HEAD O - MINISTRY OF HEALTH

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Head O – Ministry of Health

Dr Lam Pin Min: Mr Chairman, can I have your permission to take all four cuts together?

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The Chairman: Yes, please. ****

Wellness-centric healthcare model

Dr Lam Pin Min: Mr Chairman, Sir, I beg to move,

That the total sum to be allocated for Head O of the Estimates be reduced by $100.

Sir, allow me to relate this account written by a relative of a patient dying of end stage respiratory failure. He wrote:

"Last night I was at the emergency department with my uncle who was dying. He was 62 years old with end stage respiratory failure, and had a background of chronic emphysema. Emphysema is a form of chronic obstructive lung disease where the air sacs of the lungs known as alveoli are progressively damaged. My aunt was with him and was visibly shaken at the state of his condition, even though he had struggled with his breathing for more than two decades of his life.

I was touched by the little acts and the conversation that transpired between my uncle and my aunt. She was trying to make him as comfortable as possible, giving him extra pillows and asking him if he was okay. He was either unaware of the seriousness of this hospital admission or he had chosen to ignore it. Most of his limited conversation was about completely trivial things – the weather, the upcoming weekend.

At one point, he whispered to my aunt, but she could not hear him because he was wearing a large full-face mask, hooked up to an oxygen machine. She leaned closer, 'What's that dear?' I was also up close, and could barely make out what he was saying. What last words would he whisper, I thought to myself. I pictured myself in his position – maybe I would tell my wife how much I loved her or enjoyed us being together. My uncle leaned closer to my aunt and mumbled in his feeble voice, 'I am sorry I have not listened to you all these years. I love my cigarettes but I love you even more. Please forgive me.'

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I found myself immediately pondering how fleeting life is, how everything can change in a split second. After hearing this, I decided to quit smoking myself. Sometimes, it takes a wake-up call to truly appreciate things – you do not realise how good and important it is to have a healthy body until you lose it!"

3.45 pm

Sir, this testimonial of an ex-smoker illustrates very well the importance of good health. Good health does not come naturally and will not last forever. It is a goal that can be achieved easily through healthy living, healthy eating and regular exercise.

Falling sick and going to the hospital is never a happy occasion, with the exception of giving birth to one's newborn child. Notwithstanding the good reputation of our medical institutions, going to one can be a stressful experience. Patients can wait up to one hour, sometimes even two hours, to see the doctor for consultation that lasts only a few minutes. Then spending another hour just to collect the medication at the pharmacy. Thus, I believe that it is the wish of all Singaporeans to avoid going to hospitals as much as possible.

Once stricken with a disease, the qualitative added life years of a person can be severely limited, even with treatment. For example, a transplanted renal patient will be on immune-suppressant drugs for the rest of his life and this can often lead to all kinds of other diseases due to the side effects of the immuno-suppressive therapy.

Our healthcare system must therefore strive to keep patients away from the hospitals as much as possible. Even better, manage their health such that a person's entire lifetime visits to the hospital is kept to the minimum. This must be the key performance indicator

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(KPI) we should strive more in a wellness-centric healthcare model.

To achieve this KPI, it is crucial to maintain a healthy lifestyle, exercise and go for regular health screening. Although the grassroots organisations and many VWOs have taken the right step in organising mass health screening for the residents, following up on cases that need medical attention is even more important so that early intervention can be instituted.

Over the years, Medisave has been liberalised progressively for payment of medical-related insurances, outpatient treatment and investigations. An example will be the Chronic Diseases Management Programme (CDMP) where Medisave is allowed to be used for the cost of outpatient treatment, up to a cap of $300 per Medisave Account per year.

However, we know that early detection and subsequent prompt treatment of diseases can improve the prognosis and outcome. I would like to urge the Minister to consider allowing the use of Medisave for health screening but still subject to similar restrictions of capping the maximum withdrawal limit to $300 per account per year and strict guidelines on the types of screening allowable. This would prevent premature depletion and potential abuse of the Medisave savings.

One of the challenges facing affluent societies, including Singapore, is obesity. Obesity is one of the most important factors causing an upsurge in the twin diseases of hypertension and diabetes. These two diseases are the major contributing cause for the 18 million cardiovascular deaths in the world. Hypertension and diabetes can be prevented with regular exercise and by leading a healthy lifestyle.

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Obesity is linked to many other diseases and one of the most well-known is diabetes. Diabetes is one disease, if not well-controlled, can lead to many medical complications, such as kidney failure, heart disease, blindness and disability from leg amputations.

Can I ask the Minister for an update on the prevalence of obesity in Singapore and what is MOH's strategy in tackling the issue of obesity in Singapore?

In 2003, the World Health Assembly adopted the global strategy on diet, physical activity and health which targets lifestyle modifications that can combat the increase in non-communicable diseases. The WHO issued objectives for developing countries regarding school meals and healthy living. Can I ask the Minister if his Ministry has studied this strategy and whether this is relevant in our local context?

Staying healthy is actually one's responsibility. You cannot force a person to stay healthy if the person is not motivated to do so. Smoking, alcohol consumption, drug abuse and living a sedentary lifestyle are important risk factors for a future plagued by illness, pain and sufferings.

In spite of the challenges faced by the Ministry and the Health Promotion Board in promoting a healthy lifestyle amongst Singaporeans, I would like to ask the Minister for his strategy in helping Singaporeans lead healthier and happier lives. Has the Ministry considered ways to incentivise Singaporeans to stay healthy, such as lowering premium or rebates for health insurances?

I hope the Minister can share with us his words of wisdom in building a wellness-centric healthcare for Singaporeans.

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Healthcare infrastructural development

Sir, my next cut. The population of Singapore has increased significantly over the past five years and the current resident population in Singapore stands close to five million. However, the speed of healthcare infrastructural development did not keep pace with the population increase, resulting in the long waiting times and the shortage of hospital beds in our clinics and hospitals respectively.

The opening of Khoo Teck Puat Hospital (KTPH) has relieved the high workload in Tan Tock Seng Hospital (TTSH), and several months into its opening, KTPH is already experiencing high occupancy of its inpatient beds.

In addition, with the rapidly ageing population, there is an urgent need to look into infrastructural requirements to meet the increased demand. I had also received feedback that the increasing population in new towns like Sengkang and Punggol has resulted in long waiting times at the polyclinics such as Sengkang Polyclinic.

I would like to ask the Minister for an update on the healthcare infrastructural development, especially the Ministry's strategies in tackling the rapidly greying population. I would also want to ask the Minister for his plans in promoting community rehabilitation of patients with mental illnesses.

Infectious diseases and flu pandemics

Sir, my third cut. Singapore is a globalised and connected world with a very busy seaport and airport. Our tourist arrival reached 11.6 million last year. As the economy picks up, more and more Singaporeans are going for holidays abroad, judging from the sell-outs at recent travel fairs.

The excellent air, sea and land connectivity has resulted in our borders

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being highly porous and highly susceptible to all kinds of infectious diseases. An infectious strain in one corner of the world can spread to Singapore overnight.

Our battles with SARS and H1N1 have taught us the importance of close collaboration between various Government agencies and multi-disciplines in dealing with epidemics and pandemics. A breakdown in communication could result in dire consequences.

I would like to ask the Minister for an update on the infectious diseases and flu pandemic preparations. Are there scenario planning exercises to ensure the readiness of the various relevant agencies?

Homecare and intermediate and long-term care

Sir, my fourth cut. Singapore is one of the fastest ageing populations in the world. Coupled with our low fertility rate, more than 20% of our population will be above the age of 65 by the year 2030. In addition, Singaporeans are also living longer and a significant number of years of our lives will be spent in sickness.

As such, the demand for intermediate and long-term care for the patient, especially the elderly, will increase. This forms a very important component in the holistic care of a patient, from acute to rehabilitation to eventually recuperating in a nursing home or homecare.

More resources must be put into developing the intermediate and long-term care sector, as this is currently under-developed, judging from the long waiting list that these institutions are experiencing.

However, being an Asian society, the family has traditionally been the main source of support for our elderly. Many elderly sick patients would definitely

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prefer to stay in the comfort of their homes than be placed in nursing institutions.

Homecare will not be possible without the dedicated participation of the caregiver, who is a family member most of the time. In order for the elderly to age and recuperate properly and happily in their homes, the Ministry would need to look into building up the necessary resources and expertise in growing the homecare sector.

I would therefore like to ask the Minister the following:

(i) What is the current state of homecare and intermediate and long-term care in Singapore and how does the Ministry plan to develop these sectors in the coming years?

(ii) Can the Minister consider setting up a one-stop caregiver resource centre to provide a range of supportive services, including dedicated homecare medical teams to conduct medical review of stable patients at their homes so as to minimise the hassle of frequent travels to the hospitals or clinics for reviews?

(iii) Can the Minister also consider the provision of monetary allowance for caregivers to compensate family caregivers for their hardwork and sacrifices in looking after the elderly, rather than taking the easy way out of dumping their old folks in nursing homes? This would also help to free up the limited resources and vacancies in nursing homes for those families who really need them most.

Nursing homes

Assoc. Prof. Fatimah Lateef (Marine Parade): Mr Chairman, nursing home refers to a premise used for the provision of nursing for persons suffering from

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illnesses or convalescing from injury and infirmity.

As we prepare to ride the silver tsunami, we must be prepared from now our mindsets, infrastructure, facilities and services to support this. With the existing numbers of nursing homes now, it is not uncommon to hear families and spouses lamenting that long waits to get family members into one are quite long really. Moreover, many of us are unable to afford the fees of private nursing homes.

What are our future plans to meet this need? We need to project the expected numbers of elderly – elderly elderly and elderly sick, who will be requiring these facilities in the next five, 10 or 20 years. Can we also plan to have more of these nursing homes located conveniently in close proximity to our heartlands? This would facilitate family members visiting the seniors regularly and maintaining inter-generational family ties and bonds. Currently, about half of our nursing homes are already located near heartlands. We always prefer our elderly to be close to our homes or in our homes or in the community but nursing homes may be an inevitable reality in today's world where families face conflicting responsibilities. We must give thought to what makes our seniors truly happy in the nursing homes. More amount of modern amenities and parties organised by staff cannot replace the true joy that they see when they have their family members and friends visit.

On the issues of funding, currently MOH is doing a lot through Medifund contributions. With the recently announced Community Silver Trust in this year's Budget which confers one-to-one matching for donations to VWOs involved in long-term care, this will lighten the load and burden a little more and stimulate more money into this important area. When it comes to manpower and staffing of nursing homes, we must also inject

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more zest so that people will tend to choose this career.

I would like to ask what is MOH's plan on this important development of a model that we are aiming towards which is a world-class long-term care model.

Long-term care capabilities

Mr Sin Boon Ann (Tampines): Sir, the silver tsunami is almost upon us and we must be prepared for the transformation of our social landscape. One in every five residents will be above the age of 65 by 2030. Many Singaporeans can expect to live another 20 years more but the quality of life can vary greatly. A significant number will be affected by diseases related to ageing.

I would like to ask the Minister if our acute care institutions and community rehabilitation centres will be gearing up their capacity and expertise to deal with these cases. Do we have enough long-term care institutions and facilities? If so, do we foresee that funding may be an issue due to the sheer number of elderly patients and the long-term nature of their care?

Nursing homes have also voiced concerns about the lack of healthcare workers and funding for new equipment. Would the Minister share with us his analysis and assessment of this situation?

Long-term care for the elderly

Mdm Halimah Yacob (Jurong): Sir, this year's Budget talks about providing the best care for our seniors. I would like to ask the Minister how his Ministry intends to achieve this.

Long-term care should be provided seamlessly, from acute hospital care to community hospital, nursing homes and home-based care. There are many gaps in the services that are currently available to

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our elderly. There should be greater focus on home-based care instead of hospital or nursing care alone.

Sir, I have four suggestions to make. First, there is a need to provide an integrated home and community programme comprising medical, nursing and social services to the frail elderly who need intensive long-term care so that they can remain at home instead of being placed in a nursing home. The current day rehabilitation centres are inadequate as they provide only therapy and day-care services. Integrated care will include a wider scope of services with an addition of a multi-disciplinary team comprising nurses, therapists, case managers and healthcare workers.

The team will work closely with the patient's doctors be they General Practitioners (GPs), polyclinic doctors or specialists in hospitals. Such an integrated home and community care programme would also help provide support to caregivers who can continue to work and get respite from caring for the elderly during the daytime.

4.00 pm

Second, Sir, I urge for more support for caregivers who suffer from burnout, emotional stress and, worst of all, in many cases, loss of income and their own independence. This burden usually falls on the women who are often unmarried and unappreciated. I would like to ask the Minister to provide stronger support to caregivers by providing them respite from caregiving responsibilities, training as well as some financial support so that they are not left out and left behind.

Third, Sir, I urge the Minister to ensure that healthcare is affordable to our elderly, as many suffer from chronic illnesses requiring long-term treatment and medication. With rising cost of healthcare, many are concerned that they will not be able to pay for their bills and, in this regard, I am glad to hear that the $10

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million that has been set aside to help the elderly in mobility. Could the Minister provide more details on this?

Finally, Sir, manpower is a big challenge in the healthcare sector. We are short of not only doctors but nurses, therapists and other healthcare workers as well. Could the Minister enlighten this House and what is being done to address this?

Home care

Ms Ellen Lee (Sembawang): Sir, with the hospital bed crunch problem at our restructured hospitals and community hospitals, there is a greater need to re-look at how we handle our care for the sickly. There is an urgency in view of our fast ageing population and the increasing need for geriatric care. Despite the opening of the new Khoo Teck Puat Hospital, the problem is not fully resolved. The construction of the new Jurong General Hospital will take some years to be fully ready. Meanwhile, primary and step-down care alone may not be the dynamic panacea.

When a person is very sick, his family members will naturally think of the hospital as the most appropriate place for the sick person because they want the sick person to be better taken care of by doctors and nurses. Singaporeans seem to have lost the ability to take care of sick members of our family, or have no time to do so due to work demands or because the family has shrunk due to fewer and fewer or no children or siblings. In fact, for some ailments and chronic illnesses, I believe the home environment may well be the most conducive and curative environment. There are at present some groups such as the NTUC Eldercare and our hospitals which provide some form of training assistance to family members and domestic helpers to care for the elderly

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and the sick. I believe to a certain extent home care when it is properly taught and supported by a good back up team at the hospital that can be easily reached in times of need, may well be the most economical option in view of the rising healthcare costs. I therefore ask the Minister if he would consider vigorously promoting such home care as being the right care for patients and what support and programmes can be put in place to support this drive.

Home and community care

Mdm Cynthia Phua (Aljunied): Mr Chairman, Sir, geriatric illnesses span over a large variety of ailments of varying intensities. As such, I believe that we should offer more options to cater to the healthcare needs of senior citizens. There is a need to have more Government-subsidised home support services available for senior citizens living alone or with their family members. Mobility issues and physical weakness are common reasons for senior citizens to avoid seeking medical help. For some senior citizens, their limbs are so weak that just stepping out of their house is an onerous task that inflicts great amount of pain on them.

