HEAD M - MINISTRY OF FINANCE

[Mr Speaker in the Chair]: Head O – Ministry of Health (cont.)

Resumption of Debate on Question [8th March 2010],

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"That the total sum to be allocated for Head O of the Estimates be reduced by $100." – [Dr Lam Pin Min].

Question again proposed.

Geriatric medicine

Ms Indranee Rajah (Tanjong Pagar): Thank you, Mr Chairman. Before I go on to my cut, I would like to declare my interest as a director on the board of the Agency for Integrated Care. Our ageing population has given rise to a need for a whole spectrum of services in geriatric medicine and healthcare. I can assure you, it is no fun growing old. Your mind does not think it is old but your body starts behaving otherwise. I am going to be 47 very soon and I can attest to that fact. After a while, the mind slows down and a whole range of other challenges pop up. From my interaction with the elderly, it appears that the range of needs is extremely diverse. Medical conditions range from osteoporosis and macular degeneration to senile dementia. Correspondingly, the range of services required is extremely diverse. You need, for example, acute care in hospitals, outpatient treatment for age-related medical conditions in hospitals and polyclinics, step down care in community hospitals, day care centres for the aged, nursing homes for the critically ill. For those who are not so critically ill, you need full-time nursing services at home, day care or part-time nursing at home.

I would like to ask the Minister whether MOH is equipped to deal with this varied and diverse range of healthcare needs for the aged. Also, to what extent geriatric care needs to be handled by the hospitals and to what extent it can be handled by step down care or the community. How MOH can help people better understand and navigate the different types of services, so that we can have a better delivery of healthcare services to those in need.

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Ageing

Mdm Cynthia Phua (Aljunied): Mr Chairman, Sir, statistics have shown that the aged destitute has the highest number of Public Assistance recipients, consistently amounting to approximately 85%. Statistics have also shown that there is an approximate 1% increase in the total number of residents in old folks’ homes. In view of the rapid ageing population, this rate will definitely increase. There are many pressing questions of the care of the elderly that I would like to ask Minister to address, namely:

(i) How are we to cope with the rapid demands from the ageing population?

(ii) Will we be able to build more step down medical and rehabilitation care in the neighbourhood? How many of these step down medical and rehabilitation centres will be planned in relation to population?

(iii) What will be the funding like? Are we proceeding with the "many helping hands" approach? Will we do it like the way kidney dialysis centres are located in the heartlands? What is the Ministry's basic funding model if the Ministry proceeds with the "many helping hands" approach?

(iv) How are we going to train a pool of medically-trained personnel to take care of the elderly and volunteers who can provide the medical and nursing care for the elderly in the heartland? Presently the elderly homes do not have medical support. To give an example, until recently my family had to take care of our late father-in-law who passed away late last year. We had to fetch him to hospital; once he was dehydrated and got the basic drips, and we brought him back after his condition had stabilised. If there is some basic medical care in the community,

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there is no need to travel to and fro and more efficient use of the hospital care.

(v) How are we to make outpatient geriatric care more available at the heartlands? Could the services at GP clinics be reviewed to prepare them to take on some of these roles with the co-funding from the Ministry for the cost of geriatric care? Many of the elderly would not be able to walk to the one polyclinic in an estate. The journey is too long and the long waiting time.

(vi) How can we manage costs so that the services for nursing, rehabilitation, therapy and medication stay affordable in the years ahead for our elderly?

We need the Minister to show us the masterplan of how his Ministry is going to plan all these rehabilitation and care centres in our living environment to support the elderly.

Mobile medical services

Mr Terry Lee (Nominated Member): Mr Chairman, Sir, Singaporeans are ageing rapidly. The Ministerial Committee on Ageing reported in 2007 that by 2030, 20 years from now, one in five will be aged 65 and above, up from one in 12 today. It further projected that by 2050, 40 years from now, Singapore will be the fourth oldest country in the world. Currently there are segments within our population that face difficulties in travelling to the nearest clinic or hospital for treatments. Sometimes, these treatments or checkups can happen more than once in a week. Most patients have chronic illnesses that impede their physical mobility. To keep up with these treatments, patients sometimes find it stressful, a burden to the families and even contemplating suicide. In addition, caregivers of these patients are facing problems, such as time-off from work, job insecurity and higher transportation cost. In anticipation of our

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fast growing population, I would like to ask the Minister to seriously consider providing mobile medical services in their respective zones. Using mobile medical services to reach out to people less accessible is not something new. In other countries, it has been done to a large extent. Similarly, in Singapore, some of these mobile services are already provided by private institutions. However, they are not widespread and not affordable to the low-income families. I believe these mobile medical services will enhance workers' productivity and bring comfort and graceful living to the deserving old Singaporeans who have contributed much to the nation-building of Singapore.

Adequacy of healthcare professionals

Assoc. Prof. Paulin Tay Straughan (Nominated Member): Sir, my questions for the Minister are focused on the healthcare needs of our ageing population. Given our rapidly ageing population and increase in prevalence of chronic ailments, is there a sufficient number of physicians and nurses to manage the expected increase in demand for geriatric care? How many physicians are currently trained in geriatric care? Will there be incentive to encourage young physicians to specialise in geriatrics, as opposed to, say, cosmetic surgery? How will the expected rise in foreign worker levy affect the supply of nursing care, especially for our nursing homes? One way to keep healthcare cost low is to provide safe options and alternatives to biomedical care. Can the Minister comment on the role traditional Chinese medicine (TCM) plays in eldercare? Are the existing regulatory measures sufficient to raise the professional profile of TCM and level up the alternative healing sector to be effectively complementary to the former healthcare sector? Finally, what measures has MOH taken to avail support services to augment step-down home care for the chronically-ill elderly?

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Mental health

Dr Lam Pin Min (Ang Mo Kio): Mr Chairman, Sir, as more people are living longer, the incidence of age-related degenerative diseases of the brain, such as Alzheimer's and senile dementia, is expected to rise. Other mental illnesses, such as schizophrenia, depression and addiction are also on the rise. Unfortunately, the stigma attached to mental illness is still very apparent and people tend to shun mental patients due to lack of knowledge and understanding of mental conditions. More should be done to educate the public on mental health and diseases so as to help de-stigmatise this problem. There should also be better support from MOH in the form of mental health promotion and caregivers support. There is also an urgent need for the better integration of the services provided by VWOs and the Government agencies in the areas of social integration and community rehabilitation of patients with mental illness. I will, therefore, like to ask the Minister for an update on MOH's strategy in managing mental health and illness in Singapore.

Mdm Halimah Yacob (Jurong): Sir, mental illness is one of the most maligned and stigmatised illnesses that is least understood but is rising fast. Last year, IMH treated 33,000 patients, an increase of 14% from 2005. After raising this issue over a number of Budget debates, I am happy that there is now greater focus on mental illness. Hence, I urge the Minister to focus on the three areas.

First, cover mental illness under MediShield, as the cost of hospitalisation is increasing and is becoming a burden to families. There appears to be no compelling reason to exclude mental illness, even if there is such a wide range, from the mild to the severe, which is not something insurmountable as the limits can be prescribed. Other countries' healthcare systems already covered

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mental illness and studies have shown that we will not necessarily increase premiums significantly, especially if coverage enables patients to receive treatments earlier and, therefore, avoid the higher cost involved if their conditions worsen.

Second, establish more community-based services and provide more funding support to VWOs running shelters in other services for the mentally ill. This would help to reduce the relapse rate which also means less cost for the Government. A big problem for most families is that after a mentally-ill person is discharged from hospital, there is no place for them to go to for help or support, especially during periods of crisis, so they end up sending the patient back to hospital.

Third, provide more workplace support for those who are mentally ill, through educational programmes to raise awareness and reduce the stigma against them, and also help them in better job placement assistance.

Mr Ong Ah Heng (Nee Soon Central): ( In Mandarin ): [For vernacular speech, please refer to Appendix A.] Sir, Singapore is seeing a steady increase of people suffering from mental illnesses. In 2006 alone, the Institute of Mental Health treated close to 33,000 patients for mental illnesses. The Government passed the Mental Health Bill in 2008, which mandates the provision of proper care and treatment to the mentally ill. The law also provides for detention of mental patients, both for the sake of the patients and the public. In this regard, since the passing of the law, how many patients have been detained and for how long? Equally important is the Minister’s assurance to this House that no patient has been unnecessarily detained.

A related issue is the projected rise of age-related degenerative diseases, such as Parkinson's, Alzheimer's and senile

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dementia. The number of senior citizens aged 65 and above is expected to reach 19% of our population by 2030 and Singapore is expected to have the world’s fourth oldest population by 2050. I would like to seek assurance from the Minister that we have adequate trained psychiatrists and nursing staff to care for senior citizens with mental illnesses.

*Cols. 3685-3686.

Ms Indranee Rajah: Mr Chairman, Sir, one of the problems encountered by MPs on the ground is patients with mental health problems who have been released from IMH back into the community, but who do not take their medication, with the result that there is a resurgence of their mental problems. For example, one of my residents is firmly convinced that the neighbour upstairs is doing something to cause water to flood down from the ceiling into her flat. There is, in fact, no such problem. The HDB and Town Council have looked into it. But she is convinced that there is a problem, she comes to see me regularly in great distress and ask for a transfer of the flat. There are others, whose mental conditions lead them to engage in anti-social behaviour and, in some cases, they can be violent. There is less of an issue if they are staying with family members. However, some of them live alone or do not have people to look after them. Very often, the mental conditions are not so serious as to require that they remain in IMH. The mental conditions can be addressed provided that they take their medication. But the problem is that once they are released from IMH and they are staying alone, there is no one to ensure that they do take their medication. I would like to ask the Minister what steps can be taken to address the need for follow-up care of patients with mental health problems and whether this can be addressed by MOH or whether there are plans to address it through other agencies or community networks.

Dr Fatimah Lateef (Marine Parade): Mr Chairman, the area of mental health and

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illness has long been de-emphasised, due to the many stigma and complexities associated with it. Thanks to the Ministry of Health, there has been much more focus on these issues of late. Increase fundings towards this area, including almost double research funding in mental health. The cost of institutionalising these patients are many and varied. Once suitable for ambulatory community care, doctors will discharge them. Can MOH work and coordinate with more VWOs, NGOs, volunteers and community leaders to strategise and coordinate community support groups who can lend a hand and an ear to these people; tasks they can take part, including befriending, advising, social outings, ensuring and supervising taking of medications, giving appropriate feedback to medical personnel and IMH on observed behaviours, etc? This group can be given some simple training to acquire these necessary skills and can include independent and well elderly or retired nurses who can contribute to society.

12.15 pm

Sir, the cost of medication for psychiatric and mental illnesses can be high and many patients have been known to default treatment due to inability to cope with payments.

Since Medisave has been liberalised to be used to fund two chronic mental illnesses, which is schizophrenia and also depression last year, how many people have taken this up and how much costs did this amount to? Will there also be plans to include other chronic mental illness to the list?

Care of mental health patients

The Senior Parliamentary Secretary to the Minister for the Environment and Water Resources (Dr Amy Khor Lean Suan): Sir, the statistics on suicide make for grim reading. According to a press report, more people in Singapore die from suicides than in road accidents. Between 2000 and

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2004, of the more than 1,700 suicides, up to seven in 10 had some form of mental illness. This compares to the 212 fatal accidents in 2003.

On 20th February this year, one of my residents, a 37-year old IMH outpatient committed suicide by jumping from the HDB block she was living in. Her father, who was also an IMH patient, passed away last year. The deceased has a brother who is institutionalised at IMH. She also has one other brother who is mentally sound but is lowly educated. He is the sole breadwinner of what remains of her family, earning some $500 per month. The family has been assisted by my grassroots and the Southwest CDC for years.

After her father passed away, her mentally sound brother had asked me to appeal to IMH to institutionalise her as he was unable to take care of her. She was then still an inpatient of IMH. IMH subsequently replied that she was assessed to be no longer suicidal and had asked to be discharged everyday. IMH had informed her brother that if their medical social worker could not contact him to explore alternative accommodation, such as a nursing home, for his sister or he was unable to place her in a nursing home, they would have to discharge her once she is assessed to be mentally stable and no longer a danger to herself or others. IMH said that they would then put her under close community supervision and follow-up by members of the Community Mental Health Team (CMHT). Sadly, she committed suicide in February this year.

This incident begs several questions. Should patients be discharged into the community if they lack the necessary family support to continue with their medication and follow-up treatment? Does the IMH have a robust system of

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monitoring mentally-ill patients’ recovery in the community, and intervening if they suffer a relapse? How can IMH better track and care for its outpatients?

According to Prof. Chong Siow Ann, Vice-Chairman of the IMH’s medical board and Director of Research, an estimated one in two patients drop out of the treatment programmes. They need to be better monitored and engaged by health-care providers.

