features that the public would want and the associated costs with it, because for every benefit, there is a cost. Even if Ms Denise Phua does not believe that they should pay for it, someone has to pay for it, either the taxpayers or through the Government taxes or shared among all the parents, all the Singaporeans. This is the concept of risk-pooling. So, all the participants in MediShield will share the risk of congenital diseases, and this scheme will have to be enforced before the child has discovered the illness so that the congenital disease will be covered. The risk will be shared by all the parents and that is how we share the cost of congenital diseases.

Even with the congenital diseases coverage, MediShield pay-outs will still have limits. There will still be deductibles; there will still be conditions of claims. For cases of children whose cost of care goes beyond the claim limits or for whatever reason, they cannot be helped by MediShield, we will look at other ways to help them directly or indirectly, even through Medifund. So, I think we try to help these children through multiple avenues; through insurance is one way, and we are also exploring other ways to help them.

Ms Tin Pei Ling: Sir, I thank the Minister and Minister of State for their very comprehensive and very heartening replies. I have three points of clarifications. One has got to do with the silver enterprise. I thought I did not quite hear anything about that. I want to ask whether the Ministry will be considering that suggestion and having a framework to support silver enterprises.

The second is back to the point about Medisave for the elderly. I take the point that we want to make sure that the elderly have enough savings in their CPF to pay for their future healthcare expenses, their MediShield and what not. But I think for those elderly who have retired, they no longer have an income, they have no other family members and they want to rely on themselves. Would it not be better to let them have more autonomy? Because if they do not get to use their Medisave now, then they will be using the Medifund. And even if they have expended their Medisave now, eventually, they will still have to use Medifund. So, why not let them have the autonomy to choose how they want to use their Medisave for their medical-related problems at this stage while they still can?

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The third point is coming back to mental illnesses, in terms of stigma. I submit that − and I am very encouraged that HPB as well as the Ministry of Health −

The Chairman: Ms Tin, can you please ask your question?

Ms Tin Pei Ling: Yes, Sir. Will the Ministry consider working with the media in addressing the issues of stigma because it is one of the key factors, as shown in studies, to be reinforcing certain stereotypes of mental illnesses?

Mr Gan Kim Yong: Sir, I will ask the Minister of State to respond to the question on mental illness.

Let me deal with the silver enterprises. The answer is yes, we will look at it and see how we can have a framework to encourage the development of silver enterprises, the silver industry. But, eventually, as in the nature of enterprises, the private sector must take the lead and we will provide the facilitation. We will find ways to help them, to engage them, and to see how we can facilitate the development of silver enterprises.

On the Medisave for the elderly, I have addressed that in my speech. If there are specific cases, I am prepared to look at them. But, personally, I would prefer to help them with Medifund, and allow them to keep their Medisave for themselves. Because, at the end of the day, a person may find that he is likely to underestimate the potential healthcare costs as he grows old. And even if he is old and does not have a job, no longer working, retired, but he will still have needs in the future because he may live very long. And if we manage our healthcare services well, we provide adequate support and healthcare, he may live very long and he may outlive his own expectation. If that is the case, he would need all the savings in his Medisave to support his medical needs when he really grows old. So, I would encourage Ms Tin to raise the specific cases to MOH and we will take a look and see whether we can justify allowing him to draw down his Medisave or find other ways to help him.

Dr Amy Khor Lean Suan: Sir, I agree with the Member Ms Tin that the media also plays a part in shaping the perceptions of the public about mental illnesses and they could actually contribute to the stigma related to this illness. There are a number of reasons. Of course, it is lack of awareness or inaccurate understanding of people with mental issues as well as lack of understanding as to how to interact with them, and the media can be one of the reasons. So, besides public education, raising awareness of the public about people with mental illness, increasing their awareness and understanding through HPB programmes, we are also looking at possibly getting people who have recovered from their mental disorders to share about their experiences with the community, getting the grassroots and community involved in reintegrating people with mental illness. And, of course, we can also try and profile some of these cases to the media. But whether the media will publish it or not, we will have to leave it to them. We will work very hard towards this.

Dr Lily Neo (Tanjong Pagar): Sir, the Minister did not answer my question which I raised last night under my MOH cut. May I ask Minister whether he has got any plans in place to establish another type of step-down care in our ageing population for right siting, and, that is, home care? Has he got any measures to provide and to train home medical carers, such as doctors, nurses and medical workers, in order to take care of the patients who are ready to be discharged back to their own homes and to be cared for by these medical carers?