The Government must encourage the availability of more doctors and medical personnel to do home visits to treat and care for these senior citizens. We should provide support for these families to encourage them. Hence, education and relief-care support for caregivers need to be building up over time. If we are able to have a pool of relief caregivers, this would allow the caregivers to be able to walk away for a while and come back with renewed energy.

This brings us to the day-care centres and nursing homes in the community. The concerns of the community are that do we have enough day care-centres and nursing homes. If there is a shortage, how

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bad are we? Recently, we have a boost in the number of child-care centres and they were created within a short period of time. We know the numbers of elderly coming over the next 10 years. What are the planning parameters and the Ministry's estimation and its strategies on day-care and nursing homes in the community.

With the elderly, do we need a geriatric care unit in the community, for example, at each of the polyclinic? This should be a separate queue as the immune systems of senior citizens are significantly weaker than that of the young and the standard medication and treatment does not apply across the board.

Lastly, can we look into the subsidy for the elderly for day-care services and nursing homes for families since we have allowed levy subsidy of maid for such home care?

In view of the increasing elderly, we need to have more people knowing how to care for our elderly from the doctors, qualified nurses to step-down care nursing assistants and basic health care personnel. What are the plans of the Ministry to increase this pool of expertise? In addition, at the community level, some regular checks like monitoring tests, for example, the high blood pressure test and the sugar level test, can be done by certified medical personnel who are trained to do this work. In such cases, the residents do not need to travel far and this can be done near their homes.

Alternatively, if we have a good medical IT system, long-distance consultation could also be done since all our flats are going to be wired by a new fibre network. The data transmission is very fast. This will allow our limited number of medical officers to reach out to more patients in the community.

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Elderly care

Mr Ang Mong Seng: ( In Mandarin ): [For vernacular speech, please refer to Appendix A.] Our population is ageing rapidly. Currently, 10% of Singaporeans are aged 65 and above. By 2030, 20% of Singaporeans will be over 65 years old. Our total population by then will be 5 million while seniors aged 65 and above will be 1 million. We must prepare early, especially in the areas of healthcare and nursing homes. We cannot wait until 10 or 20 years later. We must start right now. The Minister has announced the building of more nursing homes in HDB estates. It is welcomed by the elderly.

I would like to ask the Minister how many nursing homes we are going to build in the next five years. As many people do not understand the difference between a nursing home and an old folks' home, I hope the Minister can explain the difference so that the seniors will understand. It is best that if he could say it in Chinese.

Secondly, the elderly's medical needs are different from that of young people. They mostly suffer from chronic ailments and need long-term medication and care. We need to train a group of doctors and nurses that understand the elderly so as to provide them good services. I suggest we set up clinics for the elderly at the same time as we build the nursing homes to provide medical services to the seniors.

End-of-life care

Mr Low Thia Khiang: Mr Chairman, Sir, the Economic Intelligent Unit 's Report – the quality of death commissioned by the Lien Foundation ranks an end-of-life care services across the world. Apart from palliative care, end-of-life care in the report also includes broader social, legal and spiritual elements of care relevant to quality of death. Singapore was ranked 18

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out of the 40 countries in the quality of death index.

Countries that ranked higher than us include the United Kingdom, Australia, New Zealand and Taiwan. Singapore's economic transformation from third world to first world was borne out of the hard work put in by past generation of Singaporeans. Now that these aged Singaporeans are pushing the end of their lives on earth, it is a shame that the quality of end-of-life care given to them is not of first-world standard.

Even countries such as Belgium and Ireland are able to achieve better scores than Singapore in the four areas covered by the quality of death report. These are basic end-of-life healthcare environment, availability of end-of-life care, costs and quality of end-of-life care. Why is Singapore falling behind so many countries in these areas?

Sir, I would like to ask the Minister for Health on MOH's initiatives towards end-of-life services. I noted the Minister seems to encourage Singaporeans to die at home to avoid consuming scarce hospital resources. The Government has shown itself capable of giving up $1.5 billion in Growth Dividends to all citizens including the richest amongst us. Could it not consider re-allocating such public money towards support and subsidies for end-of-life care in the areas of palliative care, hospice and home care for the elderly and the poor amongst us?

Polyclinics

Ms Ellen Lee: Mr Chairman, Sir, I would like to ask the Minister when will polyclinics be operated on a 24-hour basis? Although our polyclinics run by SingHealth and National Health Group (NHG) cater mainly to patients in the heartlands, they are increasingly being sought after by those living in the private

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estates as well. The usage of polyclinic services appears to be extremely high as we see many of our polyclinics having long queues with daily patient load that could well exceed 1,000 patients. This could be due to the fact that their operating hours are from 8.00 am to 5.00 pm and that their costs for consultation and medicine are generally lower compared to the privately-run clinics, especially those that remain open after 9.00 pm or 10.00 pm at night. I believe that there is a surcharge or a premium that is being paid for staying opened when all others are closed.

Moreover, these polyclinics remain open for only six days a week and they are closed on Sundays which means that the crowds on Mondays are usually higher. That there is a growing demand for healthcare services at our local polyclinics is never in doubt. I wish to ask the Minister, in view of our increased population and greater demand for healthcare services and the high healthcare costs, if our polyclinics can remain open for 24 hours.

Singaporeans' lifestyle has changed tremendously and many do not keep strictly to the nine to five regime, especially those who are working. School-going children who attend the afternoon sessions are reaching homes after 7.00 pm and their working parents are returning home much later than that. When someone falls sick in the night, even the private clinics near their homes may have closed for the night. The few clinics that run 24 hours are charging much higher fees. It is at this time that if the polyclinics are open 24 hours, they will be serving a huge void. Further, minor ailments need not be rushed into the Accident and Emergency units of the hospitals.

Polyclinics and medical IT

Mdm Cynthia Phua: Mr Chairman, Sir, presently polyclinics are an essential

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service in the community especially for the elderly, a daily service that is visited by many residents. In view of this essential service, the polyclinics are always very busy and crowded and see the whole spectrum of citizens, from infants to the common flu to the follow-up of chronic diseases of the elderly. We know we need more polyclinics simply by the virtue of the increasing population and our increasing elderly population.

It is time for the Ministry to review the roles and responsibilities of the polyclinics in the community. What are its KPIs – baby care, geriatric care, step-down care of the hospitals or walk-in care for the public? The needs are many and varied. Who are the target customers of the polyclinics? What income levels are polyclinics serving which population segments? How about our foreign workers? They do need care too. Is it part of the polyclinics' role to serve this community as well? In view of the range of needs and the target customers, it will be a challenge for the Health Ministry to ensure that the community or the target customers the polyclinics set to serve are being served well and at affordable rates for the medical care.

I am not sure of the Health Ministry's planning parameters for the number of polyclinics in the community in relation to population. Could the Minister let us know the Ministry's direction on the roles and responsibilities of polyclinics? Who are the target customers of the polyclinics and its plan on the expansion of the polyclinics in the community?

Next, just to highlight the concern on the grounds. The long queues and the waiting time: what are the measures the polyclinics are taking to cut down the waiting time? I would also like to highlight that this essential service needs to be accessible to the community and near to transport hubs as our people are getting older. The other concern on the ground is

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the opening hours. Many of the rehabilitative and follow-up cases would not be able to go to the polyclinics during office hours and, in general, they would prefer the Saturdays. However polyclinics operate for half a day on Saturdays and the ground is asking for longer hours on the weekends.

On medical IT, there are two areas of interest: one is the data collection and sharing and the other are the use of medical IT for distant consultation and diagnosis. With the integrated medical information system, this would enable the polyclinics to extend its services to the heartland.

For example, to tap on Minister Mr Lim Boon Heng's strategy of the Wellness Programme for the elderly, we could get retired nurses to take blood pressure and do basic sugar level tests at the Residents' Committee Centres. Records could be keyed into this integrated medical information system. This would reduce the need to visit the polyclinics.

Finally, with the fibre network coming into the community, the transmission of data will be at super speed. The use of medical IT for distant consultation and diagnosis is very possible and can be done easily.

4.15 pm

Promote pro-health behaviour

Assoc. Prof. Paulin Tay Straughan (Nominated Member): Sir, as life expectancy improves, it is critical that we promote healthy lifestyles so that we can prolong the periods of good health in our golden years. A key component to sustained good health is the embrace of regular health screening for early detection of ailments. Early detection can arrest the development of many chronic ailments, and will save lives in the case of critical diseases like cancer.

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Currently, the take-up rates for many early detection procedures, like the mammogram, is below optimum level. To encourage Singaporeans to step forward and take proactive action to promote long-term well-being, may I suggest that the MOH starts a health credit scheme. Each time, a Singaporean takes part in a health screening exercise at the polyclinics or other locations specified by the Health Promotion Board (HPB) or MOH, he get credits that are entered into his record. The cumulated credits can be used to offset healthcare costs invoked when he sees a doctor, makes purchases at the pharmacy, or even for hospitalisation. I hope that this incentive will encourage Singaporeans to make health screening a norm and part of their annual rituals.

Manpower in healthcare

Assoc. Prof. Fatimah Lateef: Mr Chairman, the demands in our healthcare sector is growing annually. With the increasing patient load, rapidly ageing population and increasing expectations of our populace, we have no choice but to increase the number of staff in all healthcare sectors and disciplines. Graduating only 250 doctors a year, we need to employ double this number of foreign doctors. We are also in need of more nurses, and especially allied health personnel. Our doctor to patient ratio is not optimal as in some other developed countries.

With the good NUS doctors, and now the third medical school, the numbers that are going to be added will be very small initially. The numbers will have an impact on quality of care, waiting times, satisfaction rates and other measurable KPIs. What is MOH's plan to enhance healthcare manpower? What has been the outcome pertaining to our ongoing efforts to bring back our Singaporean medical students and some of the young

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doctors working overseas? What are the Minister's views on the newly introduced scholarship for medical students studying overseas? Will this create a significant increase in the number of doctors that we can bring back in the next five, 10, 20 years? Also on one other area of concern is the distribution of manpower. Of course, staff will tend to join more glamorous and popular specialties. Are we doing more to attract healthcare staff to the disciplines which are less popular, such as rehabilitation, pathology and renal medicine, and so on. Healthcare manpower projections and planning are crucial and we have to start planning from now.

Primary care partnership scheme

Mr Low Thia Khiang: Mr Chairman, Sir, the primary care partnership scheme by MOH has helped needy elderly and disabled Singaporeans receive subsidised treatment at general practitioners (GPs) and dental clinics near their homes. The scheme is convenient, saves travel time and expenses, and eases the pressure on polyclinics to expand their services and facilities to cope with the increase patient load.

I understand that there is good support for this scheme from the GPs located in the heartlands or neighbourhoods. Could the Minister provide the statistics for the current patients' participation rate and share with the House on the experience gained by MOH on the administering of the scheme? Could the Minister also provide information on whether the annual subsidies of up to $240-$360 for the treatment of chronic conditions are enough?

The current criteria for patients to be qualified for this scheme for subsidised treatment are quite stringent: the qualifying age is 65 and above and the per capita monthly household income of the applicant must be $800 or below. If

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not, the patient has to be a disabled or earn the same income level on the Public Assistance scheme. Could the Ministry of Health consider reviewing the criteria to enable more needy patients to benefit from this scheme? For example, the qualifying age could be revised to lower than 65 years old, the qualifying per capita monthly household income of $800 could be revised upwards, and the requirement for the patients to be unable to do any of the six activities of daily living could be reviewed. MOH could also consider a tiered system of subsidies where polyclinic patients can choose to be included in this scheme but will be given lower subsidies, if they were to go to the polyclinic.

The Chairman: Ms Sylvia Lim. You have three cuts. Take them together, please.

Standard drugs list

Ms Sylvia Lim (Non-Constituency Member): Sir, first, standard drugs list. The Government maintains a standard drugs list (SDL) of subsidised drugs. However, there are some issues of transparency concerning the list and decision-making processes. First, is the SDL public information? It is not easy to find the SDL and even doctors I have spoke to were uncertain. In comparison, it is easy to locate the central drugs list maintained by the World Health Organization and several other countries online.

Secondly, there is little information about how our Drug Advisory Committee raise various factors before deciding if a drug should be on the list or not. The Committee reportedly takes into account factors, including the cost effectiveness on each drug, but what exactly does that mean? For instance, how are the findings on pharmaceutical economic research used in this decision-making process?

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Ms Sylvia Lim (Non-Constituency Member): 4.21 pm

I understand that there is, within the Health Sciences Authority (HSA), a unit called the Pharmaceutical Economic and Drug Utilisation (PEDU) Unit. This unit assists the Drug Advisory Committee to assess the cost effectiveness of such drugs and the financial impact to the Government's drug budget.

In 2008, there was an analytical study entitled "Healthcare Systems and Pharmaceutical Economic Research in the Asia Pacific Region" published in the journal, Value in Health . The authors of the book opined that the Singapore system involves "A simplified cost effectiveness evaluation", which was in fact a trade-off considering the available staff at our Pharmaceutical Economic and Drug Utilisation Unit, and how far the Drug Advisory Committee understood and accepted pharmaceutical economic concepts. Can the Singapore decision process be made more transparent? Australia and Canada both devote entire websites to inform the public of the process of decision-making and the rationale for decisions. The information includes reasons why a drug is not included, with clinical data to back up their conclusions. As we are talking about the danger of life-saving drugs, more transparency will go a long way towards building public trust.

Osteoporosis

Next, osteoporosis is a major public health problem worldwide and a particularly significance to Singapore's ageing society. The Government is aware of this as seen in the issue of the MOH's clinical practice guidelines circa 2008 on osteoporosis. Osteoporosis suffers on increased risk in fractures which may

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require hospitalisation and cause their health to deteriorate due to prolonged immobilisation. Many patients who sustain fracture do not return to their previous functional status and may require long-term institutional care. Figures from Singapore show that the incidence of hip fractures has gone up significantly since the 1960s, five times more in women and 1.5 times more in men. One year post-hip fracture, between 20% and 25% die, 30% of survivors are semi- or fully dependent. The costs to the individual, family and society are thus significant. Adequate treatment of osteoporosis is best essential to reduce these effects. What efforts have been made towards increasing public awareness and prevention so that this disease is not undertreated?

Long-term care

Finally, long-term care. The Eldercare Fund was set up in the year 2000 to grow income and provide funding for nursing homes and other long-term care providers. The Government has stated that the Eldercare Fund would not replace community support in this sector, and that community donations are vital in financing step-down care for those of low and low-middle income. According to the MOH website's write-up on eldercare, "voluntary welfare organisations should continue to raise funds from the community and do their part in helping the needy and indigent patients to foot their share of the charges using the donations raised."

In this Budget, the Government has set up the Community Silver Trust to provide donations for long-term care providers. While community-giving must be encouraged and incentivised, my question is what role the Government is playing to monitor and moderate the cost of long-term care to the patient or user?

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Overseas Medisave use

Dr Lam Pin Min: Madam, the flow of medical tourism is not a one-way traffic into Singapore. Increasingly, more and more Singaporeans are travelling overseas to seek medical treatments. These could range from complicated operations, such as organ transplant to corneal refractive procedure, such as lasik.