I fully understand IMH’s approach of not institutionalising all mentally-ill patients but constantly seeking to rehabilitate them in the community instead. To facilitate this, the CMHT programme was started in 2007. The CMHT now have a staff strength of 51, comprising doctors, nurses, medical social workers, occupational therapists and psychologists.

It has been reported that regular house calls have cut re-admission rates by 43% and hospital stays by two-thirds. While this is commendable, one wonders if the CMHT programme’s resources are adequate to handle the estimated more than 30,000 mentally-ill patients known to the IMH who are living in the community under rehabilitation.

Ideally, the family should be the first line of support for these patients. But their families may not know what to do or may not have the means to provide support, such as in the case of my resident. The patients could then become a menace to society and/or themselves. Such patients with little or no family support should receive more attention from IMH or CMHT. Otherwise, IMH should consider institutionalising them.

Voluntary welfare organisations, religious organisations as well as grassroots volunteers could be roped in to work with IMH and the CMHTs to make sure mental outpatients can live and function as

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normally as possible in the community. But the Ministry would have to provide resources to help these volunteers so that they can render appropriate support and assistance.

The Chairman: Mr Sin Boon Ann is not here. Mdm Cynthia Phua.

The mentally challenged

Mdm Cynthia Phua: Mr Chairman, Sir, most of us are fortunate not to have to care for a child who is mentally challenged. But for those who face this challenge, I would like to bring up their plight. The stigma that follows the parents of children with mental deficiencies often hold them back from reaching out to their communities for help. The Movement for the Intellectually Disabled of Singapore (MINDS) has been a great source of support for both the child and the caregivers. I truly admire the passion that is driving the people in MINDS. Can we learn from this establishment and provide such establishment for the mentally ill?

Presently, we are doing very little for the mentally ill at home. What can we do for them? Can we have more day care or drop in centres for them to be able to socialise so that we could at least give them some quality of life and to give some reprieve for their caregivers? How about training courses for them to upgrade their skills or hone them into some living skills to enhance their quality of life?

We need more financial assistance for these families too. Many of them are not in the tax paying bracket and do not enjoy the higher tax relief introduced in this Budget.

We need to act more swiftly because as one ages, dementia does set in. To care for the elderly is challenging and to care for the dementia elderly is even more

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strenuous. What is the Ministry doing to prepare for this group of people? Where can the caregivers turn to for help as the normal elderly care centre is unable to cope with the dementia elderly? What is the price for treatment and care giving? Are there sufficient care facilities and manpower? Many of these residents do not and could not explain their medical conditions themselves. Is the Ministry of Health able to share some of this health information with the community care centres to be eventually set up in the heartlands so that proper intervention can be done?

I would like the Ministry to consider a hotline for the public to call for help when it is obvious that a mentally-ill person needs help. The first sign is when they become a nuisance and do not cause harm yet to themselves. We need a special group to handle these mentally ill or mentally challenged. Many do not open the doors of their flat upon visits and HDB, Town Councils and Police officers are helpless and unable to have access to them as they are not dangerous.

And last of all, the other area that we need to address is the caregiver stress, especially for the mentally ill.

The Minister for Health (Mr Khaw Boon Wan): Mr Chairman, Sir, on the first day of Chinese New Year, I received news that Dr Chee Pui Hung had passed away that morning peacefully at home. He was 87. As I wrote in my blog, "I lost a friend, a supporter and a critic" whom I respect. Dr Chee was a legend and was larger than life. Within the medical community, he was widely and affectionately referred to as the "A-gong" of the Medical Alumni, who held together the large community of doctors, dentists and pharmacists. He lived life to the fullest, had a successful medical career, brought up three children well and even dabbled in politics in his early days. I am told that he had even chided a couple of Ministers in public when he disagreed with some of their

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policies. In his unique way, he contributed to Singapore.

Many years ago, my father, too, passed away during the Chinese New Year period. He lived a full life, without any bad habit, kept slim, remained active and socially engaged in retirement. Several days after all the children who lived overseas had returned to their respective homes following several days of New Year reunion with him, he had internal bleeding in his brain one night while watching – and I suppose fallen asleep – in front of the TV. My mother rushed him to the hospital in an ambulance. I took the first flight out to Penang but missed him by an hour. The suddenness was traumatic for the family, but after the emotions had settled, we knew it was a good death and we all quietly wished that when it is our time to go, we could do so just as swiftly.

The Japanese call this “ pin pin korori ”. " Pin pin " means to be healthy, bouncy and dynamic; " korori " means just roll over and die. The expression is so common among Japanese, they even abbreviate it to just PPK. To PPK means to live a long and healthy life without illness and when the time to go, just go swiftly: " Pin pin korori ". And there are pokkuri temples all over the place in Japan, promising the worshippers PPK. Although Japan has been in recession for two decades, pokkuri temples are doing quite well.

I studied the Japanese approach carefully because they have the most experience dealing with ageing. Just how advanced is ageing in the Japanese society? Let me share some observations. In 1963, Japan started giving silver cups to Japanese who turned 100. That year, they gave away 153 cups. There are now 40,000 centenarians and they have just reduced the cup size by 15% to save on silver. Their ageing problem is magnified

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by their very low birth rate. There are now more adult diapers being sold than children’s diapers. There are 23 million children but 44 million pets! Pet care is big business in Japan. Yesterday, if Members read the Straits Times , they would see a picture of a Japanese man: how he pampered his poodle by carrying it piggy-back on his back, just as he would piggy-back his kid, which he probably does not have. Even pets are ageing, so in the supermarkets they have pet food calibrated by age bands.

As noted by Dr Lam Pin Min and Dr Lily Neo, we have a good healthcare system. As the current and the former Head of GPC for Health, they know what they are talking about. Our system has brought us much success – low mortality, increased longevity, high clinical standards and among the most cost-effective in the world. But ageing of the population will bring new problems.

We hope for PPK, but what if we do not simply "roll over and die"? The Chinese have a saying, jiu bing wu xiao zi : "When you have a prolonged illness, very hard to find filial children". Outsourcing the care of patients is not the solution. The scene in " Money, No Enough 2 " of children dumping their mother outside the gate of a nursing home touched a chord, because that is exactly what we all fear.

I know death is a morbid subject and we have just celebrated Chinese New Year. But let me assure Members that this speech is not about gloom and sadness; it is about living well and celebrating life. Yes, we are ageing, but there is much cause for optimism. Today’s seniors are very different from the seniors of the past. I am 58 and my residents often tell me that "You look younger". So, to Ms Indranee who talked about ageing earlier on, ageing can be fun, ageing may not be so bad. When our children become seniors, they will, in turn, be even better than the seniors of today. Where is the

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evidence? More Singaporeans are exercising, jogging, swimming, brisk walking and engaging in all sorts of sports. Here, I must thank Minister Mah Bow Tan, the HDB, the NParks and the PUB for creating an increasingly health promoting environment. In Sembawang, for example, we see our residents regularly jogging away, using the bicycle tracks, the park connectors and the various parks. My GRC MPs, including Dr Lim Wee Kiak, are now working with the NParks to refresh the Sembawang Park so that it keeps up with the needs of modern Singaporeans. But we will ensure that it retains its natural, old world charms. Ms Irene Ng’s observation yesterday that some parks have become too "artificial, plastic", was timely. We would not make that kind of mistake.

12.30 pm

As we discuss this year's Budget and reflect upon our achievements, I agree with Dr Fatimah Lateef that we focus on how we can shape the future to meet our aspirations. I have heard Members' many thoughtful comments. Let me just pick up their key points.

First, the past decade has seen our resident population grow from four million to five million. In the next decade, will we add another million? The Economic Strategies Committee has noted our physical constraints and Singaporeans have also been voicing their concerns. So, I doubt it will be a "6-million people decade". But even a "5.5-million people decade" will mean a substantial increase in demand on healthcare services, as Singaporeans are getting older. In 2000, life expectancy at age 65 was 82 years. Now, it is 84, an increase of two years. With medical advances, this should increase further to 86, I think, in the next decade. This is success. It means that many more Singaporeans can live to their 80s and 90s. With better nutrition and

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lifestyle, many remain well. But, yes, some will get sick.

So we are gearing up for this demographic change. We are adding more beds, more clinics, more staff, more nursing homes, more day care centres. I have shared my expansion plan before but given time constraints, I will not repeat it. Let me just highlight the next big event: the opening of Khoo Teck Puat Hospital (KTPH) in Yishun. Over the next few months, we will open it in stages. Indeed, it will start treating outpatients and conduct day surgeries in three weeks' time. The ambition of the hospital team is to make KTPH a hassle-free hospital, and I look forward to that.

The change in patient profile from younger to older patients will have significant impact on healthcare delivery. The Prime Minister spoke about this during his National Day Rally last year. Young patients recover quickly. They return to status quo soon after discharge. Elderly patients take longer to recover and sometimes full recovery may not even be achievable. They merely change their status from an acute patient to a chronic patient. Many need some transitional care in a community hospital or a nursing home and occasional re-admissions to the acute hospital. That is why it is so important for close collaboration and effective coordination between the acute hospitals and their clinical partners in the community. Done right, this will free up acute beds for patients with more serious conditions and reduce cost for those requiring less intensive care in the community. Dr Lam referred to this as "seamless, integrated care". I code-name it as "hassle-free healthcare system". And one key enabler is the National Electronic Healthcare Records (NEHR), to allow all providers common access to an individual's critical medical information, so that they can develop and coordinate shared care plans. This will reduce unnecessary repeat tests and medication errors, and bring us one step closer to the

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vision of "One Patient – One Medical Record".

I gave the team planning the new Jurong General Hospital (JGH) the project brief to build a hassle-free healthcare system to serve the residents in the West. They accepted the challenge. Being ambitious, they self-imposed an additional target: to make JGH a paperless hospital when it opens. Meanwhile, the hospital team in KTPH, CGH and TTSH are also trying to do the same for their respective regions. They will compete to deliver the best ideas. And I told my Ministry of Health colleagues that this is our priority in the next decade. Indeed, it will take us a decade to complete this assignment.

Second, with more elderly patients requiring care in the community, including those with dementia, we are expanding our long term care sector. This is a point emphasised by several Members – Ms Indranee Rajah, Mdm Cynthia Phua. Many chronic patients can be cared for at home by their family members and their maids. But as Dr Lily Neo and Mdm Cynthia Phua observed, distress among caregivers might arise. I agree that carers need training and support, and we will help them.

All elderly patients want to age at home and many children want to take care of their elderly parents at home. We will build up the home nursing capabilities and we are working with several partners to do so. We must avoid seniors becoming permanent residents in nursing homes.

We are working with the Home Nursing Foundation (HNF) to scale up their operations. They will also extend their services beyond the low-income group to also help the higher-income group access appropriate home nursing care. Many patients do not need subsidies but may

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not have the knowledge and the contact of how to meet their needs. HNF is working with the TTSH team to ensure a smooth handover for patients newly discharged from the hospital. Once a patient is home, HNF will coordinate with other providers to meet the patient's care needs in the community. We will launch this new initiative within the next couple of months, targeting patients in the Central region.

Mr Terry Lee suggested the use of mobile medical services. Some VWOs do run mobile clinics to bring medical care and treatment to the patients at home. SATA is one example. St Andrew's Community Hospital is another. Recently, it launched a new service, what they call "hospital-on-wheels", to "bus" its team of doctors and nurses around Singapore. We are open to all practical ideas.

Third, a minority of elderly patients will unfortunately require long-term care in a nursing home. In Europe, up to 7% of the elderly live in nursing homes. We now have 62 nursing homes, serving 2% of our elderly population. This is not excessive, neither is it grossly inadequate as we are a young society and family bonding is still strong. There is, however, variance in the performance standards of our nursing homes. While some well-run nursing homes are full with a long waiting list, a few others have significant vacancies. We will push the weaker nursing homes to upgrade so that resources are put to optimal use. Still, there is scope for some expansion. That is why we are currently planning three new nursing homes and rebuilding three old ones in larger facilities in better locations within HDB towns.

But we must not make it too easy for irresponsible children to abandon their parents. Abandonment is not a major issue here but we do encounter some from time to time. Last week, Ms Indranee Rajah quoted one case involving

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her resident. When it happens, it is a very sad situation. I will talk more about this later.

Assoc. Prof. Straughan asked about the impact of the increased foreign worker levy on nursing homes. We have assessed – the direct cost impact actually is small. But, separately, we have just increased our subvention to them by about 7% to help them cope with the higher cost of treating patients with more severe disabilities, what we call category III and category IV patients. The increase will be quite substantial.