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Mr Gan Kim Yong: Sir, I thought I have explained in my speech earlier this morning our strategy in dealing with the ILTC sector and they will be looking at encouraging home care and to support home care. We would not be setting up a home care centre because home care is at home. But in order to support home care, I think Dr Neo's point is that it is important to have support services so that we can allow the patients to be cared for at home. So, we do intend to set up day-care facilities where the patient who needs therapy, who needs day treatment, can go down to the day-care centre to be treated so that he can then stay at home and does not need to be hospitalised. So, those are the day-care facilities. We will be setting up what we call the Community Health Centres. It is another primary care model that will provide allied health services to support the GPs in taking care of these patients who are recovering at home.

And Dr Neo also talked about the training of the caregivers. Indeed, this is an area that we are stepping up our training capacity to help prepare the carers so that they will be able to look after their elderly loved ones at home. We need to equip them properly.

Dr Neo also talked about transition care – how can we help patients who are discharged from hospitals when they go home. Some hospitals do have programmes to help settle the patients at home. During the first week or two, when the patients return home, some hospitals have programmes to visit them, either with nurses or sometimes with therapists, to visit their homes, to check on the patients to make sure that they are looked after, to make sure that they take their medication regularly, for a few days or a few weeks until the patient is settled down at home and his family is able to manage him going forward. So transitional programmes are also available.

We are also looking at some other models to see how we can facilitate transition between community hospitals and homes. These are in a similar strategy that we are looking at, to facilitate transitions so as to allow discharges to be carried out more efficiently, more smoothly and to also help the family members to be able to care for their loved ones in an easier way. Training and support, as well as day-care facilities in the community, are all very important, and these are the areas that we will be looking at.

Assoc Prof Fatimah Lateef: Sir, two queries: first, for the Minister because he announced that we are going to have a public-private partnership and decanting of some patients into Parkway as well as Raffles healthcare. My question is, when these patients get sent over, are they going to have sharing of medical records and, if so, how is it going to be done? Second, for the Minister of State, on the programme CHIPS, which is to promote innovation and productivity in the intermediate and long-term care services, are we going to have something similar for all the other healthcare institutions that we can tap on? I am looking, in particular, to see if MOH is interested to look at an innovative project where we could probably consider using double-decker beds in some of the hospital wards currently. That would certainly save space and also cut down on the number of new hospitals we have to build.

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Mr Gan Kim Yong: Sir, let me just clarify that the collaboration with Parkway and the Raffles Medical Group may be of different models. We have talked a little bit about Parkway. I have not talked about Raffles because the discussion is still on-going. Even with Parkway, the detailed operational arrangements are still being worked out but the principle is that, for Parkway, our own doctors will be manning the beds that we are taking over from Parkway East and, therefore, our doctors would have access to our own patients' records. But, eventually, the idea is that the national electronic healthcare records would include private hospitals so that we can share patients' records to facilitate the care of the patient, because the patient may be in a public hospital today; but tomorrow he may decide, for convenience or whatever reason, to go to a private hospital. So, we must facilitate that by making our national electronic healthcare record portable between hospital institutions. For Raffles, the arrangement is still being worked out and we will announce the details of the arrangement when it is done. I will leave the other question to the Minister of State.

Dr Amy Khor Lean Suan: The $20 billion CHIPS fund is earmarked for the ILTC sector but the productivity and innovation grant is also available for the healthcare sector at the macro level. I am sure that if there is any idea that the Member has which will help us to improve productivity in the healthcare sector, we will definitely consider it.

Mrs Lina Chiam: Sir, I would like to thank Minister Gan and Minister of State Amy Khor for the comprehensive reply. I have three questions to ask. First, is there a possibility of allowing nurses to work under a system where flexi-hours are allowed? Second, with the continuous education and upgrading of skills of nurses, will the basic role of nurses be compromised? Third, will the Minister allow Medisave to be used to make full payment for upgrading to integrated shield plan policy for Singaporeans who are 60-80 years and above? At the moment, they are allowed to use only up to $800, but sometimes they would want to upgrade to a better policy plan and would need more, say, $1,100 or $1,200. Some of these people may be cash-poor because they are retirees and they would like to make full use of their Medisave to buy all this insurance.

Mr Gan Kim Yong: Sir, I believe flexi-arrangement for nursing is already available. In fact, many of our healthcare institutions, whether it is acute hospitals, community hospitals, ILTC or nursing homes, do practise flexible hours. But, of course, even with flexi-hours, there has to be some structure and some arrangement so that nurses know when they have to come and institutions know when the nurses would be there so that they can arrange the manpower deployment. The flexibility is there, and we encourage flexibility because this will allow us to tap on, say, retired nurses, who may not want to work full-time. This is something that is very important for us to help meet our manpower needs.