The scheme to allow Singaporeans to pay for medical treatments at selected overseas medical institutions was introduced last year. Singaporeans choose this option for several reasons, the commonest being the cheaper medical cost overseas. Can the Minister update the House on the utilisation rate so far, and how has this scheme benefited Singaporeans?

Insurance for congential diseases

Madam, having a newborn child with congenital illness can be devastating news to the parents. Besides the emotional upheaval, parents whose children are inflicted with congenital diseases also face tremendous physical and financial stresses. In light of our Government's promise of an inclusive society, would the Health Minister consider extending MediShield, which is our national health insurance to cover congential diseases for children?

Medisave

Assoc. Prof. Fatimah Lateef: Madam, our infant fertility rate in Singapore is one of the best in the world today. Congenital birth defects, on the other hand, have now become a major cause of perinatal and infant mobility and mortality here. We do have the national birth defects register set up by MOH in January 1993. Those affected will require regular and frequent medical follow-ups, investigations, interventions and hospitalisation. These can incur very high costs. The parents are

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often left with not much of a choice as these conditions are rare and they require rather aggressive interventions. Take Down Syndrome for example, the commonest chromosomal abnormality which causes a multitude of congenital defects. These people can live to a very ripe old age and managing all their potential complications can indeed be hard on the families. Thus, it could be beneficial if MOH can consider allowing their Medisave or MediShield to be used for payments for the management of congenital diseases. For selective cases where familial screenings are to be carried out, can we also consider using it in a graduated fashion with specific guidelines?

Mdm Halimah Yacob: The recent flexibility allowed in the use of Medisave for outpatient treatment was well received by many. However, many have given me the feedback that the limit of $300 is far too low. Some shared with me that the consultation and medication for three months for chronic illnesses alone could cost them more than $200 and this includes treatment at the polyclinics. After that, they would have to use cash, which they do not have. As a result, some may skip visiting the doctor.

I have three points to raise. Firstly, I would like to ask the Minister whether he would allow Medisave to be used for health screening. Secondly, I would like to ask the Minister whether he could consider raising their Medisave withdrawal limit for outpatient treatment to a more realistic level, so that patients could have uninterrupted treatment. Thirdly, with rising healthcare costs, I would like to ask the Minister whether there is a need to increase the minimum required amount (MRA) which was set a few years ago, as our current MRA may not be adequate to meet our long-term needs.

The Minister for Health (Mr Khaw Boon Wan): Madam, last month, I tossed

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vegetarian lo-hei with Prof. William Haseltine. He is an outstanding academic, inventor and entrepreneur, a very rare talent. At Harvard University, he became a founding father in an evolving branch of research which sequenced DNA, and then used the human genome to identify and treat diseases. He holds many patents and founded several bio-tech companies. His current interest is to seek out healthcare innovations and apply them globally to bring about cheaper and better health.

I first met him last year at an NUS Healthcare Forum. He was intrigued by our healthcare system, delivering first world standards at only 4% of our GDP. Many OECD countries spend more than 10%. He was in town to find out more with the intention of writing about it.

Prof. Haseltine's assessment corroborates with several commentaries about Singapore's healthcare system that appeared during Obama's health reform debates. For example, a Wall Street Journal article in November 2009 described Singapore as having "world-class quality care at world competitive prices". The article added that "Singapore's example might have something to teach them about the kind of reform Americans really need."

The Austrian Health Minister was also in town last month. After spending some time at the Khoo Teck Puat Hospital (KTPH), he remarked to me that many of the policies that he was planning to introduce in Austria were routinely done here. I took that as a compliment from a well-informed peer.

We do not claim our system to be perfect. But we achieve a better outcome for our people because we have more readily acknowledged the hard truths of healthcare and forged our system based on such insights. What are the hard truths?

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4.30 pm

There is no free healthcare; someone has to pay the bill. While most people are honest, some patients and some providers do abuse the system at the expense of the vast majority of honest people. More healthcare does not always deliver better health. Beyond some point, there are limits to medical science. Many healthcare problems are self-inflicted. Dr Lam gave the example of the patient with Chronic Obstructive Pulmonary Disease (COPD). No medicine, for example, can help a patient with COPD unless he or she stops smoking.

Incentives can work in healthcare but poorly-designed though well-intentioned health policies can end up distorting behaviour. Lastly, and most importantly, we are all mortals and eventually we all have to die.

Many other healthcare systems choose to ignore these hard truths and are, for instance, based on wishful thinking that people can live forever, that more treatment is better, and there is a cure for every disease, "a pill for every ill". For the terminally ill, they will strive to prolong life at all costs, never mind the quality of life nor the futility of such efforts. The US spent 18% of its GDP on healthcare and they know that much of that is unnecessary.

My recent heart bypass has sharpened my sense of my own mortality. I have regained my fitness level. In fact, today is exactly 10 months after my bypass and I have become even more diligent in my regular exercises. Before coming here, I did four and a half kilometres on the treadmill. But I know the score of having to live with heart disease. I am 59 and I do my best to keep my body in good condition, live a full life, and hope to grow old with dignity. But I am under no

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delusion and I know that someday I, too, will leave. The question is how? Like others, I have my share of worries. Will I suffer a stroke that condemns me to severe disability? Will I develop dementia and lose my mind?

At every Chinese New Year, I wish my residents "健康长寿" or good health and longevity. They said "yes" to the first part, good health. But on longevity, many said: "not too long please" and I know what they mean. We all strive for a long, meaningful life, but the two words "long" and "meaningful" have to come together in order to make a happy person. A long life of pain and suffering is a miserable life.

I am reading Susan Jacoby’s latest book “ Never Say Die ”. This is my bedside reading at the moment. She was most critical of the American approach to end-of-life care. In it, she related her last conversation with her grandmother in a nursing home when she was nearly 100 years old. This was what she recalled: "A small boy tossed a beach ball in our direction. Gran tried to rise from her chair and throw the ball back but she was too frail to stand without help. Collapsing backward, she said in a soft voice devoid of either self-pity or anger, 'the worst thing about having lived too long is you know you are of absolutely no use to anyone.' It was agonising for me to hear my grandmother said this, because she defined herself by her usefulness."

I often visit nursing homes with my grassroots leaders. Some patients welcome our visit as it breaks their daily routine and we do bring cheer to them. But many with severe dementia live in their own lost world, oblivious to what is going on around them. Many others are clearly suffering. Often, I just looked at my grassroots leaders and by our body language, without a word being spoken, we say to one another: "Let’s hope we do

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not end our life this way." I would silently offer a prayer for the patients.

In my Ministry, we have crafted a phrase "with peace of mind" into our vision to help Singaporeans "live well, live long and with peace of mind". We meant this seriously. I took this mission diligently. My personal mission in life is to help serve the young and the old so that they have peace of mind. In Chinese we call it "老者安之，少者怀之". This came from Confucius. That was his personal mission in life when asked by one of his students.

We cannot eliminate death and suffering. But we can avoid inflicting unnecessary pain and suffering to the natural process of dying by being wise in our healthcare policies and in how we structure our healthcare system. In her book, Susan Jacoby also wrote about an American woman who, just a month before her 100th birthday, underwent surgery to install a special defibrillator and pacemaker in her failing heart. When it happened, it was front page news on New York Times . That is a great achievement in medical science. The surgery postponed her death and extended her life for a while. But it was a life full of suffering, requiring the full-time services of a home healthcare aide, paid for by taxpayers and being confined to a wheelchair with both failing vision and failing hearing. This may be an extreme example, but in the US healthcare system, such cases of aggressive medical intervention during one’s last few months or weeks are not uncommon.

We have a good and relatively inexpensive healthcare system because we have sensible and wise doctors. We must not port in mindlessly foreign practices based on fallacies and unrealistic expectations. That will only bring misery to the patients and their families at great cost to society. Singaporeans are living longer and, with it, there will be greater demand for healthcare services. They also

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want to age in place, at home and in the community, except for the occasional emergencies to the acute hospitals. Much of the healthcare services for the elderly can be competently delivered in the community, away from costly hospitals. That is why Budget 2011 places so much emphasis on long-term care. Even as we improve our hospitals, we will do even more to transform our long-term care sector and many MPs spoke about this.

We have already started this journey and we are on track. The new Khoo Teck Puat Hospital (KTPH) illustrates how we are making progress. Most MPs have visited it. You have seen how we have raised services, especially for patients in Class B2 and Class C, to a higher level, delivering a "hassle-free" hospital experience. You have also heard how KTPH is reaching out to the community outside of the hospital and supporting them to look after the discharged patients. In other words, all the hospitals’ CEOs know that their responsibility now extends beyond the hospital walls. It is not just within the hospital walls. And this transformation is not just in KTPH. There is also a quiet revolution in Changi General Hospital (CGH), Tan Tock Seng Hospital (TTSH), National University Hospital and polyclinics. We have made progress in mental health, chronic disease management, integrated care between hospitals and the community.

But the work is not finished yet. I still have a substantive agenda of things to accomplish. If we stay the course, over the next five to 10 years, we can further transform our healthcare, to be among the best in the world. Let me sketch out our plan in seven areas.

First, we will realise our vision of a general hospital in every region. In the north, KTPH has added 550 beds to our bed capacity. In the west, the Jurong General Hospital (JGH) is on track to open in 2014 with 700 beds.

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Dr Lam will be pleased to know that a new general hospital will come up in his constituency to serve the residents living in the north-east. The new Sengkang General Hospital will be located next to the Cheng Lim LRT Station. It will also be within walking distance to the Sengkang MRT Station which is in Mr Charles Chong’s constituency. It will open by 2020. Given a lead time of six or seven years to design and build, it is not too soon nor too late to start planning. I have asked the SingHealth Cluster to assemble a young outstanding team to take charge of this project. I will challenge them to build a hospital, even better than KTPH and JGH, measured from the patients’ point of view.

All the three general hospitals will have community hospitals adjoining them, and this will significantly expand our community hospital capacity. These are multi-billion-dollar investments but they are worthy investments. Together with TTSH serving the central region and CGH serving the east, they will realise our vision of bringing healthcare close to the residents living in each region of Singapore. Good healthcare will be within 30 minutes of every patient.

Second, we have achieved very good mortality indicators, including life expectancy, child mortality and other disease-specific death rates. We will now measure how specific diseases impact the overall well-being of Singaporeans. To do so, we will track morbidity indicators and strive for further improvement. My vision is to get our morbidity indicators to match the top tier of OECD countries in the key disease areas which matter to us, like heart disease, diabetes, mental disorders and cancer. We are currently about average, among the OECD countries. Let us move up to a higher tier.

This means knowing how to better treat these common diseases, whether in

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terms of prevention, early detection, treatment, rehabilitation or continuing care. For example, Assoc. Prof. Straughan mentioned just now our mammogram screening rate. We are below OECD average and we have to make progress there. This will require us to raise the capabilities and outcomes of our national specialist centres to match the best elsewhere. Where appropriate, we will invest in building new capability peaks in areas such as organ transplant, geriatrics and rehabilitation.

Third, we have been redeveloping our polyclinics to meet the challenges of an ageing population. Over the past five years, we have upgraded eight polyclinics, including Woodlands, Bukit Batok, Pasir Ris and Hougang Polyclinics. As Assoc. Prof. Fatimah Lateef put it, strengthening primary care is important. Several MPs toured the upgraded Pasir Ris Polyclinic recently. The upgraded polyclinics are now paperless, fully computerised. They are film-less with tele-radiology services. X-rays are being read in India by US Board-certified radiologists and returned within half an hour. They are scriptless, that is no more paper prescription, with e-prescription (electronic prescription) capability. They are also piloting tele-ophthalmology to cut down unnecessary referrals to the hospital ophthalmologist. The use of technology – a point that Mdm Cynthia Phua mentioned just now – all those are happening in our upgraded polyclinics.

They are also multi-disciplinary, no longer just doctors, nurses and patients, but with advanced practice nurses, clinical pharmacists, podiatrists and clinical psychologists providing consultations, side by side with family physicians. Patients with chronic diseases are given clinic appointments for their regular follow-ups. It is no longer just simply walk-in. This has cut down their waiting time for those with appointments.

In other words, our polyclinics are no longer like in

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the past and that is why I have arranged some MPs to visit them so that they do not live with the image of the polyclinics of the past.

4.45 pm

One patient emailed me last month, pleasantly surprised by the transformation. I quote him: "I visited the Marine Parade Polyclinic. The service was fast, friendly and efficient. The time from registration to payment was less than half an hour, a far cry from the days when a visit to the polyclinic was a two-hour affair". I know that waiting remains a problem in polyclinics for walk-in patients without any appointments. But for those with appointments, waiting is now manageable. We will continue to upgrade the other polyclinics. Over the next five years, Ang Mo Kio, Bedok, Geylang, Tampines and Yishun Polyclinics will benefit from this polyclinic redevelopment programme. This will cost us $50 million. For the rapidly expanding population in Punggol, we are also planning a new polyclinic in that town. This will help relieve Sengkang Polyclinic.

Fourth, we will transform long-term care like community care hospitals, nursing homes, day rehabilitation and home health care, which many MPs spoke about. Done well, this will particularly benefit the elderly with chronic diseases. The objective is to help them manage the disease well, so that they can have a good quality of life. Transforming long-term care is our top priority in the next decade. We will sharpen our focus on geriatric care. We will equip all our doctors, nurses and allied health professionals with knowledge of geriatric medicine as a core competency. Of course, the healthcare professionals must also acquire the soft skills to understand the needs and concerns of the elderly patients in order to deliver better care, as Mr Ang Mong Seng pointed out just now.

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We have begun preparations to set up a Geriatric Education and Research Institute this year to develop, coordinate and implement various initiatives to strengthen geriatric education and research. We will develop integrated care pathways starting with five groups of patients with hip fractures, stroke, heart failure, COPD and diabetes. By standardising critical elements of care and defined clinical indicators, these integrated care pathways will enable patients to transit smoothly from one healthcare provider to another across the care continuum. This is what I meant by a "hassle-free healthcare system". This is also the sort of preferred outcome that Mdm Halimah spoke about just now. Truly integrated care.

Our AIC – the Agency for Integrated Care is just one year old, but it is already making impact in the long-term care sector. They are doing what Dr Lam described as supportive services to facilitate care in the community. To give an example, AIC stations teams of what we call Aged Care TransitION (ACTION) care coordinators in hospitals to help patients with complex needs transit smoothly from the hospital back into their homes and communities. Their services include helping the patients to arrange relevant community services for the patient and their caregivers. They have already touched the lives of over 10,000 patients. "Hassle-free", "integrated care", "clinical pathways" are abstract technical terms. But when translated into actual actions on the ground, they make a world of difference for the patients and their families.

Just ask Mdm Samsiah Saifi. Her husband suffered a stroke, became paralysed and bedridden. Overnight, she became both sole breadwinner and sole caregiver. She was at her wits' end. Her ACTION care coordinator from NUH slowly coached her on the appropriate

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homecare services that her husband will need and followed up by visiting her husband to check on his condition and medication. Mdm Saifi has her handphone number to consult round the clock. This has given her confidence and peace of mind. AIC has brought cheer back to her life and that of her family. With AIC, there are now many such success stories. We are scaling up AIC operations nationwide to benefit even more patients.