Fourth, we will back up the physical expansion with the necessary manpower. In the public sector, we have been adding more doctors, nurses and other healthcare professionals, to improve the staff-to-patient ratio. We launched this in 2007, when we set aside $1.5 billion to recruit 7,700 more healthcare professionals. We are now halfway through this five-year plan. And I am pleased to report to Dr Lily Neo and Assoc. Prof. Straughan that we are on track to achieving the target. Our headcounts have increased by 44%. Our doctor staffing level has gone up from six doctors to eight doctors per 10 beds. Our nurse staffing level has gone up from 20 nurses to 26 nurses per 10 beds. Recently, I met a group of hospital Medical Social Workers where we have been adding numbers. They were "complaining" to me that many of their new recruits do not even have offices and the hospital is rapidly adding workstations to hold them. Equally important is staff retention as Dr Fatimah Lateef emphasised. Although our staff attrition rates have come down from 8% to 6% for doctors and from 10% to 7% for nurses, it is an ongoing challenge. With two new private hospitals coming on-stream, we must expect significant attrition. The only practical way forward is to ramp up training and foreign recruitment.

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Last month, in my Sembawang branch, I bade farewell to a young Party activist who left us to start her medical education in a medical school in New South Wales. I asked her about the student intake numbers. She said that she was not sure but more than 300 per year for her batch. But she knew that in her batch, there would be 60 international students. But out of the 60, 40 are Singaporeans. And this is just in one medical school in Australia. I remember blogging about it after hearing this and I made a point that I will figure out a way to "get our kids back" to Singapore. And I will. The restructured hospitals are studying an idea of offering a pre-employment grant to these medical students, to help them with their costs overseas, in return for a bond to serve them when they graduate. It was an idea that Dr Lily Neo planted in my head some years ago and I think it is doable.

We have also been embracing the value proposition of a career in the public sector. We are investing in biomedical research and supporting those with research interest. For the young doctors, we are ramping up training opportunities. This will allow every young doctor to reach his maximum potential in his chosen specialty, including as a family physician. We are setting aside $120 million to strengthen our specialist training programmes over the next five years.

We are also building up geriatric care capabilities. We will encourage GPs to undertake further post-graduate training in geriatric care so that they can better manage their patients in the community. In addition, we will also need more specialist geriatricians. We have 48 now. Over the next three years, we expect to increase it by 30% to 40%. We have incorporated geriatric medicine as a core module of our medical student undergraduate training, and have introduced incentive allowances for geriatric trainees over the more popular specialities. Next to

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the new KTPH, we are right now planning a community hospital. My project brief to the team is, let us raise the level, ie, create the next generation of community hospital. They are actively thinking about it.

Among the fresh ideas being considered is to base an institute of geriatrics and gerontology there. It can be a think tank of practical people to help conceptualise and facilitate successful ageing, working closely with Government agencies, NGOs and the community leaders.

We are also upgrading our nurses so that more can take on greater responsibilities and deliver more complex care as Advanced Practice Nurse (APNs). We are targeting 200 new APNs over the next five years.

Another important group of healthcare professionals are the Allied Health Professionals (AHPs). We have started regulating optometrists and opticians. Later this year, I will come back to Parliament with a Bill to regulate the other professions. For this year, we will target the registration of the physiotherapists, occupational therapists and speech therapists. Some 1,300 therapists will be involved.

Fifth, we are enhancing our mental health programme, a topic raised by several Members. We made this commitment in 2007 when we rolled out a National Mental Health Blueprint and we backed it up with $123 million budget. The strategy includes offering a range of treatment options from acute care at IMH to follow-up care in the community. We are making some headway. We now have many more Community Mental Health Teams to facilitate the early detection and treatment of mental health cases within the community. We have developed

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programmes for at-risk groups such as caregivers and out-of-school youths. We also have an employers-led alliance that promotes the importance of mental well-being at the workplace.

However, as noted by Dr Lam and Mdm Halimah, the biggest obstacle to an enhanced mental health programme is stigma and unfounded prejudice. Mental illness makes people fearful. High profile crisis incidents lead people to think that the mentally ill are all dangerous and should all be locked away. The lack of public empathy for the mentally ill arises from misinformation and ignorance. With treatment and support, most mentally-ill patients can recover and can function in the community.

12.45 pm

Mdm Halimah Yacob, Mr Ong Ah Heng, Ms Indranee Rajah and Dr Amy Khor have asked about the follow-up care for discharged IMH patients and crisis support. I heard with concern Dr Amy Khor's account of a resident who committed suicide last month after discharge from IMH. I do not know the details of this case and whether there are systemic gaps which could have prevented this tragedy. We should try to minimise the suicide rate but, unfortunately, not all suicides are preventable. IMH carefully selects the patients to be discharged. They must have responded positively to treatment, have adequate family or social support and pose minimum danger to themselves or to others. IMH would then teach such patients and their families on the need to comply with medication and regular follow-up to avoid future relapse. Those with higher risk of relapse are followed up closely by their community mental health teams. IMH now runs a 24-hour hotline and provides advice and support to families and patients during periods of crisis. Our follow-up care is getting better but we know there are still gaps. MPs' comments earlier confirm this.

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I am, therefore, adding a further $57 million for mental health initiatives on top of the $123 million already committed. This is a significant $180 million commitment to enhancing our mental health programme. Part of the new budget will be used to increase psychiatric nursing manpower, another will go towards setting up a long-term monitoring and risk assessment system. It will help identify and provide support for patients who default follow-up appointments or treatments, thereby reducing the number who relapse because they do not take their medication.

But for this strategy to work we need the support of the community, accommodation and job opportunities so that they can lead normal lives again. Hence, I fully agree with Dr Lam Pin Min, Dr Fatimah Lateef, Mdm Halimah Yacob and Mdm Cynthia Phua that working with employers, community partners and the grassroots is a must. IMH's "job club" has successfully placed more than 380 patients over the last two years with the help of enlightened employers. And I share Mdm Halimah's hope that more such enlightened employers would come forward to offer such job opportunities. IMH will certainly work with VWOs and the community to tap on their resources to help expand IMH's outreach to the discharged patients.

Dr Fatimah asked about the use of Medisave for schizophrenia and severe depression. Five months after implementation, it has benefited 500 patients who withdrew a total of $160,000 for their outpatient treatment.

Mr Chairman, healthcare is a complicated subject. It is also highly emotional and that is why it gets politicised very quickly. Just see what is happening now in Washington. The debate on the Obama health reforms – it is largely politicking. Health systems are, therefore, distorted in all countries, becoming dysfunctional

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when distortions become extreme. To reduce distortions, we have consciously tried to stick to the basics. And what are they? First, as stressed by Dr Lam, health outcome is largely a personal matter. Doctors and nurses can only point the way forward, the patient must play his part. This is especially so in the case of chronic illnesses.

Second, there is no free healthcare. Every healthcare service is eventually paid for by the patient, either through taxes or reduced wages. Ultimately, patients and their families pay for the bills. Our job is to make sure that the cost of delivery is as low as possible, and this means cutting out abuses and other moral hazards.

Third, specialisation and sub-specialisation have brought about much medical advances and benefiting many acute patients. But as noted by Dr Fatimah Lateef, there is also such a thing as over sub-specialisation. For the elderly with several chronic illnesses, treatment by multiple sub-specialists is often not the best approach.

Fourth, despite medical advances, we are still mortals and we will die one day. Three weeks before Dr Chee Pui Hang passed away, I visited him in his house. We had a good chat for the last time. He had been frail but rejected all attempts by his attending doctors to get him hospitalised. He had the money and the medical network to get the most up-to-date sophisticated medical interventions, but he knew that they would be futile. The interventions might extend his biological life by a few days, or a few weeks, but he knew that the hospitalisation would, in fact, reduce his social interactions and quality time with his loved ones. He wanted every hour of his remaining life to be with his family and friends in the comfort of his home. This is a wise man.

Fifth, when cure is no longer available, care becomes the the most valued by

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patients, and the highest form of care is underpinned by love and compassion. Last month, I visited the St Joseph's Home in Jurong and watched the saintly Sister Geraldine in action. And she has many wonderful stories to tell, all were inspiring. In her gentle, soft-spoken way, she leads a team of nurses, carers and volunteers, caring the patients with selfless dedication and love. I asked her, "do you have difficult patients or family members?" She said, "yes". She went on to relate one incident where the son of a patient demanded that the nurses should brush his mother's teeth within 15 minutes after every meal. He said that he loved his mother, and such a service level would be in line with the patient-centric mission of the Home and also a demonstration of love and compassion. Sister Geraldine gently but firmly reminded the man that a place in a nursing home is a gift, it is not a right. If every patient imposed such a demand, they will not be able to cope. She went on to add that the nursing staff – whether it is an employee or a volunteer or a Catholic nun and no matter how kind and compassionate – is not the son of the patient. The man got the message. The love of family members cannot be delegated away.

That was why it was so sad to hear Ms Indranee Rajah speaking about a case of abandonment of parents by one resident. Our hospital nurses have also begun to come across cases of children refusing to take back their parents after discharge. They demand that the parents be sent to a nursing home instead. The numbers are still small but we must not allow this to become a trend. I have told our hospitals to be firm with such irresponsible children.

Three years ago, I spent several days in Kenya's Masai Mara Game Reserve watching wild animals in their natural

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habitat. It was the season for their annual long march as some two million wildebeests – a kind of antelope – migrate northwards from Serengeti National Park in Tanzania, in search of water and food. Along the way, many would perish as they got eaten up by crocodiles as they crossed rivers or hunted down by lions and cheetahs in the savannah plain. One late afternoon, we were positioned near the edge of Mara River as a group of wildebeests, numbering tens of thousands attempted a river crossing. There was much hesitation as they could see crocodiles waiting in the river. Almost ritualistically, a leader would eventually emerge, go into the river alone, test the water, and suddenly make a dash across the river. The rest would then rapidly follow in a mass stampede. I prayed for their safety but, inevitably, the weakest could not make it. Most made it and continued their journey northwards. Some, visibly old and frail, dared not even cross and were left behind on the south side of the river. Just as we gathered our cameras and videos to return to camp, we suddenly saw a small group of wildebeests, numbering about 30, which had already made a successful crossing, yet, surprisingly, backtracked. They had already crossed the river but backtracked to presumably rejoin their family members which had failed to make the crossing. Instead of moving on with the rest of the pack, they risked their lives in order to be with their loved ones. It was very moving and very touching. It was an instinctive expression of family bonds, love and sacrifice. I prayed for them even more deeply because the night will bring even more dangers as they were now in a smaller group. These were wild beasts but their behaviour that afternoon was not beastly at all.

Mr Chairman, our population is ageing and living longer. We have a good health care system but past solutions will not work as well for the future. That is why we have been quietly restructuring our

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healthcare delivery system and gearing it up for our future with many more elderly patients. It is a quiet revolution, no fanfare, no sensational headline news. But if we do it well, our efforts will show positive results in 10 years' time. This I promise. I do not know if I will stay so long in the Ministry of Health, though. We have a lot to do. We need to work harder at keeping patients well in the community, avoiding unnecessary hospitalisation, achieving greater integration between hospitals and the community partners and helping patients achieve successful ageing at home.

We are not alone. Every country is trying to figure out the best solutions. The efforts are not just happening in the public sector nor are they restricted to the healthcare sector. The industries are seeing an important role for themselves in tackling the ageing problem. In Japan, Toto – the largest toilet producer – makes a toilet that has arms supports to help the old get off the toilet more easily. They were the first to come up with the toilet seat with an integrated bidet. When I first saw it in Japan many years ago, I thought it was because of infection control reasons. They said no. They explained that using water to cleanse rather than paper reduces efforts for the seniors. Zojirushi, an appliance maker, has a kettle that sends a wireless message if granny does not use it by a certain time each morning. It is a clever, non-intrusive way for families to check that things are all right with their elderly. There are many such pockets of excellence and innovations all over the world.

In healthcare, I regularly remind my colleagues that we must challenge ourselves to match the best performer in each class. But the job is not mine alone. My Ministry can only provide a supportive environment. Successful living and successful ageing are personal choices. Dr Chee Pui Hang provided an example,

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but there are many others. Prof. Chan Heng Leong, a former Head of Medicine in NUS, is another, a brilliant doctor, a dedicated academic and a good family man. He could have earned more in private sector but chose a public career to teach and to treat the poor. In retirement, he continued to contribute in the university and at the hospital. When his time was up, he refused further medical interventions and passed away peacefully at home surrounded by his loved ones.

1.00 pm

The last few days of these wise people are not mournful partings but quiet celebrations of having lived a fulfilling life. Friends and family members drop by to talk about the past and the good times together. Some, I suppose, even karaoke and probably sing Jin Daban - zuihou yi ye: hong deng jiang mie, jiu ye xing, ci ke gai kai xiang ta gao bie ( 金大班 - 最后一夜: “红灯将灭,酒也醒, 此刻该向它告别”). I do not think I need to translate because I am told that this is a very popular karaoke song amongst Members of Parliament.