On upgrading, I am not very clear what Mrs Chiam's argument is. She is saying that if we keep upgrading the skills of nurses, then they will lose the basic role of nursing. We provide opportunities for nurses to upgrade. We provide three different pathways: one is continuing with clinical nursing; the second is for administration and leadership where they become nursing managers to manage a team of nurses; and there is another group that will pursue the educational path that will provide education and teaching to the next generation of nurses. All three are very important. We have to make sure that we have enough people to continue with clinical practice so that our patients are cared for. At the same time, we also need to ensure we have sufficient leaders among the nurses that will be able to help us in managing nursing. And some of them will be elevated to advanced practice nurses who will be able to undertake more complex nursing roles. In fact, in many other countries, nurses do a lot more than what we are doing today. So, we are continuing to explore ways to enlarge the role of nurses so as to meet the manpower needs of our healthcare sector. Education is also very important because if you do not have nurse educators, you would not be able to train the next generation of nurses. So, all the three groups need to be balanced and calibrated. In our manpower plan, we have to decide how many practising clinical nurses we need, how many educators we need and how many administrators we need, so that we have a comprehensive manpower plan to develop our nursing careers.

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On her last question on integrated plans, today, there is a limit on how much an individual can draw down to pay for private shield plans. The starting point is we have to make sure that each individual has sufficient savings in the Medisave account at least to meet the needs for basic MediShield and ElderShield premiums. If you allow them to draw more, the risk is that they may have enough to draw more today for the additional plans, for example, the upgraded plans that they want, but they may not have enough for next year or five years down the line. So, we have to think ahead of time. That is why we have a certain limit to allow them the flexibility to upgrade if they want to, but we cannot totally lift the limits because otherwise they may purchase a very attractive plan today or for the next three years but, after that, they may deplete their Medisave and they may not even have enough for the basic MediShield. Their MediShield cover may just lapse, and that is not desirable. We understand the Member's concern and we want to be as flexible as we can but, at the same time, we need to balance it with a need to preserve the savings for their basic healthcare needs, especially the basic Shield plans.

Dr Teo Ho Pin: Sir, I wish to seek clarification from the Minister with regard to the three strategic objectives of Healthcare 2020 – accessibility, quality and affordability. When I look at the health clusters, I was looking at the north, you have Alexandra health cluster; in the west, you have Jurong cluster. But I am a little bit concerned for residents in my constituency at Bukit Panjang. We are neither in the north nor in the west. So I am just wondering, how does the Ministry plan to make sure that healthcare services are accessible to residents in Bukit Panjang Town? In fact, we are just beside the Minister's ward at Chua Chu Kang.

Mr Gan Kim Yong: Sir, when we talk about accessibility and the regional healthcare system, we have to bear in mind that these are not physical barriers. As an individual patient, whichever hospital you go to, the hospital will look after you. They will not say, "Well, since you are from the east, please go back to the east; if you are from the west, please go back to the west." So, wherever you are, if you are in an emergency, the ambulance will take you to the nearest hospital and they will take care of you. What is important in the regional system is that by the time you are discharged, wherever you are, I am quite sure you will go back to your home. Because you work in the west, and something happened to you, you go to the western hospital. You live in the east, so when you are discharged from the western hospital, you will go back to stay in the east. And when you go back to the east, the eastern health cluster will look after you because you will be seeing polyclinics in the east. If you need follow-up with specialists, you can follow up with the previous hospital or you can follow up with the hospital within your cluster.

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Once we have the NEHR fully up, we will be able to communicate between hospitals and the patient information will then be shared. And wherever you are, you will be looked after within the region. The idea of a regional system is to foster stronger collaboration among the various healthcare institutions in the region so that the hospitals can work with the community hospital and the nursing home to facilitate patient transfers. For nursing home patients, for example, if they need acute hospital care, they can then be sent to a hospital in the cluster. They will have working arrangements that will facilitate a patient's transfer and minimise the hassle and administrative procedures. So, when a patient is discharged and goes home, the polyclinics or the GPs in the cluster may look after him in the primary care sector and our community health centres may then be able to provide allied health services to support him. Our day-care centres will provide the day rehab to support him. So, it is all within the region. That is the concept of regional system. It does not preclude individual patients from any particular hospital. So, your patients do not have to worry, they just have to go to the nearest hospital that is convenient to them, and we will take care of them.