One primary objective is to help Singaporeans avoid unnecessary hospitalisation. For example, old folks falling resulting in emergency hospital admission are common stories. You avoid falls, you avoid hospitalisation. Tan Tock Seng Hospital (TTSH) works closely with the elderly in the community to assess or measure what is your risk of falling and then pick up the high-risk group, coach them to help them improve their balance because it is a skill that can be coached. As a result, admissions to hospitals by this group of elderly come down.

Every day, some seniors in some nursing homes will develop some complications. Without resident geriatricians, the only recourse is to call for an ambulance to send them to A&E. Khoo Teck Puat Hospital (KTPH) works with St Joseph’s Home on tele-consultation, so that the nursing home can consult the Khoo Teck Puat Hospital's geriatrician, over the Internet, before they call the ambulance. Not all admissions are necessary and timely advice from the hospital geriatrician is often what is needed. Patients, doctors, nursing homes and hospitals’ A&Es save time as a result. Everyone benefits.

For our healthy elderly who are living at home, we want to help them stay active within the community. Some eventually may suffer from age-related functional decline. In particular, mobility

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can become a problem. It raises the risk of falls and the need for greater caregiver support. A simple mobility device like a walking frame or a wheelchair can make a difference. But VWOs have told us that some of their clients cannot afford such devices. They cannot pay, so they make do with umbrellas. But umbrellas are lousy substitutes, so they still fall. The VWOs raise funds to help them pay for those walking frames and wheelchairs. What they can do is limited by how much they can collect from public donations. That is why we are setting up the Senior’s Mobility Fund and we will put in $10 million for a start. The objective is to help the VWOs reach out to more such low-income elderly and provide them with basic mobility devices. There will, of course, be some means-testing, needs-assessment and some co-payment. All these will be done by the VWOs. This way, we allow greater flexibility and responsiveness in adapting the scheme to local needs. For example, there may also be cases where some sort of transport assistance to help seniors go for their regular rehabilitation exercises may be greatly beneficial. The desired outcome is to enable the elderly achieve independence so that they can move around with greater ease to perform necessary tasks like getting to their day rehabilitation exercises or simply just going downstairs to the void deck or to the coffee shop.

Transforming our long-term care includes transforming our nursing homes. One significant step is our Nursing Home Development Programme to build new nursing homes in HDB towns. I have discussed this before, including on how to raise their rehabilitative capabilities to help their patients get well and go home. In other words, as Mr Ang Mong Seng put it, to regain their ability in a nursing home and not an old folks’ home. I will, in due course, try to explain in Mandarin the difference between the two.

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Such improved outcomes also require us to transform our home healthcare sector. Ms Ellen Lee, Dr Lam and several MPs stressed this point. This means putting in place supportive structures and services in the community. We are ramping up the Home Nursing Foundation (HNF). They now have nurses in TTSH to connect up with patients about to be discharged to ensure a smooth handover for patients who are likely to require home healthcare. Once the patient is home, HNF coordinates with other providers to meet the patient’s care needs in the community. There are now over 300 patients under their care. We will expand this programme to the other regions so that more Singaporeans can benefit from home care. But it is not just HNF, we will similarly support other VWOs like Touch Community Services and other providers such as NTUC ElderCare to expand home care.

For home and community care to work, I agree with Members on the central role of the caregivers. They are the unsung heroes and heroines, making huge personal sacrifices, whether out of love, filial piety or simply plain human decency. My Ministry will do all we can to support them with skills training, counselling, psychological support, and sometimes just a shoulder to cry on.

Dr Lam asked about caregiver allowance. Obviously, this goes beyond my Ministry’s purview. Minister Lim Boon Heng has addressed this point a few days ago. Let me give you my personal take on this issue. I believe paying caregivers to provide care-giving is an insult. It cheapens the sacrifice that they are making. If you believe in this cause, the whole society ought to be supportive. We have our fair share of and we have met some of these dedicated caregivers. When we see them and to help them, me and my grassroots leaders, we simply take money out of our own pockets, or to periodically top up the Welfare Fund. Or,

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it may be within our clan, our own extended family. In my own extended family, I have a handful of those very dedicated caregivers who sacrificed their lives, sometimes staying single in order to look after somebody that they love. Chinese New Year, we distribute ang pows, I give extra big ang pows for those people. Not to say, "this is your allowance or your bonus", but to say, "thank you for being a kind person and sorry that I cannot be with you shoulder to shoulder to help look after this relative". I think that is how we should address this whole issue of supporting caregivers as a society.

Fifth, we will step up efforts to help Singaporeans stay healthy. As stressed by Dr Lam, this is ultimately the most basic strategy: Singaporeans must take ownership of their own health, and embrace a healthy lifestyle. We have increased the budget for the Health Promotion Board to $120 million. They will find creative ways to promote the healthy lifestyle message and to involve the community extensively. Taking Senior Minister Goh’s advice, we will shift the National Healthy Lifestyle Campaign from being top-down to a more ground-up initiative. Soon we will be coming to the MPs to seek your support and active involvement to help us achieve this breakthrough.

A healthy lifestyle includes a habit to go for regular health checks. Last month, the Academy of Medicine published very useful guidelines on what to screen. My Ministry has accepted the guidelines in full. It will help Singaporeans, in consultation with their General Practitioners (GPs) to choose the appropriate health screening tests that they should undergo given their age and individual risk profile.

5.00 pm

Among the guidelines, there are two relatively costly items: colonoscopy and

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mammogram. I agree with Dr Lam that we should make these tests affordable through Medisave. Dr Lily Neo and Mdm Halimah made a similar call for mammograms before. I agree with them. We will extend Medisave, within withdrawal limits, to cover mammograms for breast cancer screening in women aged 50 and above, and colonoscopies for colorectal cancer screening for persons aged 50 and above. We will get this implemented as soon as we can make the necessary changes to the computer programmes.

Sixth, we will strongly involve the community on healthcare issues. There are several aspects to it. Keeping Singaporeans healthy requires the community to collectively keep the environment clean. Peer support helps to sustain a healthy lifestyle among all Singaporeans. Fighting viruses requires a united community response.

Our society is built on meritocracy and equal opportunities for all. But some will do much better than others. The more successful, in turn, help the less fortunate. That is how philanthropy underpins social bonding and unites people as one. Hence, the Chinese saying "滴水之恩，当涌泉相报" ( di shui zhi en, dang yong quan xiang bao ), to exhort people to pay it forward in society when able to do so.

Our migrant forefathers walked such talk. For example, in healthcare, the late Mr Tan Tock Seng and Mr Lee Kong Chian left behind their philanthropist legacies in the Tan Tock Seng Hospital and the Lee Kong Chian Medical School. They were the eminent philanthropists of the last century.

In the US, Bill Gates and Warren Buffet are spearheading a modern version of philanthropy by pledging at least half of

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their fortune to charity. At least 40 billionaires have joined their cause. Their efforts are softening the "winners take all" capitalist model. The American system has always had philanthropists who supported their top universities and their top hospitals. What is different this time is that they are parting with their fortune while they are still alive. As Mr Michael Bloomberg, one of the 40 billionaires, put it, I quote: "You don't have to wait to die to give it away. It never made a lot of sense to me why you'd want to change the world for the better and not be around to see it."

Several years ago, the family of the late Tan Sri Khoo Teck Puat indicated that they would like to donate to the healthcare sector. I suggested that they consider supporting the new hospital which we were then building in Yishun. They readily responded with a generous donation of $125 million. Tan Sri Khoo was an eminent philanthropist of this century and deserved the recognition when we named the new hospital at Yishun after him. There are other eminent philanthropists. I am happy to inform this House that the family of the late Mr Ng Teng Fong has decided to donate $125 million towards the new hospital in Jurong. That is a big boost to our efforts to provide high quality healthcare for Singaporeans living in the west. And in recognition of the significant donation, we will name it Ng Teng Fong Hospital. Both are Government hospitals fully funded by the Government. But the private donations provide additional assistance to needy patients, besides funding other worthy services.

In similar spirit, through the $1 billion Community Silver Trust, we hope to inspire successful Singaporeans to come forward to co-develop our long-term care sector. This sector has always been served by the VWOs with passion and compassion. But for the next stage of development, we need to inject more

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funds, more skills, more resources, more diversity to help raise capabilities and make them world-class. By matching donations, we preserve the legacy of the long-term care sector being driven largely by VWOs and the community. I think it will be wrong if we move in in a big way and displace the VWOs. By matching public donations, we hope to attract larger donations into this relatively less glamorous sector.

Community support does not merely come in the form of financial donations. Many Singaporeans have been volunteering their services in the hospitals. For example, a team of volunteers has been nursing the roof-top garden at Khoo Teck Puat Hospital, contributing their labour and expertise every day. I go there quite often, different time of the day, sometimes at noon. I see them sweating away like farmers. And when I spoke to them, they said, wo men zuo de hen kai xin (我们做得很开心) or we are so happy doing it. Why? Because they know that the harvests go to benefit the patients in the wards. We will continue to encourage and support such community spirit.

Finally, our commitment to continue ensuring that healthcare remains affordable for all Singaporeans is firm. Our 3Ms framework – Medisave, MediShield and Medifund – is time-tested. It is an important supplement to the Government subsidy framework which is the main financier of inpatient care. This year's Budget will put nearly $7 billion into healthcare – $4 billion in MOH budget and $3 billion in the various top-ups to help Singaporeans pay their medical bills. This has enabled us to help more needy Singaporeans and we will also continue to enhance our 3Ms. In the new financial year:

(i) We will increase Medifund budget allocation to $85 million, from $80 million to help more subsidised patients;

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(ii) We will double the Medication Assistance Fund (MAF) to $20 million, to help needy patients pay for expensive drugs. MAF will be extended to cover six more drugs – I cannot even pronounce their names – they are drugs to treat heart diseases, breast cancer and non-Hodgkin's lymphoma;

(iii) We will double the subsidy cap for surgical implants to $1,000. I remember Mdm Halimah made this request last month. This will now cover up to 90% of all implants used in our public hospitals;

(iv) We will expand Medisave to cover outpatient treatment for two more diseases – dementia and bi-polar disorder - in addition to eight existing chronic diseases, making it a total of 10. And this should have covered practically all the major chronic diseases;

(v) We will expand the Primary Care Partnership Scheme (PCPS) that Mr Low mentioned just now, to cover all the 10 major chronic diseases. This will, as he put it, make it convenient for the elderly to receive subsidised care from the many participating GPs in their neighbourhood; and

(vi) We will also extend PCPS to cover two specialist dental procedures – root canal treatment and crowning.

Before I conclude, let me briefly address some specific comments made by Members.

Ms Ellen Lee asked whether we could run polyclinics 24 hours. I am not keen. The reason is there are only so few polyclinics but there are thousands of GPs outside. I think we should try to leverage on the network of the GPs through PCPS. I think that is a much more cost-effective solution.

Dr Lam and Assoc. Prof. Straughan suggested that we incentivise healthy

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behaviour, like health screening, giving credit for citizens who participate in health screening. We do subsidise such screening for the seniors. But I am not persuaded that we need to bribe them to do what is good for them.

Dr Lam had a question on utilisation of Medisave overseas. So far, only 58, less than 60, have withdrawn about $125,000 from their Medisave for the treatment in Malaysia. What is the benefit of the scheme when I introduced it? It is to widen choices, and I still believe in it. It widens choices but the low utilisation re-affirms the confidence that Singaporeans have in Singapore healthcare. And I think we should be proud of that.

Dr Lam also asked about our preparedness for pandemics. We have now experienced two: SARS and H1N1. We did very well in both. But I agree with Dr Lam that we must never become complacent or arrogant. We must always be prepared for surprises. Our preparedness plans are multi-sectoral and they are regularly tested, reviewed, enhanced. The plan includes stockpiling pre-pandemic vaccines as soon as they become commercially available. For example, we have – I forgot the quantity – a lot of pre-pandemic H5N1. Remember bird flu? It is still around in the birds and, therefore, one day it may just jump species and there is a vaccine available. We spent quite a lot of money stockpiling it. Hopefully, we never have to use it. We have also secured new funds to support research in infectious diseases.

Ms Sylvia Lim talked about Standard Drug List (SDL) and also osteoporosis. She asked a question before in the House which I had answered. The SDL is a list prepared by experts and chaired by the Director of Medical Services, and the professionals have various criteria. I outlined them previously in this House to

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decide which drugs go in and which drugs should stay out. She talked about the SDL list, or what is called the Essential Drug List in Australia and some other countries. I want to clarify that the two are different. In many countries, with national health insurance system, the Essential Drug List is the list of drugs available. In other words, if a drug is on the list, only then will the insurers pay. If a drug is not on the list, you cannot even get the drug. Whereas our SDL is for the purpose of deciding on the degree of subsidy in public hospitals. So if a drug is not on the list, it does not mean the drug is not available. It is available, you can buy it from Guardian or even from our hospital pharmacies except that they have got to pay for it, without subsidy, that is all. So that is the reason why we did not think it necessary to make it a public document but there is nothing secretive about the list. If you ask any Government doctor, he will know what the list is. She mentioned that some doctors are ignorant about it. If it is private doctors, I suppose they ought to be ignorant because they do not work in public hospitals. Osteoporosis is something which I am not too familiar. I am not old enough yet, I suppose. But her concern is a real one, which is that with ageing, the incidents will grow and that women seem to be affected by osteoporosis more than men and, therefore, it is something that we should not take it lightly, and we do not. The Health Promotion Board is, in fact, in the midst of including the screening for osteoporosis in their integrated screening programme. They have piloted the screening programme, found it useful and they will now include it in this national integrated screening programme.

Assoc. Prof. Fatimah Lateef asked about our medical intake. The third Medical School is on track to take the first batch of students in 2013. Together with the other medical schools, they will train at a steady state of about 500 doctors annually. That is not a small number.

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Supplemented by some foreign graduates, that should be adequate for our needs. Current efforts have already improved our doctor to population ratio of 1:580, which is quite good. But I agree with her that ill distribution among specialties is a bigger challenge and we must address that. Meanwhile, the public hospitals' Pre-Employment Grant for Singaporean medical students overseas in their final years of study has been very well received. From the UK, more than 30 Singaporean students studying there have committed to come back under this scheme. I expect even a bigger number from those studying in Australia and their applications are being processed.

5.15 pm

Mr Low Thia Khiang talked about PCPS and found it a useful scheme. I think he commended on it that it is convenient for the patients, etc. But he asked whether we could review the criteria to make it less stringent. We designed this scheme for the seniors and that is why we pegged it at 65 and above. Should we reduce the age? Offhand, I say "no" because we are living longer, beyond age 65, and we are promoting re-employment all the way to 65.

But at the margin, we can allow for discretionary power when we assess the applicants, whether to put them onto the PCPS scheme. He has an interesting suggestion, which is, why can we not have subsidy which is tiered, instead of a common subsidy. I am not keen because the current subsidy is already quite heavy, so I do not know how much more tiering can we do.