Indeed, Mr Chairman, everyone, rich or poor, will say goodbye one day. And we all want to end well. But to end well, we need to stay well and live a healthy and fulfilling life. We have different starting points but all can live well. Over the weekend, I was so happy to read about Jeremy Lim's achievements at his GCE 'A' level examinations. He was an NKF Ambassador when I first met him several years ago. He was born with a brittle bone disease and told me that even a severe cough could fracture his ribs. He is wheelchair bound but has never allowed the disability to hold him back. As he put it to Zaobao over the weekend, "We cannot determine what life will bring us, but we can determine our life journey". He added, "I cannot walk like other kids, but I can still do many things that other kids can". He told Straits Times this: "I

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focus on the things that I have, rather than the things that I don't."

Life is really a series of successive moments. We cannot change the past moments and we do not know what the next moment will bring. But we can all seize the current moment and live it to the fullest helping others and touching their lives. How?

Lao-tzu's prescription is 2,500 years old but I think it remains relevant today: “上善若水, 水善利万物而不争”. This, I need to translate because it is in classical Chinese and Lao-tzu is not the easiest to fathom. He said: "Water nourishes all life, but itself does not gain anything." What he is trying to tell us is we should all live a life like water. We are here to help others, be kind to everyone else, not to help ourselves. This is a high ideal, but I think we all can strive to be as close as possible to that ideal.

Medisave for health screening

Dr Lam Pin Min: Mr Chairman, Sir, over the years, Medisave has been liberalised progressively for payment of medical-related insurances, outpatient treatments and investigations. An example would 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 restriction of capping the maximum withdrawal of $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 of Singaporeans.

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Health screening

Dr Fatimah Lateef: With developments and research in the medical field, there is now an increased battery of tests available for health screening for a variety of conditions. Some Singaporeans have not been very proactive in coming forward for health screening. Perhaps, they are complacent or, rather, they are confused how to choose and proceed.

Can MOH invest more in educating the public pertaining to health screening? Can MOH also consider allowing Medisave to be used to fend off some cost of health screening? Liberalising too much will open a whole new Pandora's box and we risk having unnecessary tests added to the list. Will MOH be able to come up with a list of approved testing for screening for various groups with some degree of flexibility, of course, and consider allowing a small portion of Medisave to be utilised for this with a fixed cap or ceiling on an annual basis? This would be very much along the lines we have allowed Medisave to be used for part payment for chronic diseases.

Affordable long-term care

Mdm Halimah Yacob: Sir, as many Members have pointed out, our healthcare system will come under increasing pressure from an ageing population and other chronic illnesses. Hence, we need to ensure that our system remains robust and affordable and will be affordable for long-term care. I would thus like the Minister to consider the following issues.

First, to provide integrated care so that patients can move easily from acute hospitals to community hospitals to nursing homes or their own homes depending on their needs. So co-location of facilities like the Khoo Teck Puat Hospital, promoting greater synergies amongst the different levels of care and greater sharing of information and records

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amongst them would certainly provide better integration of care.

It is also necessary to ensure that the different subsidy level between acute hospitals and community hospitals does not derail right siting as people would certainly prefer to stay where the subsidy is highest and the cost lowest. MOH should also make it easier for people to take care of their sick family members at home by strengthening home visits by doctors and other healthcare professionals and making these services cheaper as there are limited subsidies now.

The second area is financing of healthcare. The 3M system, together with the 3E system (Eldersave, ElderShield and Elderfund), provides a strong foundation for healthcare financing. I urge the Ministry to constantly review these schemes to ensure their adequacy. At the same time, there is a need to review other policies which have an impact on affordability.

Last year, I asked for more subsidies for some procedures carried out in the C or B2 wards such as the knee replacement surgery. I hope to get an update from the Ministry on the progress of this review.

The other area is the cost of medicine which can be very expensive for treatments such as cancer. The Minister had mentioned that instead of subsidising all expensive medicines, he would consider extending Medifund to middle-income Singaporeans who cannot afford the high cost of medicine. Can the Ministry give an update on this?

Third, in order to help families take care of those who are ill, there has to be stronger community-based care for the elderly or those suffering from severe illnesses such as mental illness. Our community-based care is weak which is the reason why most opt for institutional

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care, thus crowding out our hospitals. I would like to urge for stronger community-based care and, in particular, more subsidies for home-based care.

Affordability of community hospitals

Dr Amy Khor Lean Suan: Sir, as the Minister and other Members of this House have noted, the healthcare system is being restructured to meet the challenges of a rapidly ageing population. A key focus would be to build up step-down care facilities to complement the public hospitals.

Acute care hospitals, like TTSH, are seeing a changing profile of patients. They are currently not equipped to handle older patients who are being admitted more frequently, have multiple problems and require longer hospitalisation. This has added to the pressure on hospital beds leading to the recent incident at TTSH where patients were put on movable trolley beds and placed temporarily at the hospital's corridors.

Integrating the whole spectrum of services from acute hospitals to home care would help to optimise scarce resources and remove strains on certain facilities, chief of which are the public hospitals. For this to be successful, we need a mindset change of both the healthcare providers as well as patients and their families. All things being equal, it is generally more expensive to stay in an acute care hospital than a community hospital. Nonetheless, anecdotal evidence on the ground suggests that there tends to be resistance to admission into community hospitals.

There is some public perception that community hospitals are poor cousins of acute hospitals, lacking the full range of medical equipment and specialists. It does not help that many community hospitals are run by charities or religious groups

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which do not have the financial muscle to match salaries at the public and private hospitals.

REACH's Policies Study Work Group on Ageing and Health conducted a study of 800 Singaporeans aged 25 to 64 years and found that 44% of respondents held the misunderstanding that stroke patients can only be discharged from acute hospitals when the patient is completely well and not when the patient is stable and ready for rehabilitation services.

The survey also found that the decision to transfer the stroke patient to step-down care facilities such as community hospitals or day rehabilitation centres is strongly influenced by the out-of-pocket expenses required for these services. All things being equal, even though the total bill size for a stay at an acute hospital is more, the out-of-pocket expenses for the community hospital are generally higher than that for an acute hospital. This is due to the different means-testing systems employed as well as the lower allowable Medisave claims for community hospitals or no claims allowed for day rehabilitation centres and home care services.

I would thus like to ask the Minister to intensify its efforts to educate the public on the value and benefits of rehabilitation and correct the misperception that community hospitals are the poor cousins of acute hospitals. The Ministry should also review the quantum of Medisave that can be claimed for community hospitals and allow the use of Medisave for day rehabilitation centres. This will lead to greater optimisation of different healthcare facilities.

The Chairman: Mr Sin Boon Ann is not here. Ms Sylvia Lim.

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Medisave for outpatient treatment

Ms Sylvia Lim (Non-Constituency Member): Sir, since 2006, Medisave can be used for outpatient treatment for chronic diseases such as hypertension up to a limit of $300 per year. However, it would seem that this has been under-utilised. According to the Ministry's reply to my Parliamentary Question last month, only 15% of chronic disease outpatients paid bills with Medisave in FY2008. Of those who did utilise Medisave for payment, only 30% of claims reached the annual limits on withdrawal of $300.

I recently met an elderly gentleman with hypertension who has Medisave balances but is unable to use them to pay outpatient bills. This is because of the current policy that the outpatient must pay the first $30 of any bill. He showed me that many of his polyclinic bills were below $30. According to MOH's data, the median size of polyclinic bills for chronic diseases is $36 with three months' medication. With the $30 deductible plus an additional 15% of the balance to be paid in cash, Medisave would not be usable or useful for many of such bills.

Sir, there are elderly sick who have little cash and savings. Yet, they are not allowed to draw their own Medisave money for medical treatment but are asked to get family support. This increases the elderly person's dependence on family members. The elderly gentleman I mentioned told me that he would sometimes default on his follow-ups due to finances. This could precipitate a worse inpatient condition which will deplete his Medisave even more rapidly.

The Government may be concerned about Medisave accounts being depleted but safeguards already exist via the annual $300 cap, the requirement to co-pay 15% and the administrative fee of $3.50. Sir, the Government should consider removing the deductible. There is

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anger amongst some elderly sick that even in their poor health condition, they have been denied the use of their own savings for healthcare.

Adequacy of Medisave

Mdm Halimah Yacob: Sir, Medisave is one of the biggest pillars of our healthcare system. However, with increasing medical cost, there will be tremendous strains on our Medisave. I would like to ask the Minister the following questions on adequacy.

First, has the Ministry done any projections to assess how much Singaporeans would need to save in their Medisave in order to meet their long-term care needs, say, over a 10- or 20-year timeframe? Second, could the Ministry give an assessment on whether our Medisave at the current level of monthly contribution rate is sufficient to meet our future needs and whether there are any plans to increase the level of monthly contributions? If so, what would be the impact of such a change on other CPF needs of the account holder? Finally, has the Ministry considered whether there is a need to review the Minimum Required Amount (MRA) which was set some years ago to ensure the adequacy of our Medisave?

Mr Khaw Boon Wan: Earlier, Dr Lam referred to a recent positive commentary on our healthcare system by the Washington Post . It described Singapore as "the only rich nation that boasts universal coverage with health outcomes better than ours [meaning the United States] while spending one-fifth as much per person on health care".

Our system is not perfect. Indeed, we still have many problems to iron out, including the current shortage of hospital beds on certain days. But it is among the most cost-effective in the world, delivering a high clinical standard without

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inflicting too much financial hardship on patients or taxpayers.

Over the years, many have come to study us. My most recent visitor was a delegation from Armenia, formerly in the communist bloc. Armenia, as Members may know, is a small landlocked country but with talented people. We used to have an Armenian community here in Singapore. They told me that there are still about 100 of them living here. There is an Armenian Church and, of course, our world famous Raffles Hotel was set up by three Armenian brothers a century ago. The delegates who came to study us were serious and bright. They asked critical questions. But for most of the last century, they were bogged down by the communist system of central planning. Twenty years after the fall of the Berlin Wall, they are at a cross-road. They know that their current system of free healthcare and centralised delivery is not sustainable. They read about us and its Health Minister led a team here to probe. I shared with them abundantly, and my parting comment was that health reforms would take decades. And even then, it would always be work-in-progress. Earlier, we discussed our healthcare delivery system. This afternoon, I will discuss how our financing model can be improved further.

1.15 pm

In the new financial year, our budget to subsidise patients will increase by 10% to $2.2 billion. I am grateful to the Finance Minister for his support. In fact, the increase is more as the Finance Ministry has also topped up Medisave accounts, Medifund and Eldercare Fund by $710 million. These top-ups are, in fact, subsidies as they help Singaporeans pay for their future healthcare needs.

Such Government subsidy for healthcare is the first layer of protection for Singaporeans, which ensures universal access to basic healthcare by all.

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Because the 3Ms label does not include this item, Government subsidy is often taken for granted. I have been trying to see how we can slip in the "S" (for subsidy) into the 3Ms. But in the end, I still end up with just 3Ms. I suppose the small "s" in the 3Ms could be "subsidy", but in real life our subsidy actually is a big "S" and not a small "s" at all. It is our huge Government subsidy which differentiates our healthcare funding model from that in the US, Japan and many European countries, where hospitals and clinics would charge all their patients at full cost without subsidy.

In Singapore, 80% of the patients in our hospitals choose Class B2 or C wards. In these wards, the bulk of the cost is picked up by the Government. For example, a Class C patient going for a hip replacement surgery, which is a major surgery, would cost the hospital, on average, $17,500. Eighty per cent of the cost, or $14,000, is paid by my Ministry through our annual subvention to the hospital. The patient co-pays the remaining 20% or $3,500, which are largely covered by MediShield and his Medisave savings.

Mdm Halimah spoke about knee replacement surgery, which she raised last year. We have fixed the problem by revising the claim limits. On average, the cost of treating such a patient in Class C now is about $16,000. My Ministry subsidises about $11,500 with the patient co-paying the remaining $4,500. With Medisave and MediShield, many do not have to pay anything out of pocket, unless they insist on some costly fanciful implants.

This is our approach to subsidising care. As medical advances and hospital operating costs go up, we increase our subvention to the hospitals so that patients remain subsidised in accordance

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with the prescribed subsidy policy. We actually miss the target sometimes. For example, Class B2 subsidy is 65%, with patients co-paying 35% of cost. But, in reality, B2 patients today co-pay 30%, which is five percentage points below target. We will have to close the gap eventually, but let me assure Members that it will be gradual and will not inflict unnecessary hardship on our patients.