Mr Gan Thiam Poh: Mr Chairman, Sir, I would like to seek a clarification from the Minister pertaining to my suggestion earlier on to give free MediShield coverage for the low-income group and homemakers. I learned from him just now that 92% of Singaporeans are covered under MediShield. May I ask the Minister, what about the remaining 8%? I suppose out of this 8%, there will be those that come from the low-income group and this also includes the homemakers from this group. How will the Ministry ensure that it reaches out to these Singaporeans so as to encourage them to get insured, though there is a Medisave top-up?

Mr Gan Kim Yong: Sir, I explained earlier that out of the 8%, a significant number of them may have good reasons why they opted out. We do not know the exact numbers because they do not tell us the reasons for opting out. Some of them would already have insurance coverage by their employers; some would have bought their own health insurance, so they do not see the need to continue with the MediShield. Not all the 8% are from the low-income group. But for the really low-income and those with no income at all, rather than giving them free MediShield insurance, we have many other ways to help them. One way is through our Medifund, through subsidies directly from our health institutions, which can support them. Because for this low-income group, or if the whole family has no income or are on public assistance, joining an insurance scheme may not be the most sensible thing for them. So it is better for us to provide direct intervention and subsidise them, and support them when they really need healthcare services.

Mr Low Thia Khiang: Sir, I understand that a substantial sum has been committed for development of the National Electronic Health Record system. May I know what would be the total estimated expenditure when you have developed the system fully which, I understand, will also be extended to private healthcare institutions? I would like the Minister to clarify how important it is for this system to complement or help the delivery of the national healthcare system, and how will patients benefit from the system.

Mr Gan Kim Yong: Sir, the National Electronic Health Record system is a very complex undertaking. It will take many years to fully implement it. In fact, many developed countries have started way before us, and they have not fully completed it. One of the challenges is that the healthcare system is evolving as we implement the National Electronic Health Record system, and the system also has to evolve with the way we structure our healthcare sector. Therefore, it is quite a complex project. We do it in phases. As I mentioned to the Member, for the current phase, we are on target. By June this year, we will roll out our programmes.

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From the individual patient's point of view, this project is quite critical for us because it would facilitate the flow of information, and this flow of information would allow patients to be able to flow between different healthcare settings. This would improve the care that we can provide for the individual patients, so when the patient is looked after by a polyclinic, when he goes to the specialist clinic, the records are there, when he needs to be hospitalised, the records are there. They do not have to search for manual records and they do not have to call up and find out what drugs they have been taking, and so on. So, all the records would be there and this would facilitate better care for the patients, and this would also allow the institutions from different sectors to collaborate, to look after the same patient. The National Electronic Health Record is a very important part of the overall healthcare infrastructure that we would be developing.

Ms Irene Ng Phek Hoong (Tampines): Sir, I welcome the grant to help families to hire a domestic helper to care for their elderly. I also fully support the move announced by the Manpower Ministry yesterday to give maids the compulsory day off every week. Since the announcement of the compulsory day off for maids, there have been some concerns by some residents who care for the frail elderly and for the elderly with dementia that they might not be able to cope without the maid even for a day a week.

Can I ask the Minister to alleviate their concerns by perhaps making it a considered effort to reach out to them, to provide them with the skills and the funding given to make sure that they have the ability to take care of their elderly and not be so reliant on their maids because the experience now is that ---

The Chairman: Ms Ng, can you just ask your question, please?

Ms Irene Ng Phek Hoong: Perhaps, the Minister can look into linking caregiver's course to the grant to make it compulsory for caregivers to go for such training because the explanation now is that when there is a caregiver's course, they tend to send their maid instead of family members. My next question is: can the Minister also provide a wider range of subsidised home-based services that function on weekends so that families who give their maids day off during the weekend can avail themselves of these services for their elderly?

Mr Gan Kim Yong: Sir, our training for caregivers is neutral. We also welcome caregivers who are not maids but family members to attend our training so that they are better prepared to look after their frail and elderly. In fact, quite a lot of our participants are family members. Of course, some of them do send their maids to be trained so that they can better help the family members look after their loved ones. With regard to the compulsory day off, it is more a question for the Ministry of Manpower. I understand that family members do have the option to provide pay in lieu . So if there are circumstances requiring the maid to be at home to help look after the disabled or those who are elderly, I think there is flexibility provided. Your other question is on providing services and facilities on weekends. These are the things that we would look at to make our training and support facility services more accessible beyond the working hours.