On end-of-life care, he mentioned the Economist Intelligence Unit (EIU) – Quality of Death Report. I thought I discussed this in this House before and explained the ranking. It was quite a good ranking – 18 out of a whole list of many countries. But if you look at the list of countries which are ranked, I myself consider the

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assessment fair because of the efforts we have put in the last few years. If we were to be rated five years ago, I think our ranking would be poorer. But at No.18, we are No. 2 in Asia. And the reason for the lower ranking vis-a-vis, say, some European countries like Belgium has nothing to do with being first-world or third-world, but it has to do with the degree of ageing of the society. We are still a very young society as compared to Europe. Relatively, Europe is rather old and because it is older, their facilities for providing and looking after end of life care would be much better developed. But our ageing is coming on strongly, definitely in 10 years' time, so we have started the planning exercises five to 10 years ago. I am quite sure, in five years' time, if EIU were to do a similar assessment, our ranking will further improve. I am confident about that one.

But I take his point that end-of-life care is a very important topic in healthcare. I spend time thinking about it all the time because this is the last stage of one's life. You really want everyone to part not just with peace of mind, but gracefully, with dignity. And I think, as a society, we should do our best to do so. And do not just look to the Government to be the provider because that will always be a sub-optimal solution.

I was just reading an interview given by Harvard Professor Clayton Christensen to Forbes Magazine and he was talking about how he looked after his dying father. He just dropped everything he was doing and spent time with him. And he told the Forbes interviewer "that was the best period of my life". Reading it reminded myself of my mother. She died of ovarian cancer many years ago when I was the Permanent Secretary in the Ministry of Trade and Industry. After doing all the necessary surgery, chemotherapy, etc, my eldest brother who lives in Canada – he has been living in Canada for many years – did what

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Professor Clayton did. He just dropped everything, came home to Penang and looked after my mother. I often look back and think, how I wish I could have done the same thing too. That is what end-of-life care is all about. As a Ministry, we will do all we can to support end-of-life care as much as we can. The important thing is, as I have said earlier, do not, without wisdom, mindlessly port in all the American practices, wrong practices of aggressive treatment and putting the terminally-ill in costly acute hospitals, subjecting them to all sorts of pain and sufferings, with zero improvement in quality of care, if anything, just introducing harm and sufferings.

Assoc. Prof. Fatimah Lateef and Dr Lam Pin Min asked if Medisave or MediShield can be extended to cover congenital diseases. I am sympathetic to this request, but I am not ready yet to reform MediShield. When we do, I intend to extend it to cover congenital illnesses and also mental illness. The key is how to do it in a way to make sure that the premiums remain affordable. And that is the challenge. I think we will find creative solutions to that.

Mdm Halimah asked about Medisave 300, whether we can raise this cap of 300 to a higher level. Of course, the cap is not cast in stone and we will review it periodically. An immediate adjustment is not necessary because the vast majority of patients do not have difficulty with the cap. Do not forget this is the cap per account. So, if a patient has several children, it is 300 times whichever number of Medisave Accounts. She asked about the adequacy of the Medisave minimum required amount. That is a figure that we adjust periodically to take into account medical inflation. The recent increase in Medisave contribution rate of 0.5%, I am quite sure, will help many

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more members to achieve higher savings later on.

I think I have addressed all the cuts submitted by Members. There were a few cuts on obesity, and so on, which we will tackle in the later part of the day.

Madam, in the last five years, we have made a lot of progress – it was making our healthcare system better. In independent surveys, our patients rated our public hospitals and polyclinics as either "good" or "very good". Three in four rated them as "excellent value for money". Many foreign experts have studied and praised our healthcare system. But we must press on with reforms, underpinned by wisdom and realism, and a generous dose of humanity. If we stay the course, in another five years, Singapore healthcare will be even better than today. I thank Members for their continuous support for my Ministry.

Mental health

Mdm Cynthia Phua: Madam, mental healthcare has always been costly and medical treatment has to be given on a long-term basis. Low and mid-range income groups who are caring for mentally-ill family members would need financial assistance to cope with the long-term medical care, especially when the family members are not working. Many a time, within the family, there are many mental patients as well.

Last October, we raised this issue in Parliament. I wish to take this opportunity to request for more funds to be allocated to management of their welfare. We need to address the needs of the patients who are recovering from mental illness or whose illness is under control. We really need more day care and rehabilitative facilities at the community and the number and sufficiency would entail the Ministry to do an in-depth study for these mental patients. Alternatively, could the

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Minister set aside funding to support VWOs who provide such services and to help them set up such centres? Funding will need to go into training volunteers and subsidising these facilities for needy families. I look forward to the Minister’s support for more of these day care centres.

The real issue on the ground and the community is that many do not know the condition of mental illness. More education and engagement of the families and the community need to be done. Just recently, there is an article by the Straits Times on the good work done by a psychiatrist from Australia. He mentioned that if the mental patient can be detected early and given the right treatment, they would be able to recover. However in our society, mental illness is still being stigmatised and many people may know but refuse to do treatment early. The Ministry needs to work with the schools and universities for early detection.

In the community, we came across many new cases where family could not manage to persuade the patient to have early treatment, resulting in nuisances being caused to the neighbourhood and the patient himself who suffers the mental illness. The present law does not allow the Ministry to do direct intervention of bringing new mental patient for treatment. As a result, the community suffers. Recently, it took me a while to persuade the Police to help the Residents’ Committee members, with the support of the family, to bring a resident who had been causing stress to his fellow block of residents to IMH for treatment. Basically, he switched on the radio at full blast 24 hours of the day.

The hotline mobile team of IMH will only respond if the person is a known patient of IMH. I would like to urge the Ministry to look into the need to amend the necessary law and allow the Ministry personnel for direct intervention to bring

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new mental patients for treatment; if not, the community would be even more disturbed and stressed.

Mr Sin Boon Ann: Madam, mental health problems still hold some stigma in the society and will prevent patients from seeking help and professional advice early and impede their re-integration into the workforce and community after treatment.

I would like to ask the Minister about the progress we have made with our present framework to educate, identify and treat Singaporeans with mental health problems, including milder ones, such as depression and mood swings. Would the Minister also share with us the programmes to prepare and re-integrate patients into mainstream society?

Another area of concern in a rapidly ageing population, as data from other countries has indicated is that longevity does not guarantee good health or mental health. We must be prepared for cases of elderly dementia and other mental health problems which afflict the elderly. Do we have enough professionals and facilities to cope with this unexpected trend?

Healthy Singaporeans

Ms Ellen Lee: Madam, I want to talk on the topic of Healthy Singaporeans – what programmes are available to help Singaporeans cope with close relatives or neighbours who suffer from psychiatric morbidity?

Madam, I have spoken on this topic before, on the rising number of Singaporeans (both young and old) affected by some form of mental illness. The problem does not seem to have reduced in spite of greater awareness being generated. The increasingly hectic and fast paced life in Singapore has been impacting Singaporeans in many ways, notably emotionally, physically and mentally. Even people who look sane and

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sound reasonable may be undergoing some stress, but they are not revealing or seeking help as nobody wants to see a shrink or be seen with one.

Many people in Singapore suffering from psychiatric problems are still severely disadvantaged in the quantity and quality of care available to them. There is not much understanding and regard given to their rights and needs. And these are, often times, due to family members not wanting to admit that one of their members may need psychiatric help or treatment. The problem extends to their caregivers, close relatives including neighbours, as they are affected directly or indirectly by those who suffer from psychiatric morbidity within their close physical proximity. The stresses and pains of these caregivers and neighbours, especially those living in the heartlands and high-rise buildings, often go unrecognised and are, therefore, untreated or unmanaged. As a result, families have broken up and neighbours' disputes are on the increase.

Appropriate referrals to psychological services, professional help and timely intervention are imperative to ensure those requiring help are identified and addressed. Would the Ministry consider enhancing and provide higher funding for current programmes? Would it be possible to rally institutions such as the HDB, NEA (in relation to noise pollution), Town Councils, grassroots organisations, professional medical help and counsellors to assist such vulnerable groups of people? If the general public, caregivers and community groups are sufficiently aware of households struggling with a member of the family, relative or neighbour who suffers from psychiatric problems, they could be advised on constructive ways to manage the person’s condition in a constructive manner and be linked to support services at the same time.

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Madam, given that there is an increasing trend, we should act quickly.

Mental health providers

Mr Chiam See Tong: Children and adults with special needs deserve better protection. It will reduce the anxiety of both caregivers and patients with special needs, like the mentally-ill and autistic children. I urge the Government to issue special I-cards to these patients.

It can be an electronic chip that stores confidential information about the patient's illness, special needs, contact and details of primary caregivers and the organisation that issues the card. Such a special identity card should also reduce the workload of the Police, the court and other parties that are involved in any offences that are committed. Making an arrest especially is a challenge.

5.30 pm

Parents with special needs children

Mr Laurence Wee Yoke Thong (Nominated Member): Madam, I thank the Minister for informing the House of the new improvements to our already excellent healthcare system.

Madam, it is natural for parents to be very anxious and concerned when their young are not developing normally. Their fears, most times, are unfounded, hopefully, but sometimes they become a reality. One example, a mother whose child, now 22 months old, was later diagnosed with a Global Developmentally Delayed (GDD) syndrome. When she first brought her son for medical attention, the paediatrician, after examination, reassured her then that her son's condition is temporary and the child will soon outgrow the system. However, as the days went by, her instincts and suspicions became stronger since, as a reference point, she based her son's behaviour vis-a-vis the older brother – a typical child. Remember

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the saying "parents are the children's first teachers". After seeking proper assessment and diagnosis by the psychologist, her fears were confirmed.

Point number one: may I suggest to the Minister that medical personnel in contact with parents should pay careful attention to what the clientele are saying. Though they may be laypersons, the service should be friendly-centric as far as possible. I think this is more of an enforcement issue rather than policy as I see it.

Point number two: to help parents make informed decisions, frontline medical personnel should be more aware of the different types of services available so as to provide timely, appropriate advice to parents. Otherwise, they have to do their own homework, going around asking for information or going to the Internet to search, especially now with the current situation of intake of more foreign doctors in our healthcare service system. In this way, we are, first, enabling our parents; and, two, empowering them to be their own advocate for their children's well-being at the end of the day.

In conclusion, however, may I place on record the good work and progress of our national healthcare system in addressing the numerous issues and challenges as it strives to make Singapore a hub of excellence for a world-class healthcare system.

Traditional Chinese Medicine

Ms Ellen Lee: Madam, I would like to touch on the topic of Traditional Chinese Medicine (TCM) and about extending TCM to all polyclinics. There is now even greater awareness of the usefulness of Traditional Chinese Medicine and its unabated use is evident in Singapore. With more robust legislation and greater professionalism of TCM practitioners, I am glad to see TCM clinics across our

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restructured hospitals and polyclinics such as in Yishun.

I am asking the Minister if he would consider extending TCM clinics across all polyclinics. Many heartlanders, no longer just the elderly but younger people including non-Chinese, are embracing TCM and related services and acupuncture for their ailments. TCM services can be housed within our polyclinics so that strict codes of practice are adhered to, thus ensuring that there is quality service. It could also lower the costs for needy people in addition to providing accessibility. By the same token, perhaps selective use of Medisave monies for chronic illnesses management, such as rheumatism and arthritis, can also be extended to TCM.

Mr Chan Soo Sen: ( In Mandarin ): [For vernacular speech, please refer to Appendix A.] This year marks the 10th year since we started the registration of Traditional Chinese Medicine (TCM) practitioners. Singapore is the only country other than China that legislates the registration of TCM practitioners. With the registration, there has been a significant improvement of professional standard and image of TCM practitioners. As a result, as my colleague Ms Ellen Lee mentioned, TCM has increased its popularity, with more and more Singaporeans seeking TCM treatment.

Does the Ministry of Health have plans to further raise the standard of TCM practitioners and the quality of TCM practice in Singapore in the future? Are there plans to encourage our local universities and institutions to do more in terms of research and development of TCM?

Recently, some TCM practitioners told me that due to the restrictions of the current legislations, TCM organisations could no longer offer Degree courses in TCM with overseas, mainly mainland

*Cols. 3831-3832.

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Chinese TCM universities. If this is the case, would there not be negative impact on our efforts to raise the standard of TCM practitioners in Singapore, as some TCM practitioners who intend to upgrade their professional standards will not be able to obtain a Bachelor Degree locally.

Another area of concern amongst the TCM circle in Singapore is whether the Government has any plans, at some point of time, to recognise the medical certificates issued by TCM practitioners, or to allow medical benefit claims to be extended to TCM treatment. As my colleague Ms Ellen Lee pointed out, are we going to recognise the medical care provided by TCM practitioners?

To date, the Government's stand is that it depends on the policy of the respective employer. As the public sector is a major employer in Singapore, may I ask whether the public sector as an employer is willing to recognise the medical certificates issued by TCM practitioners and allow medical benefit claims for TCM treatment? If not now, then how about some time in the future when professional standards of TCM further improve?

Mr Khaw Boon Wan: Madam, we launched the National Mental Health Blueprint in 2007. The Minister for Finance gave us very strong support, with $178 million invested so far. The key thrust is to strengthen and develop mental health services in the community. The two key words are: de-institutionalisation and de-stigmatisation. We are half way through the implementation, but some impact is already being felt on the ground. Recently, I met a group of psychiatrists. I asked them point blank how do they compare, how do they rate the current state of mental health as compared with, say, five years ago. They told me that the progress was significant as a result of the

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Blueprint but they added that we still have much to do. The situation, as described by Ms Ellen Lee and the others, confirms the psychiatrists' assessment that the cup is half-full. We will press on to top up the cup.

Mdm Cynthia Phua, Ms Ellen Lee, Mr Sin Boon Ann asked for more help, more services, more support for this programme and for the patients, and I agree with them. We will do more, we are doing more, a lot more will continue to happen over the next few years. The key is we need to detect patients early so that there is timely intervention. But to do so, we need to reduce the stigma surrounding mental illness so that the patients can be confident to come forward to be treated and, after receiving treatment, to integrate back into the community.

Under the Blueprint, we have set up a series of multi-disciplinary community mental health teams to bring about early detection and to initiate treatment. They are organised under four different programmes, separately targeting children, youths, adults and the elderly. Each programme caters to a specific age group. The programmes are at different stages of implementation. By that I mean we have tried it out in small areas of Singapore and now, in the final stage, we want to bring it up nationwide. But the initial results are promising, improving quality of life for the patients and their families and, importantly, reduce their re-admissions to hospitals – usually IMH. We are scaling up the programmes nationwide.

We certainly need to involve the community much more intimately. First, we are building up a community network to support the patients through neighbourhood social services, general practitioners (GPs), polyclinics and other care centres. Today, we have a GP Partnership network where stable patients are put on a shared-care programme with GP partners managing and providing

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follow-up in the community. This way, patients do not have to go back to IMH and it is also much more convenient for them. There are nearly 50 GPs and more than 600 patients on the programme. We are also putting multi-disciplinary mental health intervention teams in the community. They will support the GPs to manage simpler cases as well as provide basic psychotherapy, counselling or case management. This is an area where we will always be short of physiatrists and the more we can train up and make use of allied health professionals to support the doctors the better it will be.