After Government subsidies, Medisave forms the second layer of protection. As Mdm Halimah put it, it is a key pillar of our healthcare system. Medisave turns 26 this year. Collectively, we now have more than $45 billion in Medisave. At the individual account level, all salaried employees have healthy Medisave balances for themselves and their dependents. There are many statistics to prove this point, but let me just highlight one. By age 50, the average Medisave balance of all salaried employees would have exceeded $27,000. This is good for 18 hospital admissions if he chooses Class C. And even if he chooses Class A, it can cover six hospital admissions. This assumes he has no insurance coverage. But 90% of all Singaporeans have MediShield coverage, which would reduce the patient's share of the bill substantially. For these Singaporeans, their Medisave balances can cover even more hospital admissions.

This is a remarkable achievement. Medisave is one main reason why sophisticated but costly healthcare services are within the reach of all Singaporeans, including the lower-income group. In the current health reforms debate in Washington, serious economists are all advocating what they call "HSA" (health savings account) as a necessary solution for the American healthcare system. Medisave is a HSA – a health savings account; we pioneered it long before economists developed this insight and coined this term.

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The idea came from Minister Mentor Lee. Dr Goh Keng Swee sketched out a rough outline. Senior Minister Goh fleshed out the details, persuaded Singaporeans to accept this idea and got it successfully implemented. We have all three to thank for this innovation, which has now become an integral part of Singaporean life.

Mdm Halimah asked about the existing Medisave contribution rates. This is tied in with the overall CPF contribution rate and is a factor in employment cost and overall competitiveness. I have no grave concern on the adequacy of the existing Medisave contribution rate. But I must add one caveat on the self-employed who form 12% of CPF members. Many are careful and contribute regularly to their Medisave. They too have an average Medisave balance close to the salaried employees of similar income band. My worry is the 140,000 self-employed members who have an average Medisave balance below $10,000, some just a mere few thousand dollars. Out of this group, only 40% had made some contribution to their Medisave last year. Even then, it is usually just nominally. They would get into problems if they or their dependants fall sick. And it would be worse if they also do not subscribe to MediShield and ElderShield. We must all help to get them into Medisave, MediShield and ElderShield, so that they can enjoy the same protection as the salaried employees.

Mdm Halimah asked about the adequacy of the Medisave Minimum Sum. She asked if it is adequate to meet the needs of an ageing population. The current Medisave Minimum Sum is at $32,000 and is not bad for those opting for Class B2 or Class C wards and have MediShield and ElderShield coverage. We will continue to adjust it annually to take into account medical inflation, so as to preserve the purchasing power of the account holders. My concern is that currently, most are not able to achieve the

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Medisave Minimum Sum by the time they reach 55. The top 40% of income earners are all right, but not those in the lower-income group. That is why we have to be careful in not over-liberalising the use of Medisave for other purposes, which it was not originally designed for.

I have the unpleasant task of being the gatekeeper to Medisave. I heard Ms Sylvia Lim. Yes, Medisave is your own money, but if it runs out prematurely, the member will be in trouble. And I am trying to prevent such an outcome. That is why we have stringent Medisave withdrawal rules and limits. This will help to balance current consumption against future needs and ensure that Singaporeans have enough Medisave to look after their medical needs during retirement.

Ms Sylvia Lim spoke about the Chronic Disease Management Programme (CDMP) and the deductible of $30 that we put in. She made a couple of observations: one, that the utilisation rate of this scheme seems below expectation, less than 15% of chronically ill have made use of this scheme. It is not a surprise to me because when we estimate the total number of chronically ill, it is based on the disease incidence. Like in all population, probably half of those with chronic illness do not even know they have the disease. And that is why we must step up mass screening. And even among those half who knew they have a chronic disease, not all come forward. Many studies have shown, and again also observed in Singapore, that only half of those who knew they have chronic disease will come forward to see a doctor. And among those who come forward to see a doctor, not all comply; they may decide that changing lifestyle is too troublesome; taking medication is too troublesome, or for whatever reasons. So, when 15% of potential users of this scheme come forward, I thought it was not bad. At first, I thought we cannot even cross 10%. But, yes, we should now aim higher and

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try to get more people to make use of this scheme. I have spoken to some who are on regular chronic disease management but not using the Medisave. I asked them, they said "why should I", and they gave a couple of reasons. One, some of them are paid for by their employers, so there is no need for them to use their own Medisave. Secondly, some are quite smart, they said that Medisave pays interest rate – I do not know what it is now – 4%-5%. They have enough cash, and they say they will pay cash, which in the bank you cannot even collect 0.5% interest rate today. So, there are all sorts of reasons why we ended up with only 15% utilisation. I do not think we should be discouraged by this figure.

The deductible is a problem that can be easily overcome, and I have spoken to GPs and our own polyclinics. And one way they do it – which is quite legitimate and in fact advisable – is they package it up. So, yes, each visit may be only about $30 or $40, as noted by Ms Sylvia Lim. But these are chronic disease management programme, we expect the patients to come forward three or four times a year depending on the risk profile. And, in fact, we want the patients to come forward. We would be very worried if they only come once and disappear. Then compliance would be a problem and their diabetes or high blood pressure will not be managed well. So, many clinics have now offered what is called package deal. They charge per year or even per two years and the whole sum, let us say, $250, will attract the same deductible of $30. The rest can be deducted from their Medisave. So, this is one way to overcome this deductible issue but, more importantly, it secures compliance by the patients.

Recently there was some public discussion on the use of Medisave for health screening. I think Dr Lam Pin Min and Dr Fatimah Lateef have suggested

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that we consider expanding Medisave for health screening, subject to certain limits and guidelines.

I am sympathetic to the call as I believe in prevention. Regular screening and early detection followed by medical intervention and lifestyle changes can avoid future complications and costly medical treatment down the road. There is a case for allowing some Medisave withdrawals for health screening. The question is what kind of health screening? There is a wide range of health screening tests; not all are fully justified or necessary. More screening is not necessarily better. Some accrue benefits more to the provider than the consumer. We must be mindful of such pitfalls. As Dr Fatimah put it, we may be opening a Pandora's Box. A mindless liberalisation of Medisave for health screening may not improve health outcomes, but instead prematurely deplete Medisave balances.

1.30 pm

Let me give one example of health screening which is being promoted in the West: genetic screening to predict the risk of a person getting a particular disease later in life. These are sophisticated tests and, of course, very expensive. The clinics love it because it improves their topline and bottomline. Last month, the Journal of the American Medical Association published a timely research finding on the effectiveness of the current gene markers to help doctors predict which women would develop heart disease. The study found that we still do not yet know enough about genetics for health risk prediction. The article concluded that "instead cholesterol levels, blood pressure and family history remain the better indicators for determining who is at risk for having a heart attack, stroke or dying from heart disease". At the moment, the traditional screening methods are still more reliable and very much cheaper. But they are less

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glamorous and bring in less revenue for the clinics. I am sure genetic forecasting will become more useful in future, as their scientific promises are fascinating. But meanwhile, the results are still disappointing. As one International Herald Tribune (IHT) article put it: "If you want to learn your odds of getting different diseases, consult your family history. Or visit a fortune teller. For most traits, genetic testing is little better than consulting the tea leaves."

Genetic testing is one example. But there are many other sophisticated screening tests which are also being promoted. All are expensive. The benefits or cost-effectiveness of such tests are often dubious. I call this unethical screening. Health screening is therefore a complex issue and the risks associated with unethical screening are real. We must not fall into the trap of such commercial practices.

As a first step, my Ministry will set up an expert group to review the range of healthcare screening available here and recommend a framework to determine what constitutes appropriate health screening. We will then be in a better position to advise Singaporeans, as suggested by Dr Fatimah, so that they do not get fleeced. She did not use those words, I do. Prof. Lee Hin Peng will chair this expert group. He is a senior public health specialist and has a special interest in cancer screening and prevention. We propose to put this group under the auspices of the Academy of Medicine.

Separately, we will study the financial implications of health screening so that should we decide to open up Medisave for it, we will know how to prescribe the necessary withdrawal limits. This was the approach we took when we opened up Medisave for outpatient chronic disease management. It is a prudent approach to exploit the benefits of Medisave liberalisation, while minimising the downside risks

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of over-servicing and over-consumption. Meanwhile, I have noted the various suggestions by Members and I will try to incorporate them in due course.

Another area of Medisave usage is in the intermediate and long-term care (ILTC) sector. Several Members have commented on the need for rational Medisave withdrawal rules to encourage right-siting of patients in the community. And I agree. Today, Medisave can be withdrawn for community hospitals, subject to a daily withdrawal limit of $150, up to an annual cap of $3,500. This is largely adequate for patients undergoing rehabilitation. However, we are stepping up the capabilities of the community hospital so that they can also serve sub-acute patients, for example, those with hip fractures, and elderly with kidney and urinary tract infections. Traditionally, such patients are kept in acute hospitals where their Medisave withdrawal limits are higher, at $450 per day. But it makes sense for the patients to be transferred to a community hospital where the total cost is lower. However, current withdrawal limits may deter such patients from moving to community hospitals because of higher out-of-pocket payments, as Dr Amy Khor pointed out.

To fix this anomaly, we will do two things. First, we will subvent the community hospitals which partner the acute hospitals to provide sub-acute care, more. The daily norm cost for such cases will increase from $271 to $400 per day. So this is quite substantial. Second, we will (a) raise the daily Medisave withdrawal limit for community hospitals from $150 to $250, and (b) raise the annual Medisave withdrawal limit from $3,500 to $5,000. Together with the enhanced nine-tier subsidy framework for community hospitals implemented last year, these adjustments should make it cheaper for sub-acute patients to move from an acute hospital to a community

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hospital. I thank Dr Amy Khor for this suggestion.

Medisave can also be used to pay for day rehabilitation services, subject to a daily limit of $20. We will also be raising this limit from $20 to $25.

We are working with the providers to raise the clinical standard of community-based rehabilitation care. We will involve more skilled therapists in the delivery of care and establish individual care plans and improved outcome monitoring to help ensure patients receive the care they need. With better treatment, costs will, however, go up and that is why the increase in Medisave withdrawal limit should benefit the patients.

These changes to Medisave withdrawal limits will be implemented in June, in a couple of months' time.

After Government subsidies and Medisave, health insurance in the form of MediShield, ElderShield and their private supplements, form the third layer of protection. The value of health insurance and the benefits of risk-pooling are well established. Practically all countries have incorporated insurance into their healthcare systems. The Germans under Chancellor Bismarck introduced this innovation a century ago. But we are again unique by insisting on "deductibles and co-payment" in our health insurance framework. We reject comprehensive health insurance based on "first dollar coverage". Many other countries adopt comprehensive health insurance and are now bogged down by abuses, over-consumption, over-servicing and wastages. They are all trying to reform their insurance policies, eg, in the US, by introducing "deductibles and co-payment" but find it politically challenging. Former Health Minister Yeo Cheow Tong incorporated this important feature into

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our health insurance policies and we were wise to have avoided these pitfalls.

Even the Germans who pioneered health insurance are now trying to reform their national health insurance system as abuses are causing massive deficits. Employers have been shouldering the rising premiums but this has affected their business competitiveness. They are saying "enough is enough" and are demanding that employees should shoulder future premium increases. Last week, an article in a German business weekly, Focus Magazine , discussed this issue. The article was titled "Saving Money With Singapore" and this is an English translation of their German title. I am sure it is more elegant in German. Its sub-headline read: "The Government is looking at an Asian health regime as a model for the reform of the statutory health insurance system". The article said that they "are looking into one health system in particular – that of Singapore". I do not know if our 3Ms is implementable in Germany as our politics are different, but clearly we must be doing something right.

MediShield and ElderShield are not compulsory but, through an opt-out approach, we have achieved good coverage. MediShield coverage has exceeded 93% for all working adults, and the ElderShield per-cohort coverage is about 90%. As noted by Dr Lily Neo, there is room for further expansion, but the current picture is not bad.

I have done several enhancements to MediShield and there is scope to do more, for example, to extend it to cover mental illness and congenital illnesses, when the economic condition is conducive. Mdm Halimah and Ms Denise Phua raised these two ideas several times. I have not forgotten them.

I have also enhanced ElderShield, but I think further enhancement is necessary.

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ElderShield now pays out $400 per month for up to six years. This is just about sufficient for the lower-income group who can qualify for heavy subsidy in nursing homes, but it will not be enough for the higher-income group. They should top up their basic ElderShield with ElderShield supplements. Some do. About 14% of ElderShield policyholders subscribe to ElderShield supplements. It will be a better picture, if another 30% or 40% also join in.

In response to Dr Lily Neo, we are looking to further enhance the basic ElderShield by raising its payout to, say, $800 per month. But this will require some premium adjustment. I am trying to see how we can avoid this and I am studying the alternative of maybe bringing forward the entry age from 40 to, say, 35 or 30, which should mean lower premium adjustments. Effectively, this will allow Singaporeans to spread out their larger premium payments over a longer period of their working life, instead of the current 25 years, in return for higher payouts should they become severely disabled.