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Mr Yeo Guat Kwang (Ang Mo Kio): Sir, we are doing more for mental health. I just want to check with the Minister of State whether the increase from 1,000 to 1,700 beds is really sufficient. Would the Ministry consider giving more support to the caregiver for mental health patients and try to structure a better system to facilitate the home care?

Dr Amy Khor Lean Suan: Sir, in fact, the focus really is to allow as many of these patients who have been stabilised in hospitals to go into the community, to be cared for in the community so that they can reintegrate into the community as soon as it is possible. Therefore, what we are doing is to provide for mental health services within the community itself to allow patients who are stabilised and discharged into the community to continue to be cared for in the community by mobile teams.

As regards the additional beds, that is really for those who have to be institutionalised and who have to receive care within that setting. We are going to expand services for home care like dementia patients. Alzheimer's Disease Association, for instance, is working with us to expand their elder-sit service. This is like babysitters, but they are eldersitters for dementia patients, and they will provide therapeutic activities for these dementia patients. So, you can allow the caregivers to have some respite from caring for these dementia patients. The facilities that we are providing are multi-faceted. It is not just institutional care, but also care within the community.

The Chairman: Dr Lam, are you seeking a second clarification?

Dr Lam Pin Min: Mr Chairman, I have one last clarification and two wish lists. I am impressed by the massive expansion plan in the infrastructure for healthcare, and I understand from the statement yesterday that we will require about 20,000 healthcare workers by 2020. Even with the ramping up of the training for doctors, nurses and allied health professionals, I believe we would not be able to meet the target just by tapping on the local pool. I believe we would probably have to hire from overseas. Can I just ask the Minister how confident is he in meeting the target because, if not, we would potentially face a manpower crunch when the time comes? The two wish lists will be whether the Minister can consider removing the minimum age limit for the Community Health Assist Scheme (CHAS) as well as extending the additional FDW grant for ageing at home to families with younger patients with severe disabilities that require full-time care by the FDW, if it is not this year, maybe hopefully next COS.

Mr Gan Kim Yong: Sir, the short answer to the first question is that we must meet the target. But I think we are confident. We have looked at our pipeline. We have looked at the potential source of manpower − locally trained as well as Singaporeans who are now overseas and foreign manpower. We have to work together, both local and foreigners here and overseas, to come together to deliver healthcare services for Singaporeans. On the two wish lists, the minimum age of CHAS: we have just lowered it from 65 to 40. We have just barely started implementing it. We register Dr Lam's persistent request and it is duly noted. We would take a look and see whether it is necessary for us to lower it further. If Members remember, the main purpose of CHAS was to look after the chronic diseases in the community. From our studies, this is more critical for those who are 40 and above. We will continue to review to see whether there is need to lower it. On the FDW grant, again, that is more a MOM cut. But I think we will register his request and we will review it in due course.

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The Chairman: Mrs Lina Chiam, you have the last clarification, please.

Mrs Lina Chiam: Thank you. A clarification on the point I made on the role of nursing. What I meant is that if all these staff nurses are being asked to upgrade themselves, who takes care of the basic nursing care? Because when I was trained as a nurse many, many years ago, my nursing was different from now. As I understand now, we have to move forward and modernise the nursing care. Who would take care of the basic nursing care like patient care after surgery, medicine and the usual sort of things? I believe it must be the Assistant Nurses and some others. Will their job be compromised?

Mr Gan Kim Yong: Sir, as I mentioned, there are three tracks. One of them is for nurses to remain in the nursing practice, clinical nursing where the nurses will continue to be nurses. They are not educators. They are not administrators. They will remain as nurses. So, the nurses on this nursing track will continue to look after the patients. Even administrators will continue to look after patients, although they have a special focus on administration and leadership. Even nurse educators also practise. If you do not practise, you will lose the skills for nursing and then it would be very difficult for you to teach the next generation when you do not have the skills anymore. Whichever track you are in, we will also continue to make sure that your nursing skills remain current. Patients will have nurses look after them, especially from those on the nursing track.

The Chairman: Dr Lam, after a very healthy dose of clarifications, can I ask you to withdraw your amendment, please?

Dr Lam Pin Min: Mr Chairman, I would like to thank the Minister, Minister of State as well as the MOH team for having good 20-20 foresight with their Healthcare 2020 Masterplan addressing their accessibility, affordability and quality of healthcare in Singapore. I would also like to thank the Members of the House who have spoken so passionately on issues that concern the health and well-being of Singaporeans. With that, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

The sum of $4,080,897,400 for Head O ordered to stand part of the Main Estimates.

The sum of $640,715,200 for Head O ordered to stand part of the Development Estimates.