Second, we are strengthening the capabilities amongst the community organisations and social service providers to better manage the patients in the community. Training is being rolled out to equip staff with the right skill sets. So far, we have trained over 2,000 grassroots leaders and frontline staff in eldercare agencies. We have also put in place community support mechanisms such as helplines to link up patients with the appropriate services or resources they need. Mdm Cynthia Phua talked about the hotline in IMH currently serving essentially their discharged patients. The intent, certainly, is for such a national helpline to look after all patients, not necessary just ex-IMH patients.

Third, we will help our patients pick up skills needed to return to the workforce so that they can achieve independence in the community. This is key. To avoid relapse, the better we are able to get them properly reintegrated back, the best chances of recovery for those patients. But to do so, I need the support of many more enlightened employers to provide job opportunities for these ex-patients. The Institute of Mental Health (IMH) has a "Job Club" which helps to support patients' reintegration to the workforce. Since its launch in 2009 – so that is less than two years – more than 550 patients have been successfully placed within the

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Job Club scheme. We certainly need more employers to come forward to help us.

For us, we will continue to provide the service providers with adequate funding. Recently, the Tote Board Community Healthcare Fund has pumped in an additional $15 million for us to push this programme. It is a very important boost to our efforts and I will always try my best to seek more funds to support this cause. My sense is this: that actually money is not the real bottleneck, but enlightened people, whether it is employers or family members or neighbours who are prepared to keep their minds open and to accept that this somebody – fellow Singaporeans, fellow human beings – let us give them a hand. If IMH decided that they can be returned to the community, it is safe. There is a wide spectrum of mental illness, not everyone and it is only a small number who may cause danger to themselves or to others, and those patients are all in IMH. Those that we released back to the community, they have stabilised. The key is we support them and, from the doctors' side, make sure that they take their medications.

Mr Laurence Wee and Mr Chiam See Tong spoke up about a different subject of helping the parents of children with special needs. Children with development difficulties are prone to displaying difficult behaviour; aggression, disobedience or even engaging in dangerous activities, and it is a major, major source of stress for the parents and can even impact their mental health. All these can take a toll on family relationships and, often, parents are just at a loss of what to do. KKH and NUH have been conducting Parents' Forums for a long time for such parents. More recently, we have a new initiative which we are very proud of – KKH is partnering an Australian Parenting Research Centre to launch a training programme to equip parents to understand their child's difficult behaviour

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and develop their own ways to manage them effectively and prevent the further development of behavioural concerns.

This is a parenting support course, delivered through a network of qualified facilitators. The original programme in the state of Victoria, Australia, has been around for several years and has been very successful. We are bringing to Singapore, adapting it to local conditions. We hope we can achieve the same results as it did in Victoria. Here again, money was not an issue. We get the support of Temasek Care which is a foundation of Temasek Holdings. They pumped in money so that the course is heavily subsidised and parents will find the fees affordable.

5.45 pm

Ms Ellen Lee and Mr Chan Soo Sen spoke on TCM. As pointed out by Mr Chan, we have now 10 years of TCM regulation and we have made some progress in raising the standard of practice and training. Of course, there is scope to do much more. To me, the key question is this. Going forward, do we simply just copy what China is doing and then adapt it here? Or do we try to forge a niche role for ourselves in Singapore, given our different history and greater exposure to western medicine?

I believe either approaches are sensible. The second approach is, of course, much more challenging but it also opens up new opportunities. Let me give some illustrations. For example, for western drugs, it is standard practice to report adverse events. Some patients may take the drugs and had some problems, and adverse events have to be reported to the Health Sciences Authority (HSA) routinely so that we collect those information, get them analysed and we can give proper advisory to the consuming public. But this is not done for Chinese herbs.

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Likewise, there could be adverse events as a result of taking Chinese herbs and western drugs. Are there adverse events as a result of the interaction between the two? If so, I think somebody, somewhere, need to know. There are really no such good resource centres, not even in China.

I have been discussing with HSA because of their expertise in western drugs and I have also discussed with the leadership of TCM recently. Can we not do something like this? We can develop a resource centre. It will not only be good for Singapore but it may become a very good resource centre for the region, or even for China. I think that is a possible niche role for us in TCM.

Likewise, some of our western-trained doctors are very interested in TCM and I know they have started doing joint studies and clinical trials with TCM physicians. I know of a small group in SGH which has been doing similar studies for several months now, looking at diabetes because the Chinese have their own way of treating diabetes too. Of course, there are western ways of treating diabetes. We want to see, through such joint efforts, if TCM improves the effectiveness or outcomes. If we can subject those TCM practices to scientific scrutiny and then publish them in western medical journals, that would be of benefit to the world. Perhaps, this could be another niche area for Singapore.

Over the next few years, I certainly hope the TCM leadership can think through these questions, and there could be other possibilities to help us determine the way going forward. If the TCM legislation needs to be amended to facilitate the next stage of TCM development, I would be happy to do so.

But we must acknowledge the vast difference between TCM and western medicine, both in philosophy and in approach. They are two different things,

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almost like two different religions. The different regulatory regimes reflect these differences. The global healthcare system is based on western medicine. TCM is considered as a complementary medicine, regulated to different benchmarks. A TCM physician is not regulated to the same extent as a western-trained doctor. A Chinese herb is not regulated to the same degree as a western drug. That is the reason why Medisave does not cover TCM and that is also the reason why many employers do not accept medical certificates (MCs) issued by TCM physicians. Whether this will change in the future will depend on how TCM intends to reform its practice and approach. In fact, it is also not obvious if TCM needs to or even if it wishes to, can reform and emulate the western medicine approach. China, for many years, has tried to integrate TCM and western medicine and has not found it easy. One professor in Nanjing TCM University, when I visited them, told me they tried and the result was liang bai ju shang (两败俱伤), that means both sides suffered when they tried to integrate east and west. Zuo bu lai ( 做不来), that is, they cannot do it. If you look at the outcome, there are many times more western-trained doctors in China than TCM-trained physicians.

Meanwhile, we will continue to raise their level of professional standards within the traditional TCM framework. TCM practitioners wishing to upgrade themselves with a degree have several options. The two local TCM colleges have partnered PRC TCM universities. Their Diploma graduates can go on to acquire a recognised PRC degree. The NTU also runs a double degree programme in Biomedical Science and Chinese Medicine course. I heard Mr Chan Soo Sen's comments just now. He might be mistaken. It is not as if the Diploma graduates of the local TCM school cannot continue to train and get a China university TCM. They can. It is no

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different than say a nurse in Nanyang Polytechnic and with a twinning degree programme that we are now trying to set up through MOE, will finally get a degree from, say, the University of Manchester, or whatever. Likewise, it is the same thing here. What MOE does is to regulate which institution in Singapore can issue a Singapore Degree but for Diploma, that is a different story. They do facilitate the Diploma graduates from continuing on to get a foreign degree. That approach will continue.

Ms Ellen Lee noted the setting up of TCM clinics in many hospitals and asked if we should allow them to be set up in polyclinics. There are more than 1,000 TCM clinics in Singapore, mostly in HDB towns. I believe access to TCM clinics is not a major issue.

Wellness-centric community health model

Assoc. Prof. Fatimah Lateef: Madam, the incidence of lifestyle diseases continues to increase. Singaporeans must take ownership of their health. We need to do more to facilitate this, encourage more proactive health promotion and people coming forward for voluntary screening. Our infrastructure too has to support this. These are some of the ways and essential ingredients I would like to mention. First, a more proactive health promotion programme that increases awareness of health risk associated with certain personal behaviours. Two, patient-centric health management goals. Three, encouragement to have a single provider relationship where they can receive on-going education, primary care and advice on specialty care. Four, continued surveillance of health indicator factors.

The most important step in all these is actually strengthening our primary care set-up with more seamless community care centres, integration across GPs and also family practitioners as well as polyclinics and more ambulatory care set-

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up in the community in the various areas. Can I know MOH's plan pertaining to this?

Rising obesity in Singapore

Mr Sin Boon Ann: Madam, with growing affluence, rising obesity has also become a national problem. Other than the health risk for the individuals, there are other related problems such as healthcare expenses, loss in productivity and so on. Unfortunately, despite common knowledge about the impact of diet and lifestyle, the number of obese Singaporeans continues to increase. I would like to ask the Minister for an update on the Ministry's effort in dealing with rising obesity in Singapore and an account of its effectiveness in dealing with this issue in recent years. In terms of infrastructure, are we providing enough easy access to physical activities, spaces and safe walking trails? As more Singaporeans work longer hours, is there sufficient access to healthy cooked food in our many coffeeshops, hawker centres and food courts? Should we influence the eating habits and preferences of Singaporeans by limiting the number of advertisements in the media by fast-food chains?

Healthy lifestyle

Mr Ong Ah Heng (Nee Soon Central): ( In Mandarin ): [For vernacular speech, please refer to Appendix A.] Madam, we have now about 300,000 senior citizens aged 65 and above but by the year 2030, the number is expected to increase to 900,000. We need to ensure that our senior citizens stay active and healthy, and continue to contribute to our society. If they fail to reach this goal, we might see our senior citizens, say, 20% of them, ill and bedridden and it will require a lot of resources to take care of them.

There is a common belief that as we age, we should get less active and enjoy

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life. In reality, we cannot enjoy life as we age by becoming less active. I have known many cases of senior citizens such that when they retire from work, they also retire from life. I know this friend of mine who retired from work at the age of 55. All he did thereafter was to lie on the sofa and he even used the remote control to switch the channels. Now he is 72 years old and has suffered from dementia for almost 10 years!

Madam, our senior citizens must stay active, healthy, continue to contribute to society, and enjoy life. I would like to ask the Health Minister if there is a masterplan to help our senior citizens live longer and stay active.

Workplace health

Assoc. Prof. Fatimah Lateef: Madam, working adults spend a large portion of their time daily at their workplaces. It becomes an important area where healthy lifestyle and practices can be inculcated. Staff well-being is important as an organisation's loss of manpower hours, medical leave and inability to function optimally due to illnesses can have a negative impact on companies. The workplace has been established as one of the priority settings for health promotion in the 21st century according to the World Health Organization (WHO). Workplace directly influences physical, psychological, economic and social well-being of workers which, in turn, affects the health of their families, community and eventually society. A health promoting workplace can now become a pre-requisite for sustainable social and economic development. MOH has started a workplace health promotion grant. How many companies have taken this up? What is MOH's plan to enhance health at the workplace?

Mr Ong Ah Heng: ( In Mandarin ): [ For vernacular speech, please refer to

*Cols. 3833-3834.

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_Appendix A * _ .] Madam, the working adults spend more than half their waking hours at the workplace. The workplace is also where most people identify as the source of their stress.

A healthy staff is an asset to any organisation. This is a fact well-recognised by all companies. Bigger companies, which have more resources, would find it easier to implement workplace health programmes, sometimes together with our Health Promotion Board. However, I notice that this is not the case with the small and medium sized enterprises (SMEs). SMEs may not have the resources like the big companies to implement workplace health programmes for their workers.

The Health Promotion Board's website has listed a series of programmes designed to promote healthy living. Many of these can easily be adopted at the workplace.

A large proportion of our total workforce in Singapore is employed by SMEs. I would like to ask the Health Promotion Board whether there is any action plan to engage and incentivise SMEs to implement workplace health programmes.

Mr Heng Chee How: Our population is ageing because of low fertility and rising longevity. With Singaporeans living longer, resources must be found to fund their additional years so that individuals can sustain their standard of living and quality of life.

To enable Singaporeans to enjoy their added years and to minimise the delay of medical expenses, efforts in the community to help them age healthily have been stepped up. These efforts included, amongst others, the national Wellness Programme, the mass exercise platforms promoted under the Senior for Physical Activity (SPA) Committee and

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numerous initiatives by the Ministry of Health and the Health Promotion Board.

6.00 pm

Madam, besides active ageing, a key part of sustaining a standard of living is to enable Singaporeans to work for more years. Here, I would like to make two observations about the growing importance of workplace health.

First, many people are spending a significant amount of their waking hours at work. Second, many people are working more years. These two factors together mean that workplace health is a necessary and important second engine to complement and supplement community health efforts. There is a third factor to render workplace health even more important going forward. With the passing of re-employment legislation that will take effect from January 2012, companies will be legally obliged to re-employ workers beyond age 62 up to age 65. At the same time, we have an ongoing national drive towards higher productivity to enable real wages to rise sustainably in the coming decade. Employers will therefore be looking closely at the value add of every worker in this process. All these considerations mean that workers at large and older workers, in particular, must be better enabled to upgrade their employability and value at work.

Employability is not only about skills, it is also about health and fitness to do the job. Hence, we need to further enhance our workplace health efforts to go upstream and beyond payment arrangements like portable medical benefits which are schemes that help answer the question of who pays when workers fall ill. We have to move upstream from those to encourage the regular systematic and sustainable adoption of workplace health. Put simply, we should be looking at introducing a

*Cols. 3835-3836.

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wellness programme at the workplace as well to complement the one in the community. This is easier said than done and calls for much more resources and attention than just urging companies to come out and do a couple of activities and then to reward them on that basis.

If we were to take a leaf out of the Wellness Programme in the community, I would imagine that for the Wellness at Work programme, I would similarly need to build on certain key features such as, first, a systematic way to more intensively engage companies and educate them on the research benefits of effective workplace health, to incentivise companies to commit themselves to such programmes, to enable companies to make proper assessments of their workforce health needs while not jeopardising the workers' employment, so that they do not pick on particular workers in order to get rid of them for poor health.

Madam, if I may just conclude quickly. I hope that MOH will take more measures in this area and make strategic use of workplace health as a productivity tool to be both pro-business and pro-worker.

The Senior Parliamentary Secretary to the Minister for Health (Mr Hawazi Daipi): Madam, let me first thank Members for their contributions to this debate. Dr Lam Pin Min, Assoc. Prof. Fatimah Lateef, Assoc. Prof. Paulin Straughan and Mr Ong Ah Heng have all given useful suggestions on how to make our healthcare system more wellness centric and pro-health. Indeed, this shift to prevention has been one of the biggest health trends in the past decade. People are more empowered than ever before to take personal ownership over their health. Information on how to eat and live healthily is readily available. Just whip out a smart phone, or log onto the Internet and you will find

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dozens of applications to help you count your calories, track your exercise regime and even help you quit smoking.

Healthcare systems around the world are responding to these challenges. In Singapore, we are too. In Minister Khaw's speech, he has outlined wellness as one of the main priorities of MOH over the next few years. What this means is that our healthcare system should not only focus on taking care of the 10% of Singaporeans who fall sick but also ensuring that the 90% of Singaporeans who are well can continue to stay healthy.