The final layer of protection is Medifund. This is the ultimate safety net to catch anyone who falls through the top three layers. We have been building it up since its launch in 1993. With the proposed top up of $200 million, it will reach $2 billion.

Medifund is again unique in Singapore. We consciously set aside budget surpluses during good time, so that our ability to help the vulnerable during bad times is not diminished by the adverse economic climate.

Last year, when we anticipated more patients asking for financial help, we increased the Medifund disbursement to $75 million. It was helpful. While the economy this year should be better, I will nevertheless further raise this year's Medifund budget allocation to institutions

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to $80 million. This will be funded, as usual, using the interest earned by the endowment fund.

Separately, I have been thinking about how to help lower-income Singaporeans cope with expensive drugs, over and above our current subsidy policy. Last month, I disbursed an additional $8.5 million to Medifund Committees to enable them to help more patients, especially those requiring HIV medications. This year, I will inject a further $10 million from Ministry of Health’s operating budget to help deserving patients cope with seven high cost medications used for diseases such as breast cancer, colorectal cancer, ovarian cancer, COPD and asthma. This should be helpful to many patients suffering from these diseases. We will leverage on the Medifund mechanism to help disburse this additional financial assistance to deserving patients. This includes means-testing and some co-payment by patients as the hospitals deem fit. If the idea proves useful, we can increase the budget allocation to this new Medication Assistance Fund (MAF).

Mr Chairman, our multi-layered protection framework, code-named 3Ms, builds upon and enriches our Government subsidy framework which we inherited from the British. It allows us to combine the best of the British taxation model with the best of the market-based American insurance model. It is not perfect but it has served us quite well. I fully agree with Dr Lily Neo that "we need to continually tweak it so as to cater to the growing needs and expectations of our people". With the support of Members, I will continue to do my best to ensure that all Singaporeans can afford basic healthcare. This is my pledge.

Special needs medical screening

Dr Lam Pin Min: Mr Chairman, children with special needs have an array of different diagnoses – from learning disabilities like dyslexia to profound

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mental developmental delay; behavioural issues like autism, attention deficit hyperactivity disorder (ADHD) to psychiatric problems.

Early detection of children with special needs will allow early intervention, leading to better outcome for these children. Currently, there is a lack of awareness amongst parents about these conditions and also a severe shortage of medical screening services for these children. This is aggravated by a shortage of professionals to provide such services.

Does the Ministry have plans to raise awareness of these conditions amongst the public and also to grow this sector to cater to the increasing demand in Singapore?

Health promotion and a healthy nation

Dr Fatimah Lateef: Health promotion, as defined by the World Health Organization 2005 Bangkok Charter for Health Promotion in a Globalised World, refers to the process of enabling people to increase control over their health and its determinants, thereby improving their health. The Health Promotion Board has been spearheading health promotion in Singapore.

1.45 pm

Looking at our statistics of chronic and lifestyle diseases, we need a more concerted effort. Thus, increase awareness and education, more proactive health screening, reinforcement at workplaces; where most of our working adults are, and even in institutions of higher learning and schools. Besides the physical, psychological wellness must also be given a greater thrust. Will there be more funds allocated towards this? Are we increasingly investing in innovation towards enhancing health promotion and

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will we see more proactive collaborations between MOH and Health Promotion Board with relevant agencies such as MOM for workers' health, MOE for students' health, as we strive towards the goal of more healthy nation?

Workplace health promotion

Mr Yeo Guat Kwang (Aljunied): Sir, with the drive towards longer employment and implementation of the Re-employment Act that will come into effect soon, there is a greater need to keep the workforce healthy. After all, the three key elements in supporting a longer term of employment are; having the skills, having the willingness to work and, more importantly, being physically and mentally fit to work. Employers need to support this drive to help Singaporeans to work as long as they wish.

The tripartite at workplace health promotion helps to improve the health and fitness of workers and to create a healthy working environment by promoting healthy lifestyle for a better life has made a good progress. The programme includes a basic health screening followed by way of empowering Singaporean workers to take personal responsibility for their health. In short, raise their awareness and help them create the drive to take actions to CHEERS – Cease smoking, Healthy Eating, Exercise Regularly and manage Stress.

Offering attractive salaries alone is often not enough to keep staff productive and loyal. It is important for us in making our economy at workforce more future-ready and more competitive. We must strengthen such a holistic workplace health programme for our workers in all workplaces to achieve both physical and mental well-being. I would like to urge the Ministry of Health (MOH) to provide more resources and budget to further support the workplace health promotion to achieve HEALTH – Health and everyone

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achieves lifetime health. I hope MOH could give more financial incentives for companies to provide regular basic health screening at work. Health screening is an important means of praising workers' awareness of their own health status and health profile. The basic health screening will also provide the companies with a reference to tailor their health promotion and integration programme so as to help their workers maintain their health and manage their lifestyle habits and reduce all the risks for chronic illnesses.

Apart from physical health, MOH should also provide more support in the area of emotional health. This is an area not to be forgotten of as many seems to regard the workplace as a major source of stress. Workers who have problems dealing with stress arising from personal or work related reasons may inadvertently affect their employees around them as well as their own work productivity; thus affecting the morale of the company.

Workplace health

Mr Ong Ah Heng: ( In Mandarin ) : [For vernacular speech, please refer to Appendix A.] Sir, the Health Promotion Board has correctly identified that the workplace is an ideal place to promote health issues. It is estimated that about 65% of our population aged 15 and above are in the workforce. Many of us now spend more time at the workplace than at home.

While basic healthcare coverage is being provided by the majority of companies, there is a disparity in medical benefits provided by large corporations and SMEs. Currently, there are 130,000 SMEs in Singapore. I was told that some small companies do not reimburse their staff if they fall sick and their only entitlement is medical leave with no pay cut.

First, I would like to ask the Health Minister how the Government can

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encourage SMEs to provide better medical benefits to their workers. Second, how can the Health Ministry collaborate with the Ministry of Manpower to ensure that more workers will get good healthcare coverage at their workplace?

*Cols. 3687-3688.

Banning trans fat

Mrs Mildred Tan (Nominated Member): Sir, many cities such as Boston, New York and Philadelphia have banned trans fat, a food ingredient commonly found in french fries, donuts and other fried foods. Trans fat has been linked to heart disease in humans and diabetes in experimental animals. In Singapore, three in 10 Singaporeans have exceeded WHO's recommended daily limit. Will the Ministry of Health (MOH) consider banning this or increasing public education in the harmful effects of trans fat or consider mandatory labeling; similar to what NTUC FairPrice did with the household products?

Sir, this suggestion is not new. Back in December 2006, the Health Promotion Board (HPB announced that it would not ban the use of trans fats in food products. At the time, it gave a long list of reasons mainly based on consumer choice and practical implementations, for example, we consume less fat than Americans. The HPB is hesitant to pass legislation on trans fat as this would result in trade barriers, especially since many food products found here are imported from various countries. About 70% of packaged food products currently do not carry trans fat labelling and will be affected. This would limit the choice of food Singaporeans have. Legislation limiting trans fat to 5% of a product's total fat content would affect 30% of packaged food here.

Since then, HPB in 2007 announced it would allow food products with little or no trans fat to be labelled accordingly, but it had said "no" to Mdm Halimah Yacob's

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suggestion to move towards compulsory labelling and in the same year, NTUC FairPrice then took up the call to voluntarily declare trans fat content on its household products. Last year, 2009, in response to Ms Ellen Lee's query on educating the population on the effects of trans fat, the Ministry said that HPB will step up public education on the harms of excessive consumption of trans fat, and work closely with AVA to review trans fat in food supply.

This was in view of the local studies conducted, which showed that 30% of adults here, particularly those aged 18 to 39, exceeded WHO's recommended daily limit. After three years of deliberation, is it time for us to introduce mandatory or compulsory labelling of trans fat content in food? At the same time, we should keep in mind the possibility of banning such food in the near future.

Sir, while I agree that diet is a matter of personal choice and that we need to take into account practical considerations such as trade barriers, product labelling, and so on, we need also to weigh in such issues as general public health issues and its expenditures and informing the public. Therefore, prevent is better than cure.

Sir, can the Government at least for the moment support initiatives such as labelling efforts by giving local food companies and supermarkets a grant to do so and to increase funding in public education in this area?

Myopia

Mr Low Thia Khiang (Hougang): Chairman, Sir, I understand that myopia is the leading eye disease in Singapore. We have among the highest cases of myopia in the world. There is a growing concern that blindness from myopia would become a substantial public health problem in the

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near future. It was projected that more than 80% of the entire adult population could be myopic within two to three decades. I would like the Minister to share his view on the problem and whether it is indeed a public health concern.

It is observed that increasing myopia is related to the heavy amount of reading and near-work that the children are exposed to in school and at home. Such activities are definitely on the rise with advent of the Internet. I would like to know what new initiatives the Ministry of Health (MOH) has embarked on to prevent the onset of myopia on the younger generation and what is the outcome of the vision care programme?

Although laser surgery has been performed to correct myopia in adults in Singapore since 1992, the results have generally been very good. However, SNEC does not believe that it is safe and advisable for children to undergo this surgery currently.

Intense medical research in recent years has led to new discovery on treatment of various diseases. I would like to know whether the National Medical Research Council has committed funds for research related to myopia and if so, whether there is any discovery of new effective treatment or clinically proven method of preventing the onset of myopia.

Assessment of special needs of children

Dr Amy Khor Lean Suan: Sir, I understand that at KK Women's and Children's Hospital (KKH), it takes about three months for a child to get an appointment for diagnosis of whether or not he has learning disabilities. Waiting times for therapy sessions are even longer. As a mother of a son with dyslexia and Attention Deficit Hyperactive Disorder (ADHD), I can empathise with the anxiety

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of parents who desire to send their children for early diagnosis.

My son had great difficulties coping with his studies and school life when he was in primary four. On the advice of his form teacher, we brought him for an assessment at the Child Guidance Clinic where he was assessed to have dyslexia and ADHD. This was 10 years ago.

We were then told that if we wanted to enrol him in a Government-supported intervention programme, we would have to wait for months as there was a long queue. Fortunately, we were able to place him in a private centre. Once he was correctly diagnosed and put on an appropriate intervention programme, his condition improved tremendously and he was able to cope with his learning disability. From doing badly in his subjects at Primary Four, he was subsequently able to do relatively well at PSLE. He is a much happier and motivated boy now.

Over the years, the services for special needs children have increased and improved significantly. But there are still remaining gaps that need to be closed. One example is the long queue for medical assessment at KKH. I understand that there is also a shortage of trained manpower such as therapists. This constraint is felt most starkly in the early intervention services. As parents become more enlightened, the demand for such medical assessment would increase.

I would like to ask the Minister if more resources could be deployed to shorten the waiting times for early diagnosis and also intervention programmes.

Children with special needs

Mr Ong Ah Heng: ( In Mandarin ): [For vernacular speech, please refer to Appendix A.] Sir, the medical and dental needs of children with disabilities are onerous and deserve our attention. It is

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difficult to carry out medical procedures on these children. As a result, it places a lot of stress on the child, their parents and medical staff. For example, how do you prevent an autistic child from acting violently when an x-ray examination is being conducted or an injection is being administered?

Until recently, parents of children with special needs are at a loss when it comes to dealing with their children's many requirements. The situation is made worse when parents have to cope with heavy medical expenses on their own.

It is the right move for our Government to step in to help the parents by allowing them to use MediShield. I would like to ask the Health Minister two questions. Firstly, what is the current status of MediShield insurance for children with special needs? Secondly, what else can be done to ensure that basic healthcare is available to these children, for instance, are they provided with basic dental care?

*Cols. 3689-3690.

Traditional Chinese Medicine

Ms Ellen Lee (Sembawang): ( In Mandarin ) : [For vernacular speech, please refer to Appendix A.] With the development of Traditional Chinese Medicine (TCM) particularly in China over the past few decades, and increasing interest in complementary medicine the world over, public interest in TCM has also risen in Singapore. Many of our elderly as well as the young are seeking help from TCM. TCM practice in Singapore is primarily confined to outpatient care. The Traditional Chinese Medicine Practitioners Act was passed on 14th November 2000. Besides registering TCM practitioners, the TCM practitioners Board also accredits TCM schools and courses, and regulates the professional conduct and ethics of registered TCM practitioners.

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The registration of TCM practitioners started in 2001 with the registration of acupuncturists. With effect from 1st January 2004, those who wish to practise TCM are required to register with the TCM Practitioners Board and possess valid practising certificates. Our restructured and private hospitals have also set up TCM units/departments in view of the rising demand and awareness of the positive effects of TCM.