This is a significant shift. It will require fundamental changes in the way our healthcare institutions work. It will involve community partners coming together to champion health. Make no mistake about it. It will be a very difficult and uphill journey, but we should strive to succeed because if we do, it will mean that people will lead longer, fuller and healthier lives. In the final analysis, this is really what the Ministry of Health should aim to achieve for Singaporeans.

This is why I was quite intrigued to learn about "blue zones". Blue zones are communities of people tucked away in different parts of the world who are living out the mantra "live long, live well". People there commonly lead active lives past the age of 100 years, with high levels of well being. One of the "blue zones" is Okinawa in Japan, which Dr Lily Neo has spoken about, and which Minister Khaw has visited. Another "blue zone" is Sardinia in Italy, which has one of the highest rates of centenarians in the world.

Researchers have gone to study these "blue zones" and have come back with a list of common lifestyle characteristics from these areas. If you allow me to paraphrase, they include simple things like: keep moving, eat till you are 80%

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full, put more vegetables in your diet, manage stress, surround yourself with supportive friends and belong in your community.

If these "secrets" sound familiar to all of us, they are in fact quite similar to some of the simple prevention messages that the Health Promotion Board (HPB) has been advocating: stay active, eat wisely and strive for positive mental well-being. However, the difference is that the people in the "blue zones" have made it a way of life.

In Singapore, we know this is the hardest part. Many of us eat out and work late. I think some Members have alluded to this that we are working longer and we want to put more years into our working life. By the time we get home from work, we are too tired to exercise. This has led to more sedentary lifestyle and rising obesity as Dr Lam Pin Min and Mr Sin Boon Ann have pointed out.

This was why we launched the National Healthy Lifestyle campaign in 1992. We introduced programmes to help Singaporeans make prevention a way of life. We are reaching the 20th year anniversary of the campaign now, and it is timely to do a stock take. The campaign has led to a greater awareness of healthy lifestyle among Singaporeans, but as Assoc. Prof. Fatimah Lateef has said, we need to do more to encourage proactive health promotion. The prevalence of obesity has increased to double digits, that is, 11% last year. If we do not do anything to arrest the increase, we will soon be plagued with an obesity epidemic and the associated chronic conditions, which would be a huge drain on our healthcare system, let alone at the personal, family level.

The approach towards promoting healthy lifestyles amongst Singaporeans has been largely top-down thus far. To successfully move towards a wellness

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centric healthcare system, we will need a more ground-up approach as articulated by Minister Khaw.

This is what they do in the "blue zones": rely on social capital to live long and live well. They surround themselves with supportive friends and community. In Okinawa, they have what they call " moais " – groups of five friends committed to each other for life. Many of these social circles support healthy behaviour which can be equally, if not more, "contagious" than obesity and smoking.

The other thing about the "blue zones" is that communities work out what makes best sense to them. The communities have different diets, different ways of managing stress. The Sardinians, for example, manage stress by gathering in the streets to laugh with each other. The Okinawans like to do gardening. They recognise that different things work for different people.

In a similar way, we need to find out what works for us. Members have raised some suggestions. Assoc. Prof. Fatimah Lateef has urged more health promotion programmes to increase awareness of health risks associated with certain personal behaviour. Mr Ong Ah Heng has asked if more can be done to engage our well developed and well connected grassroots organisations and networks to nudge us toward better health behaviour. I agree with these suggestions. We should find ways to better empower the individuals to take ownership of health, and leverage on the power of social capital in our communities, or what we call our " kampung spirit ". We need to inspire Singaporeans to health. From there a movement will emerge with a natural momentum. We are hopeful.

The National Healthy Lifestyle Campaign will be remade to support this. Together, we will build a new health

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promotion model, with a ground-up approach supported by all Singaporeans. In reply to Dr Lam Pin Min and Mr Sin Boon Ann, we will also make obesity the focus of the campaign. MOH and HPB will work with grassroots leaders to co-create a model of health that works for each community and which targets obesity. We will provide the expertise, tools and training to develop a team of Health Champions in each constituency, who will then act as agents of change to champion healthy living. The analogy I would use is that we are handing Singaporeans the keys to health and together, we will open the door.

I know of one of these Health Champions, Mohamad Hashim Mohamad Shah, the Chairman of Marsiling Malay Activity Executive Committee, who has started his own journey. Before becoming a Health Champion, he weighed 91 kg. However, after a year of exercising and adopting a healthier diet, he now weighs 83 kg! Seeing the benefits of his efforts, together with seven other Health Champions in the constituency, they have formed a health interest group with about 80 residents in Marsiling. Having learned about elements of chronic illnesses and how to be effective health advocates from the HPB, they each reach out to 10 residents. That is why they are called " Ketua Sepuluh " (Leaders of 10) because each one of them reached out to a group of 10 residents. The health interest group meets every month to share tips on healthy cooking and weight management. Many of them go for brisk walks every weekend, while others take up aerobics, cycling or swimming. Some ladies who did not learn swimming at an earlier age are now learning to swim which is encouraging. The Champions are not stopping there. They intend to grow the interest group to 200 people. In fact, there is also a pipeline of residents being trained to become Health Champions.

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HPB provides the expert guidance and North West Community Development Council helps to coordinate the Health Champions Network in Sembawang GRC and Nee Soon Central and Nee Soon East SMC. I applaud the Health Champions for the efforts to start their own "blue zones" and hope others can also share their enthusiasm and keep the momentum going.

From Health Champions, we move to activities. Activities tailored to the needs of the local community will be developed, and include Healthy Cooking Demonstrations and physical activity programmes like community aerobics and qigong . Non-traditional stakeholders will also be roped in. For example, childcare centres and schools will be engaged to roll out programmes like "Walk-to-school with Kids". Shopping malls will also be encouraged to implement health promoting initiatives for shoppers. One of these initiatives is "Mall Walks" where Singaporeans can do brisk walking and other exercises in a safe and weather-proof setting. Well, we did that when we launched the last National Healthy Lifestyle Campaign led by Senior Minister Goh and we thought that walking together in a shopping mall was quite fun.

A prototype of this new "ground-up" National Healthy Lifestyle model has already started in the Southwest CDC District. Here, the Health Promotion Board and National Environment Agency (NEA) are partnering with Yuhua Hawkers Association to engage hawkers on using healthier ingredients like whole-grain noodles, brown rice and healthier oil. Other prototypes in Northwest CDC and Sembawang GRC are in the works; they will develop their own unique arrangements. I believe when Nee Soon GRC is formed after the GE, they will also be included in the programme. Where best practices emerge, we will see if we can work for the rest of Singapore. We hope to gain a natural momentum that will lead

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to other such initiatives being rolled out across the island.

Let me now talk about workplace health. This movement towards health has another important setting – the workplace. As Assoc. Prof. Fatimah Lateef, Mr Ong Ah Heng and Mr Heng Chee How have pointed out, the workplace is an ideal place to promote wellness and good health practices, since working Singaporeans spend a significant portion of their time at the workplace. But it is not just about being pro-health, it is also about being pro-business and pro-worker.

I agree with Assoc. Prof. Fatimah Lateef and Mr Heng that workplace health is intricately tied to productivity. Better health means better effectiveness on the job, more alert employees, lower absenteeism and overall improvements in workforce morale and engagement. For employers who want to promote workplace health, it must make business sense, and it does.

6.15 pm

Many organisations have effectively created health-oriented work cultures. In the US, Kaiser Permanente, a leading healthcare group, eliminated trans-fats from its patient menus, employee cafeterias, and vending machines in 2008 to protect its patients and employees from the risk of coronary heart diseases. In Singapore, some of our hospitals have also made healthier foods cheaper. The Austrian Health Minister, whom Mr Khaw talked about earlier, recently visited the Khoo Teck Puat Hospital and was impressed by how health promotion was built into the design and workings of the hospital. They were pleasantly surprised when fruit grown on the hospital ground was served to them as snacks.

For smaller employers – a matter which Mr Ong Ah Heng spoke about – there are understandably more challenges, but it is not impossible. Some SMEs have

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shown the way. Asia Polyurethane Manufacturing, for example, is a small outfit of just 29 employees. Yet, they have launched initiatives like health screening, aerobics classes and talks on nutrition for their employees. To their CEO Mr Erman Tan, the business case for workplace health is strong. It enhances employee morale and teamwork, and has a huge impact on productivity.

SMEs will be our focus over the next few years to spark this health movement. Collectively, they are Singapore’s largest employers. In reply to Assoc. Prof. Fatimah and Mr Heng on what our plans are to enhance health at the workplace, we will do three things to persuade business leaders. First, we will make it simple for SMEs to implement workplace health programmes. We will offer customisable off-the-shelf workplace health packages to SMEs. They will simply have to choose the package they want. This frees them from the administrative hassle of sourcing and coordinating health activities for their employees. Second, we will continue our funding support for SMEs through the Workplace Health Grant which offers 90% funding to implement programmes, up to a cap of $10,000 per application. Assoc. Prof. Fatimah may be pleased to learn that since the scheme was extended to SMEs in 2009, 90 SMEs, including Asia Polyurethane Manufacturing, have benefited. For larger companies, a further 200 firms benefited each year from the Workplace Health Grant. Third, we will strengthen and form new partnerships with trade associations so that health activities can be offered to their member companies. The Singapore Manufacturers' Federation (SMa) is the first to partner HPB – 100 of its member companies have pledged to implement comprehensive workplace health promotion for their employees.

The National Tripartite Committee (TriCom) on Workplace Health, which I

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spoke about last year, has been key in driving these ideas. They have just reported their recommendations in November last year. Under the TriCom, Workplace Health Promotion elements have been integrated into national frameworks, like SPRING’s Business Excellence Framework and the Guidelines for the Re-employment of Older Employees. HPB is now collaborating closely with the Ministry of Manpower to further tie Workplace Health with Workplace Safety, as Mr Heng Chee How suggested. MOH has set up a group to oversee and monitor the implementation of the TriCom’s recommendations.

Let me now move to children's health. Children and their parents are a key link in the health movement. We see many parents attending parenting seminars to find out from experts how to bring up their children to be healthy, confident individuals. Here, we have many opportunities to create healthy habits in the way our children eat and keep fit. We know that what we learn when young stays with us.

Again, we are approaching this from many angles. The National Healthy Lifestyle Campaign this year will focus on the family. Parents will find accessible resources right at the community level throughout Singapore, such as organised walks, classes and support groups.

Schools are also an important setting of influence. Jamie Oliver, the British celebrity chef, is leading the school food revolution in Britain. He said that "eating a healthy school meal is a great foundation for a kid’s education and future health." We share the same vision. HPB has thus worked hard to change children’s eating habits and attitudes.

Dr Lam Pin Min spoke about school meals. In Singapore, HPB has partnered

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with schools to incorporate guidelines on healthy eating and to limit student’s exposure to foods that are high in fat, salt and sugar – all those things that make food tastes nicer. We are encouraged by the efforts schools have undertaken to translate this vision into reality. About 90% of our schools have adhered to HPB’s guidelines and achieved Healthy Eating Awards.

HPB has also partnered infant and child care centres and pre-schools to provide supportive environments. Through the Healthy Eating in Child Care Centres Programme, centres are provided with guidelines on offering healthy food and drinks to children. This is now included as one of the items in the licensing of childcare centres.

On the supply side, culinary training workshops have been introduced for tuckshop vendors to raise their awareness of nutritional guidelines and healthy meal preparations. We are also working with the food suppliers to modify and introduce healthier food items in school tuckshops. Members may know now that schools are not allowed to sell certain types of aerated drinks, which are too gassy and too sweet, and they are not allowed to sell fried food more than once a week.

Aside from diet, we know that exercise is also important. Research has shown that exercise helps children to be more attentive and think better. I am happy that MOE has reviewed its physical education curriculum and increased physical activity time across the various educational levels.

Apart from targeting school-going children, there is evidence that suggests that conditions in the womb and during early childhood can influence health later in life, including risk of obesity and chronic diseases. This is why HPB has expanded its target audience to include parents-to-be as well as parents of young

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children through the Healthy Origins and Firm Foundations programme. Here, HPB, in partnership with maternity and children’s hospitals, is developing resource packages for new mothers-to-be to provide them with tips on how to maintain healthy pregnancies and raise healthy children.

Madam, we have spoken about changes that will be taking place across many physical sites in our communities. There is one development, however, that will place active health management right at the fingertips of Singaporeans, so that health promotion can be 24/7, anywhere and everywhere. Members already know about MOH’s development of the National Electronic Health Records (NEHR). While most of the NEHR will transform the way that hospitals work, one part of that will directly impact you and I. This is the development of a personal health management platform. While this will take a couple of years to develop, we have already taken steps towards better personal health management, like the HPB Diet Tracker iPhone app. What we can look forward to are mobile applications built upon the platform that will support healthy behaviour and personal responsibility for health. In fact, this is the way that many countries around the world are moving toward – telehealth and mobile apps for personal health management.

Getting healthy is a process, a journey of small steps. And if we go back to the "blue zones", it is the simple things that make a difference – what we eat, whether we exercise, how much we sleep. We can all take small manageable steps in our everyday life. These small changes will lead to big improvements in our health. When these changes become a natural part of our routines, we would have formed our own personal blue zones. If we can expand this in the community, get volunteers and advocates amongst community leaders to sell the ideas to our

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residents, then we will be able to develop blue zones in our community. Let us journey together to live long and live well.

The Chairman: Time for clarifications. Dr Lam Pin Min.

Dr Lam Pin Min: Madam, I would like to thank the Minister for right-siting the new Sengkang General Hospital (SKGH). I am sure the residents in Sengkang and Punggol, including Pasir Ris and Hougang, will be very happy with this news. I would like to seek a clarification from the Minister – what will be the bed capacity of SKGH, and whether we can bring forward the completion date, instead of the 2020 that was announced by the Minister.

Secondly, I am also quite delighted about the setting up of the Seniors Mobility Fund. I would like to ask the Minister how can this Fund be utilised and what it covers. Can the Ministry also consider setting up an Assistive Technology Centre that can research and produce equipment to assist the elderly and the disabled to cope with their activities of daily living?

Mr Khaw Boon Wan: Madam, the size of the Sengkang General Hospital is one of the subjects that we are studying now. It is part of the planning. But Members can assume that it will be similar to Khoo Teck Puat Hospital. It should have a capacity of 500-600 beds. It depends on the catchment population size. That is some of the data that we are looking at. But it will definitely be a full-fledged general hospital, meaning that it covers all the major disciplines.

The idea of a regional general hospital concept is that in each region of sufficient population, the general hospitals plus its partners – community hospital, nursing home and so on – should be able to look after maybe 85% to 90% of the healthcare needs of the region. It is only

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the occasional patient with cancer or severe transplant requirements, who need to go to SGH or NUH. In this way, it brings convenience for the people but, of course, it does not mean that if you are a resident in Sengkang, you must go to Sengkang General Hospital. You are free to choose to go to Changi General Hospital or Khoo Teck Puat Hospital. That contestability must always be there, and that will bring about better service level.