From my knowledge of TCM, it does not use static anatomy as a starting point for understanding the diseases and does not rely on detection equipments. However, TCM relies upon inspection, listening and smelling, inquiry and pulse-taking to directly observe the dynamic human life function. It is also based on syndrome differentiation to guide the disease treatment. This method can save a lot of examination cost for patients. Western medicine has absolute advantages in medical fields such as surgery, diagnosis of organic diseases, first aid, prevention of spreading of epidemic conditions, and life-sustaining devices where modern science and technology is used. However, Chinese medicine excels in treating chronic inflammation, functional disorders, endocrine disorders, degenerative diseases, senile diseases, general clinical syndromes, sub-health state of the human body, and complex health problem.

In view of the increasing use and recognition of TCM as an alternative medicine, I urge the Government to provide assistance in monetary/non-monetary terms to raise the quality and standard of TCM practitioners and TCM administration so that TCM can indeed be more acceptable and "recognisable" as another source of help for patients.

*Cols. 3691-3692.

2.00 pm

The Senior Parliamentary Secretary to the Minister for Health (Mr Hawazi Daipi): Column: 3538

Sir, I will try to cover all grounds before the stipulated guillotine time.

I thank Members for speaking on, among other issues, special needs and health promotion. Speaking of health promotion last month, two UK researchers revealed preliminary findings suggesting that it was possible to be bored to death. Before Members get worried about their own health since all of us get bored from time to time, let me qualify that statement. What the study found was that people who regularly feel bored are more prone to becoming unhappy and unmotivated. This, in turn, can lead them to adopt unhealthy habits, such as smoking, taking drugs or drinking, which increase their chances of dying from conditions such as stroke and heart diseases.

Most Singaporeans I know have the opposite problem – they are so busy they hardly have time to feel bored! We are a time-starved people. We work deadlines, manage family commitments, and run countless errands. Small wonder that we often hear people grumble, "I wish I had more time for the things that matter in life."

Good health is one such thing that matters to all age groups, as Dr Fatimah Lateef has rightly pointed out. The Ministry of Health (MOH) invests heavily in health promotion precisely because it is the crucial first step to good health. It is much better to keep healthy rather than seek treatment when conditions develop. This is why our preventive healthcare budget has increased by 67% over the past decade to $112 million in FY2010. Our aim is to help Singaporeans of all ages – children, adolescents, adults and the elderly – to have the means and ability to lead healthier lifestyles. We want to nip chronic health problems in the bud and reduce the disease burden on our ageing population. I think many Members have alluded to the silver tsunami that is

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coming and asked how we are going to manage it. It is a tall order which requires hard work from all of us, but it is worth doing.

Unfortunately, when we need to prioritise our time, a healthy lifestyle is often the first to go. Many Singaporeans, stressed from work, often do not eat healthily or exercise regularly. Worse still, they succumb to high-risk habits, such as smoking or heavy drinking, mistakenly viewing all these as a pressure-reliever or a lifestyle choice. They do not realise or may even ignore the fact that it could cause them greater pressure, both financially and emotionally, when health conditions develop down the road.

This is why there is a strong case for healthy lifestyles to be advocated at the workplace. The outreach strategy is sound as two out of three Singaporeans aged 15 years and above are working. I spoke briefly about workplace health in last year’s Budget, and I will spend more time outlining our plans for workplace health promotion this year.

The business case for improving workplace health is simple. Healthier workers mean less absenteeism and lower medical costs for the company. This is the first step to boosting productivity and the bottomlines. Healthy, active employees are also good "walking advertisements" for a company’s work ethos and culture, which helps them in talent recruitment and retention. Healthy and alert employees also contribute to a safer work environment. Indeed, more local companies are recognising the value of good workplace health programmes and have taken steps to implement these.

NatSteel is a good example. I visited NatSteel last month and was impressed by the fruits of their employees' wellness programme. They have wisely banned the sale of cigarettes within their premises

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and extended the lunch-time break to encourage participation in on-site health programmes. I was told by some workers there that they actively take part in the lunch-time programmes to promote good health of their workers. Employees are also given subsidies and other incentives to participate in healthy lifestyle activities. There have been tangible results – the average days of medical leave taken has fallen from 3.4 days in 2005 to 2.3 days in 2009. With more motivated and healthier staff, the monthly average resignation rate has also fallen from 0.9% in 2005 to 0.7% last year. For comparison, the monthly average for the manufacturing industry is double that, at about 1.6%.

One employee’s effort in keeping himself healthy left a lasting impression on me. Mr Arumugam Kerisnasamy, a security guard, has a family history of chronic diseases. Determined to keep these diseases at bay, he put himself through the Health Promotion Board's "Lose to Win Challenge" and NatSteel’s own "Weight Optimisation Challenge" late last year, losing about eight kilogrammes over a four-month period. Mr Arumugam continues to exercise and watch his diet. He now weighs 96 kilogrammes – about 11 kilogrammes less than when he first started the programme. His fitness level has also improved considerably. During my visit, he shared how grateful he was to NatSteel for their support and encouragement in his weight loss journey. He also told me that he was driven by the strong desire to take charge of his own health so that he can better his work performance and also provide for his loved ones. I think we all have much to learn from Mr Arumugam.

Let me talk about support for Small and Medium Enterprises (SMEs), something which some Members have spoken on. Some SMEs may want to roll out similar measures like NatSteel, but

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they lack the scale, resources and infrastructural support to do so. MOH and HPB recognise the constraints faced by our SMEs and will do more in the coming year to help them.

Today, several industrial and commercial landlords, such as Ascendas Services, CapitaLand Commercial, JTC Corporation, HDB and Mapletree Investments, participate in HPB’s WHP@SMEs’ Doorstep programme. A simple but popular programme, it conducts health screening and health programmes for SME employees at the doorstep of industrial parks and commercial buildings where the SMEs are located. This is how HPB brings the programme to the doorstep of the companies. It has been well received and we intend to roll this out to more locations over time.

I agree with Mr Ong Ah Heng and Mr Yeo Guat Kwang that more can be done. The National Tripartite Committee on Workplace Health, co-chaired by Mr Lucas Chow and Mr Yeo himself, has recommended to MOH a slew of measures to better support our SMEs in workplace health promotion. Let me mention a few that we have implemented or are considering in the coming year.

To help SMEs who face budgetary constraints in starting workplace health programmes, the TriComm and HPB have introduced an enhanced SME Grant since May 2009. The grant now funds up to 90% of the cost of such programmes, capped at $10,000 per application. HPB also recently relaxed the grant guidelines to allow funding for off-site health programmes, such as basic health screening at CDMP-GP clinics and chronic disease intervention programmes. HPB has committed up to $180,000 to 22 SMEs under this enhanced scheme. I encourage more SMEs to sign up for the scheme.

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Money alone cannot fully address the situation. SMEs often lack dedicated manpower and protected time to implement workplace health programmes well. To help them, HPB will introduce a workplace health package this month where pre-selected vendors will deliver the packaged health screening and interventions, covering four key areas of healthy lifestyle – physical activity, healthy eating, mental well-being and smoking control. Companies simply have to choose their preferred activities from among the health interventions in these four areas.

Some Members have raised the concern over mental well-being programmes that can be introduced for employees at company level. This is one example in which HPB is trying to reach out to employees, to help the workers manage their health issues through activities, including for mental well-being.

We also know that the work demands of each sector are different. Some sectors, like hospitality, wholesale and retail, and transport and logistics, face greater challenges in implementing workplace health initiatives. For example, in the hospitality sector, it is hard to get service staff who work different shifts to get together to exercise, especially those who work the night shift. To address this, HPB and its partners will be adopting a more customised approach, by tailoring outreach activities and capacity building sessions tailored for specific industries. Industry workgroups, comprising representatives from trade associations, unions and private companies, will be set up to provide feedback on the needs and challenges of their respective industries.

Within Government, HPB has already started working with other agencies to align and streamline our promotional efforts. For example, HPB and the Ministry of Manpower (MOM) have been working closely to integrate workplace

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health promotion into the Workplace Safety and Health legislative framework, as well as the Guidelines for Re-employment of Older Workers. They will also be engaging employers, employees, healthcare providers and insurers to pilot a health management framework linking corporate and individual health to appropriate incentive systems. This will be an exciting area for development as we push for greater productivity in our workforce.

Sir, I know I can count on our unions and trade associations, like NTUC and the Singapore Manufacturers’ Federation (SMa), to step forward and lend us their support. NTUC has already partnered HPB to launch a weight management programme next month to promote healthy living at the workplace. SMa will also hold a kick-off event in May 2010 where some of their SME members will pledge their commitment to implement workplace health programmes. So we have the unions and employers' association to help us in promoting weight management with their members and employees. As we intensify our engagement efforts with SME leaders and associations, I hope more will do the same and motivate their members to improve workplace health.

Let me quickly update Members on smoking control legislation. Singapore is a pioneer in this area on several counts. We were the first Asian country to ban tobacco advertisements in 1971. In 2004, we again led Asia by using graphic warnings on cigarette packs to discourage smokers from lighting up. To date, we are one of the only nine countries in the world recognised by the World Health Organization (WHO) for our nation-wide network of smoking cessation services.

Nevertheless, smoking is an issue that will take years to address and we will persist in it. We already have some successes. Less contraband is being

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hawked on the streets, in no small part due to Customs’ vigorous enforcement efforts. Many public places are also going smoke-free, thanks to the National Environment Agency's smoking ban. Over the years, smoking rates dropped from 20% in 1980 to 12.6% in 2004, but the latest figure of 13.6% in 2007 shows a slight rebound. So we still have a lot of work to do.

This is mainly due to an increase in smoking amongst certain population segments, in particular young adults. The smoking rate for young males, aged 18 to 29 years, has increased from 18% in 2004 to 25% in 2007. For young females, the increase was from 7% in 2004 to 9% in 2007. I am concerned about this trend as young adults might not fully appreciate the negative consequences of being hooked on smoking.

Besides stepping up HPB’s public education efforts, we intend to augment the Health Sciences Authority's regulatory arsenal by updating the Smoking (Control of Advertisement and Sale of Tobacco) Act to current operating realities. The Act was last amended in 2003 and the latest proposed amendments are to incorporate more stringent tobacco control measures in response to an increasing trend of smoking among young adults, and the emergence of new tobacco products.

After extensive public and industry consultation, we are planning to ban misleading labelling, and lower the maximum tar and nicotine limits, among other changes. I look forward to Members' support for the amendment Bill when we table it in this House later.

2.15 pm

Let me now move to detection and prevention of diseases. Mr Khaw earlier spoke about our considerations in making screening more affordable through the use

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of Medisave. I shall now update the House on clinical developments.

The Integrated Screening Programme was introduced in June 2008 to facilitate appropriate health screening for Singaporeans aged 40 years and older at CDMP-registered GP clinics. Five conditions are currently covered – diabetes, high blood pressure, lipid disorders and obesity – all these are risk factors for heart attacks and stroke as well as cervical cancer. The programme has served Singaporeans well by lowering the cost of screening through bulk purchases and subsidies for lower income Singaporeans.

We are looking at including colorectal cancer screening under the Integrated Screening Programme. Colorectal cancer is the most common cancer here – 1,500 Singaporeans become afflicted with this disease annually. Over the course of a lifetime, one in every 20 men and one in every 30 women will get colorectal cancer. Last November, we started a pilot in Queenstown, Tiong Bahru, Bishan and Ang Mo Kio where Singaporeans aged 50 years and older were invited to go for colorectal cancer screening at CDMP-GP clinics. To-date, 416 participants have completed the screening, and 39 participants, or 9% of them, were referred for further assessment. We also intend to step up efforts to increase awareness and uptake of colorectal cancer screening among Singaporeans.

Cervical cancer is another noteworthy disease that we are tackling. Pap smear screening is key to detecting this cancer at its early and even pre-cancerous stages, where treatment is most effective. Vaccination against the human papillomavirus (HPV) is an interesting new approach, though not without limitations. For example, it is only effective against 70% of cancer-causing HPV virus, and

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there is limited data on the long-term effectiveness. The Expert Committee on Immunisation is reviewing the evidence on HPV vaccination and will report its finding to MOH subsequently.

Sir, on children's health, I would say that good health boils down to eating enough and eating right. A balanced diet is crucial to improving physical well-being and our resistance against diseases.

But we must guard against too much of a good thing. Chinese New Year is just over and like during the other festivities like Hari Raya or Deepavali, some of you would have suffered from the side effects of over-eating. Imagine the ill effects on our our children of over-eating on a daily basis! Childhood obesity is fast becoming a problem in developed countries. Left unchecked, it would lead to our children developing all sorts of chronic diseases that they would have to live with the rest of their lives. The problem is becoming so severe in America that it has caught the attention of President Barack Obama. He recently set up a taskforce under the First Lady to tackle this growing problem.