On the Seniors Mobility Fund: the key word is "mobility". We are quite prepared to define it widely and loosely. Anything that will help the seniors move around. We look at it from the outcome point of view. Right now, you are stuck and you need a wheelchair or you need a walking frame so that you can move around, and move out of your apartment. I think talking to our patients, one clear conclusion is always this for the elderly. The moment they lock themselves up in an apartment, almost certainly their health condition just goes downhill. It does not get better. Therefore, the more we are able to get them socially engaged, that is most crucial. That is why Minister Lim Boon Heng's Committee is so busy, working with all Members on the Wellness Programme in the community. Let us support him and his Committee – get our residents out of their apartments. But for some who have difficulty because they are not able to move about, this Fund of $10 million will come in handy.

The approach we are taking is not a macro bureaucratic way, whereby the Ministry of Health is the one who invites applications and then assess them. That is a wrong way of doing it. But we will give money to the local VWOs. Our job is to sniff around and see which are the good VWOs doing good work on the ground, helping these residents to move around, and then we will support them with the

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money. It is not restricted to just devices. That is why I talked about services. It could be a transport service, if necessary, to bring the seniors to a day rehabilitation centre, which we know is a major gap on the ground currently. We will work through the VWOs.

If we should set up a technology centre of a higher caliber research type, then $10 million is not enough.

But we will have facilities where we help senior citizens who have stroke or whatever to shop around for devices that will help them move around. We do have those centres. We set it up in Khoo Teck Puat Hospital and, I think, in due course, there will be similar facilities in some HDB towns. As for the completion date, I mentioned 2020 to be safe, but I will work very hard to try to bring it forward, if we can.

6.30 pm

Mdm Cynthia Phua: Madam, I would like to clarify with the Minister on two points. The first one is on the polyclinics. Is he going to extend, in terms of medical IT, to allow for distant consultation? I just met a resident who is diabetic, has high blood pressure and eye problem. She is also a recovered cancer patient. So, she has to go to three different places: Singapore General Hospital, the Cancer Centre as well as the polyclinic for the follow-up consultations. But these are just follow-up checks. Could she go to the polyclinic and maybe have a distant consultation with the relevant specialised doctors?

The second issue is the mental patients again. Currently, in the community, we are really finding it very difficult to bring the patients to IMH to seek treatment and they are not known patients to IMH. So, when can the hotline or the mobile squad be ready to take such patients?

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Mr Khaw Boon Wan: On the greater use of technology, this is something we strongly believe in. We have tried various things: tele-radiology, tele-opthalmology, tele-stroke, because tele-medicine certainly has a great scope for further exploitation, and we will push along this line. But for the specific example that Mdm Cynthia Phua mentioned about tele-consultation, we do that to a certain degree. Tele-opthalmology belongs to that category, but you must have enough volumes, because it is not just a technology, you must have a specialist at the end of the line who is there to do the consultation, even though not in front of the patient. So, that has to be organised. For opthalmology, I think there are sufficient cases to do so. For the specific example that she mentioned, I am not so sure whether there are enough cases. But, in terms of priorities, this is the priority which we will always push.

For the mentally-ill hotline, I do not know yet, but it is something that I am pushing.

Assoc. Prof. Paulin Tay Straughan: I just like to follow up on the Minister's response to my health credit proposal. I think we should not see it as a bribe to get people to take proactive actions towards prolonging their health. The concern I have is that one of the reasons the low-income individuals do not go for health screening is because they are so afraid that they will find something and that they cannot afford the treatment subsequently. So, they take a very fatalistic approach to life, and they would rather not know because knowing causes them problems. A health credit scheme like this would give them a lifeline: come for health screening, let us detect your illness early, especially cancer. The health credit will help us subsidise or help them pay for early treatment which will be a win-win situation for the individual as well as the family and the State.

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Mr Khaw Boon Wan: My answer will be this: have confidence in 3Ms. Really, I mean it sincerely. 3Ms will ensure that no Singaporean would be denied any kind of medical treatment. So, if you are screened and you have cancer or whatever, and if you are poor, you will be looked after. Do not worry about that.

I was reading the Straits Times which has a section on "Mind Your Body", the latest issue of which is two or three days ago. There was an article by a consultant oncologist in the National Cancer Centre. He made a similar point. He has been a cancer consultant for 10 years now, and he has never seen a patient who has difficulty despite 3Ms. 3Ms is the way to go. So long as you understand it and you navigate it through, there is never an issue of not being able to afford any kind of treatment. So, I do not really think that this health credit is necessary. Neither do I think it will be effective for the example that the Member gave. For example, let us say, if a person found that he actually needed cancer treatment, that may be tens of thousand of dollars. How much credit are you going to give? $5, $15, $20 for a screening. So, how much credits can you accumulate in order to handle a major heart bypass, for example?

So, have confidence in 3Ms. As Health Minister, I do receive appeals from patients who get into trouble once in a while. But almost all the time when I look into the details, who are the ones who got into trouble? They are outside of 3Ms. They never buy MediShield, they never save in Medisave because they are self-employed, like taxi drivers or hawkers, that is when they get into trouble. I think our answer to Singaporeans must be, please, 3Ms is fantastic, stay in it. Please make sure you are in 3Ms. So, all workers have no problem because they are compelled to save, but they must subscribe to MediShield.

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Just two days ago, I was reading Shin Min and Tan Kin Lian was quoted by Shin Min as saying that in Singapore, for the bulk of people who go to B2 and C wards, if they have MediShield, for those who stay after retirement for another 25 years, even if they are very unlucky to be sick for 10 years, his calculation was that $30,000 is enough. Or if you want to be very safe, try $40,000. And that is more or less the Medisave Minimum Sum that we have computed. A majority of Singaporeans with Medisave are now able to achieve that saving level. And more will be able to save that too.

Mdm Halimah Yacob: I think the Minister did not respond to my point about the importance of upgrading the day rehabilitation centres. The Minister did mention that he considers the day rehabilitation centres as part of the seamless process of providing long-term care for the elderly, and also for ensuring that we can site the long-term care in the community and at home. But if you look at the current day rehabilitation centres, they are really inadequate because they only provide social services and a little bit of therapy. The day rehabilitation centres need to be upgraded to cover other services, for instance, nursing, medical care, or even if you need a manager to manage and help the family when they move from the hospital to the home. It also provides some respite and relief to the caregiver so that the caregiver can put those who are ill at the day rehabilitation centre and go to work, and not depriving themselves of a source of income. We do not need this problem. We do not have this issue being raised many times in Parliament about the need for caregiver allowance. I hope the Minister would consider that because the current centres are really inadequate.

Mr Khaw Boon Wan: The answer is "yes", and I agree with Mdm Halimah.

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That is one of the motivation behind this $1 billion Community Trust Fund. The objective is really to upgrade long-term care. We are happy with current level of long-term care as provided by the VWOs all these years. I think we are grateful to them for delivering this level of service, but what we are hoping in the next decade is to raise it to a much higher level of capabilities, especially in rehabilitation. They would need money, they would need skills, they would need training and they would need resources. That is what this $1 billion injection of fund is meant to achieve, and we would do it in a way without displacing the VWOs.

As I said just now, if we come in a big way, and then get them out of business, push them out and become a public service, I think we would be poorer for it. The ideal situation is how we can combine funding both from the Government as well as from society, but, more importantly, professional skills of the Ministry of Health with the community VWOs' passion and compassion. If we can combine the two and fuse it well, I think we will get a world-class long-term care. This, I am optimistic and I am confident. We cannot achieve it in one year. I think we probably need a decade to achieve this transformation. But if we do it well, in five years we should be able to see significant difference.

Ms Sylvia Lim: Madam, I would like to make one clarification and seek a few more from the Minister.

First, it relates to the Standard Drug List (SDL). I think when the Minister first started his response to me, he suggested that I was making him rehash things which he had answered before in Parliament but really the crux of my cut is about transparency, and I do not believe that there was any Parliamentary Question (PQ) filed previously about transparency concerning the SDL. The first clarification for the Minister is this.

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The lists which are readily available online, which I mentioned, include the WHO's essential drug lists which the Minister had previously mentioned that our SDL was based upon with local adaptation. That is published online and the Minister was saying that it is really not a secret. So, if the SDL is not a secret, then why not consider publishing it?

My second point: the Minister mentioned that he did not see why it was necessary to publish it, but I would like his comments on these possible benefits which have been pointed out to me as well. First of all, private doctors have commented that they would find it useful to look at the lists because they could refer their private patients to get the subsidised drugs from polyclinics. Secondly, they will also be in a better position to price their own drugs. And, thirdly, for sick people or families with sick people, they would find publication of the lists useful in their own research about treatment options.

The third clarification from the Minister is concerning transparency of the decision-making process which I do not think the Minister really touched on. He has mentioned in the past about factors taken into account by the Drug Advisory Committee but exactly how they weigh the factors, and so on, is not very clear. As I mentioned in my speech, there have been pharmaco-economists who have said that our process appears to be a trade-off because it is a simplified evaluation. So, would it not be in the public interest to give more information in order to let the public have confidence in this assessment process?

Last of all, just now, the Minister mentioned the 3Ms again. From what I know, from data in year 2000, the 3Ms only accounted for 10% of our total health expenditure. Recently, I filed a Parliamentary Question to ask whether the Minister could update on this but he

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only gave the inpatient coverage but not the general. So I wonder whether the Minister could update on how much the 3Ms cover the national health expenditure.

Mr Khaw Boon Wan: First, on the question of transparency, I have no issue with greater transparency. My colleagues know me well that in the Ministry of Health, I have a statement, which is "there is no secret in the Ministry of Health". There are only two secrets in the Ministry of Health. One is personnel records of staff; two is patients' records. That is privacy. Everything else is to be open because health policies ought to be argued on logic. If I formulate a particular policy, those are the assumptions and reasons. If you have a better way of doing it, I would like to know too so that we can change the policy. I now hear Ms Sylvia Lim talking about possible benefits of making this list public. I really have no problem. If need be, we just put it on the website, except that it will be a long string of chemicals. My initial reaction was what value does it give, other than satisfying some curiosities. But if it is so important, for me, putting up the list is not an issue at all. What we do not want is intense lobbying by pharmaceutical companies for self-interest and they have subject me to lobbying very often.

Every time a top CEO comes to see me, we usually do not talk about other things. He would say, "Please put my new drug onto your list." This is self-serving, not so much to improve the health of the people in a way which is sustainable and affordable, because some of these are very expensive drugs, when cheaper options are available. One of the reasons why we spend 4% and America 18% is this – we use lower cost alternatives, because they are equally effective. Why should we over-spend and spend additional money? But we will take a look and see if it is really so important to many people to put this list on the website. I personally have no problem at all.

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6.45 pm

What is the contribution for the 3Ms? I cannot recall the answer in 2000 that Ms Sylvia Lim mentioned. But the recent reply I gave about the 3Ms was because I wanted to give a meaningful answer. National health spending is a big basket of things. It perhaps includes buying and selling of herbs like ginseng, or cordyceps. All these, we all know, are personal expenditures. Over-the-counter drugs, like supplements, aesthetic treatments, and they too are in the national health spending. Whereas 3Ms is very specific, largely for inpatient care in public hospitals. In fact, it is also for private hospitals, because we also open it to private hospitals, largely for inpatient care. In recent years, we have opened it up to some outpatient care, but it remains small.

Therefore, I have said that if we want to look at contribution, then we should compare apple with apple, ie, we should look at 3Ms spending versus total spending on inpatient care. Then it is a more meaningful figure. Whereas if we look at 3Ms spending versus total health spending, which includes aesthetic medicine, etc, and worse in the case of Singapore, because we have a significant medical tourism sector, even foreigners' spending also comes into our national health spending. So what meaning does it give? If I give her a figure, what does that mean to her? That is why I compute it to say, 3Ms versus inpatient care which includes public and private hospitals. And I thought the figure says a lot about our funding system in Singapore. If she reads the answer carefully, half of inpatient care was borne by Government. This is not just inpatient care in public hospitals but also inpatient care in private hospitals, which includes foreigners' spending, and so on. Despite all those things, it is half. So, if we look at public hospital inpatient

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care, the Government subsidy is much more than half. I do not know – maybe 70%, or 80%. Then half of the remainder is 3Ms – Medisave, MediShield and insurance. And the rest is employers and out-of-pocket. When I gave that figure and I dived deeper into the breakdown, it gave me a lot of comfort. I think with many years of careful planning in our 3Ms healthcare financing sector, we have got a system which is not bad. Let us do not do silly things to destroy it.

Mr Ang Mong Seng: Could the Minister brief the House, if possible in Mandarin, on the differences between a nursing home and a home for the aged?

Mr Khaw Boon Wan: Madam, since it is rather late in the day, let me continue in English. In layman's terms, the simplest is to look at the length of stay. I look at nursing homes as a facility, not unlike a hospital. When a patient goes to a hospital, he expects to get well and then he goes home. Likewise, if a person goes to a nursing home, because he has some disability, he hopes to improve so that he can also go home. But because rehabilitation takes a longer time, it may take several weeks or, often, several months. Whereas an old folks' home is one where somebody may not be severely disabled, but because he has no home to go back to – he has been forsaken, and therefore he is in a sheltered home. That is an old folks' home.

Unfortunately, over the years, our nursing homes are behaving almost like old folks' home, because the patients go there and hardly come out, except when they die. So I am putting this challenge to the nursing homes – let us improve on our ability to rehabilitate the patients. If a patient goes in and, say, he is unable to do three activities of daily living (ADL), we hope, after a while, we can reduce it to two activities, and then reduce it to one, and then the patient can go home. That, I think, is success. In some

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countries, they have been able to do it. But to do that, we need many more physiotherapists, occupational therapists, rehabilitation specialists, etc. We need money which we will inject. Again, coming back to the $1 billion Community Trust Fund, that is what I want to tap on, to work together so that we can upgrade the nursing homes.

But because of this historical baggage of nursing homes, which are almost like sheltered old folks' homes, Senior Minister Goh has a suggestion for me. He says, "you have to re-brand it – stop calling it a nursing home." For this new generation of nursing homes that I hope to create, he said, we should call it "convalescent homes". A patient goes there for convalescence with a view of going home. In fact, the Chinese translation of nursing home is quite a good one, liao yang yuan (疗养院) (nursing home), and that is different from lao ren yuan (老人院 ) (old folks' home).

( In Mandarin ): [For vernacular speech, please refer to Appendix A.] When you go to an old folks' home, you go there because you have no home and no children who look after you. So it becomes a home for old folks. Whereas the nursing home is like a hospital, except that there are no specialist doctors because they are not necessary.

The Chairman: Mr Low, a quick clarification.

Mr Low Thia Khiang: Madam, the Minister earlier said his brother dropped everything in Canada to return home to take care of his aged mother. But I am sure he would agree that not everyone can do that. Many need to work to feed their family and they are unable to leave their jobs just to take care of a terminally-ill family member. In that respect, I would like to ask the Minister what is his perspective of end-of-life care, for people who are terminally ill. What support

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services is MOH providing to help people who need the services? My understanding is, currently, hospice is pretty expensive and home care support is limited.

The Chairman: Minister Khaw, just before you reply, I am going to extend the time so that it will allow you the comfort to give your reply properly.