In Singapore, we have made obesity the focal point of our National Healthy Lifestyle campaign last year, and this will continue this year. As a lead up to the campaign proper, HPB will launch a weight loss reality TV challenge, similar to the highly popular Lose to Win Challenge in 2009. Community and workplace stakeholders will also be engaged to champion health programmes to provide supportive health promoting environments for optimum weight management.

We know that food advertising to children is a problem, and are working with industry stakeholders to address this. To complement these efforts, HPB is developing guidelines on food marketing to children in schools and will continue health education efforts in the school setting. HPB will also work with MOE to

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instil a culture of physical activity amongst our young, so as to build lifelong habits for a healthy lifestyle.

Mrs Mildred Tan asked specifically if MOH will consider banning trans fat in food sold here due to the increased risk of coming down with cardiovascular diseases from consuming it. I share her concern. Today, three in 10 adult Singaporeans exceed WHO's recommended daily limit of less than two grammes of trans fat a day. Two-thirds of these people are younger adults aged 18 to 39. Our children, especially those who snack frequently, are affected as well. We clearly need to limit the intake of trans fat in Singapore before it gains a foothold in our daily life.

Regulating trans fat, however, is a complex issue. We have adopted a more cautious voluntary approach so as not to create trade barriers, reduce consumer choice and bring about unintended increases in food prices. The concerns that we raised in 2006, as mentioned by Mrs Tan, are still valid, but we are looking at some ways to ensure that people are better informed about healthy choices. After carefully studying the experiences of other countries and taking into account our local situation, we are now prepared to take targeted steps to control the problem.

The experts told me that a total ban is not practical. Many of the catchy headlines we read about trans fat bans in New York and California actually refer to limiting trans fat to a very low level. We will do likewise. We are considering limiting the trans fat content in fats and oils to not more than two grammes of trans fat per 100 grammes of product. This is in line with the practice of developed countries which have implemented trans fat reduction measures.

For other food products besides fats and oils, HPB will continue its approach of

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engaging the food industry and encouraging all of them to voluntarily reduce the trans fat content in their products. Response has been encouraging, especially from larger players in the market. Some companies have voluntarily reduced trans fat in their products, eg, Gardenia, Sunshine, FairPrice, Lam Soon and Nestle. SMEs, like Al Dente Food Pte Ltd, have also come forward to partner us in this effort. I look forward to the support of other industry players on this and other healthy eating initiatives like HPB's Healthier Choice certification.

Mr Low Thia Khiang asked about the state of myopia in Singapore. Myopia develops mainly in childhood, but stabilises as we get older. Many of us will recall that one generation ago, fewer children wore spectacles. The proportion of school children in Singapore with myopia is indeed high but has also stabilised over the past five years. Today, about 30% of Primary One school children and two-thirds, or 66%, of Primary Six children have myopia.

The causes of myopia are not well-defined, although studies have identified risk factors like near work mentioned by Mr Low, and protective factors like regular outdoor activity. Local research is ongoing to gain more insights into risk factors and causes of myopia. Our schools have taken the necessary measures to manage the problem but a large part of the solution depends on habits at home. Through the National Myopia Prevention Programme, MOH and HPB help tackle both sides of the equation by educating parents, educators and children themselves on good eye care. Vision screening for pre-school to secondary school students is also provided through the Programme. We must collectively press on our efforts to delay the onset and reduce the progression of myopia in children on these fronts. But we acknowledge that it is challenging.

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As these recent cohorts of children age, myopia will inevitably become more prevalent among adults. The concern is that myopia may predispose older adults to other eye problems. HPB will encourage seniors to go for vision screening as part of a broader suite of elderly functional assessments which it will roll out soon. They are also augmenting optometry and optician services nationwide to deal with problems as they emerge.

Fortunately, myopia is a problem easily correctable by spectacles or contact lenses. With affluence, many adults have also gone for the more costly option of laser surgery or LASIK. The technology is evolving. Surgeons are now able to make more precise, three-dimensional measurements of the eye that better guide the reshaping of the cornea. However, as with any surgical procedure, patients have to be carefully assessed for suitability, and LASIK itself carries risk that patients should be aware of. At our public hospitals, the success rate of improving vision in adults via LASIK is more than 98%, though not all will achieve perfect vision. This is comparable to results overseas. Rates of serious complications are low, but side effects such as dry eyes are common, occurring in up to half of all patients.

Let me now talk about special needs children. Besides mainstream school children, I want to highlight another group that we are devoting more resources to – the special needs children. Dr Lam Pin Min and Dr Amy Khor have raised some good questions about our plans to support this group of children. Since 1991, the Child Development Programme has helped identify and treat children with developmental problems in their early childhood. Under this programme, child development experts from KKH, NUH and three community-based clinics work together to provide diagnostic and early

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intervention services for special needs children aged 0 to 6, complementing MCYS and MOE's efforts under the wider Enabling Masterplan on Disability. Through these efforts, and the determination of patients and their families, many have risen above their developmental difficulties. Some ex-patients have since secured places in our tertiary institutions and even participated actively in National Service.

I have seen our healthcare professionals in action. They are doing good work and coping relatively well despite the huge caseload of some 5,200 patients, including 2,000 new cases annually. However, certain support services, like psychological counselling and speech therapy, are stretched as we have only catered for a projected total caseload of 3,200, with 1,200 or so new cases per year. This was the global norm as recently as three years ago.

This rising trend in workload, which experts attribute to increased awareness and better diagnostics, is not unique to Singapore. The situation is exacerbated by a global shortage of trained manpower, which had led to a resultant increase in waiting times worldwide. We acknowledge that parents have to wait before sending their children for screening, but we are managing this by trying to increase the manpower. But I would like to inform Members that this is not just a problem in Singapore but it is also faced by many countries in other parts of the world. This is why we are injecting $46 million into the Child Development Programme, to help us expand capacity and bring down waiting times for these early childhood developmental services. It will cover our needs over the next four years and it is on top of the $16 million already committed from 2007 to 2009. Most of these monies will go towards the training and recruitment of child development manpower, especially psychologists and speech language and physiotherapists. At steady state, we hope to

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serve more than 6,000 cases yearly and further bring down waiting time for key services.

But let me add that the holistic management of children with special needs is a very complex issue. Multi-agency efforts across the social, educational and healthcare sectors are required for the child to reach his or her full potential, as I am sure Mr Ong Ah Heng is aware. In the majority of children with special needs, such as those with severe mental retardation, autism and cerebral palsy, medical intervention plays only a limited and supportive role compared to the provision of social and educational support measures.

These children require early placement in special schools where they can receive appropriate training and education. The child development programme which I have just outlined caters to those with mild to moderate problems. The most appropriate developmental setting for this group is in the mainstream – integrated and inclusive schools where they can receive educational, social and community support as well as therapeutic intervention from healthcare professionals.

2.30 pm

Before I conclude, let me address Ms Ellen Lee's and Assoc. Prof. Paulin Straughan's questions on raising the quality and standard of traditional Chinese medicine (TCM) in Singapore. Today, MOH does this through raising the standards of TCM training courses and continuing professional education of TCM practitioners. Since 2006, MOH has worked with two main local TCM colleges to replace certificates and diploma courses with higher requirement Bachelor courses, jointly conducted with top TCM universities in China. NTU's School of Biological Sciences has also started a double degree biomedical science and Chinese medicine course with the Beijing University of Chinese medicine. Its first

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batch of 59 students will graduate this year. Taken together, these measures have augmented the pool of TCM practitioners with degree level training from 101 in 2006 to 164 last year. In addition, TCM Practitioners' Board has set up a new sub-committee to look into continued professional education for TCM practitioners. We will continue to encourage all registered TCM practitioners to take part in such courses. In 2006, the TCM Practitioners' Board also published an ethical code to guide TCM practitioners in maintaining the quality and standard of their practice.

Sir, let me conclude by saying that there is this saying that "health is wealth". It becomes a mantra to many of us, but this is more true in more ways than one. By staying healthy, one need not spend so much on medical bills, so that he can spend on his other pursuits. But besides that, keeping healthy will enable an individual to have a higher quality of life. Most of us want to achieve that but there is always a big question of whether we take that first big step to make sure that our health is well maintained and improved regularly. This is something that no amount of money can buy. I urge all Singaporeans to take the simple first step of taking control of their diets and start exercising so that by 2020 we will be a healthier and wealthier nation.

Dr Lam Pin Min: Mr Chairman, I have three clarifications for the Minister. First and foremost, I would like to ask the Minister while waiting for the new Jurong General Hospital to be ready, what is the plan for the old Alexandra Hospital and whether it can be made fully operational to help relieve the current shortage of beds.

Secondly, I am happy to note that MOH is investing another $57 million for mental health programme. I would like to

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ask the Minister what are the deliverables and KPIs to help determine if this money will be well spent.

Last but, most importantly, the Minister mentioned in his speech just now that although he is 58 years old this year, his residents commented that he looks much younger. Sir, I would like to clarify with the Minister whether he has found an elixir for youthfulness and whether he can share with us his secret recipe for staying young.

Mr Khaw Boon Wan: Mr Chairman, there is no elixir, no secret recipe. Technology does help – I colour my hair. But, no Botox. I think the mind is important, the attitude to life. As I quoted Lao-tzu earlier – what is life all about? It is never about ourselves, it is about others. And if we lead a life in that direction, whatever the physical form, I do not think it matters.

While waiting for Jurong General Hospital, we will retain Alexandra Hospital. The original plan was to close it down immediately when Khoo Teck Puat Hospital is up. But when I reviewed the situation about three years ago, I decided not to close it. I think we cannot afford to close down Alexandra Hospital while waiting for Jurong General Hospital. So, we will keep Alexandra Hospital running as it is; in that way the addition to our bed capacity is really 555 beds, which will come on stream over the next few months. Like IRs, we will open Khoo Teck Puat Hospital in stages – no gambling tables but there will be operating tables.

For the additional $57 million, the emphasis will be on community mental health. We have some KPIs. One will be in terms of additional psychiatric resources (nurses, doctors) that we will be pumping in. I cannot recall the numbers but those are the commitments

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that we have made to the Ministry of Finance when we secured the additional money. The second one will be making sure that the community home visit teams will be truly effective. I accompanied those teams on some of their home visits. I visited some of these patients and I can see for myself that, truly, the service is well appreciated. I remember there was this dementia patient who happened to be in Mr Low's constituency. The patient has dementia for several years now. The original SOP would be that each time there is a crisis – and often there will be a crisis – it is a big operation. They have to call the ambulance and that level has no lifts. The lifts are coming but at that moment, there were no lifts. And carrying the patient down was a major operation. So, they were so appreciative when I visited them – the whole extended family was there. Not all the extended family stay there, but those who stay nearby all came to wait for me and expressed how appreciative they were. I think we know now what to do. Our job is to scale it up so that more can benefit.

Mdm Halimah Yacob: Mr Chairman, I would like to seek a few clarifications from the Minister. First, the Minister said that he would not consider extending MediShield to cover mental illnesses, but he would when economic times are better. Could the Minister indicate some timeframe, because I had raised it during better economic times and he said that timing was important. So, I think giving us a timeframe would be useful.

Second, the Minister talked about the Medical Assistance Fund (MAF) to be set up to help Singaporeans pay for expensive medicine under Medifund, but he talked about helping the low-income Singaporeans. I think very expensive medicines, like cancer medicines, also affect the middle-income Singaporeans. Will there be flexibility, when this Fund is located under Medifund, to extend assistance also to

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middle-income Singaporeans for them to be able to afford expensive medicines?

Third, I did ask the Minister whether he could consider providing more support for home-based care subsidies. The Minister did not respond to that point. I think more subsidies for home-based care is important if we want to promote right siting. Otherwise, people will crowd the hospitals because they do not have support at home.

Finally, I would like to ask the Minister out of that over $40 million that is now allocated further for mental treatment, whether there would be more of that component be given to the VWOs who are doing a fantastic job to provide support for mental patients, like shelters or other forms of day care services. Would he also extend a portion of that amount to provide support for caregivers, because caregivers of mentally ill patients are also suffering tremendously? Could he extend a portion of that amount to support them in training or other kinds of support for them?

Mr Khaw Boon Wan: Sir, when I said that the MediShield changes to include, for example, the mentally ill will have to await better times, what I meant was that if we want to extend payouts, premiums have to be adjusted. So, it depends on how much the premiums will be. If I am taking so long on this subject, it is because, obviously, the premium increases are not small. If they were small, I would have done it yesterday. But because the impact of the payouts on the premiums is not insignificant, that is why I have been sitting on this for so long. I find it hard to commit to a timeframe because there are still adjustments to be assessed, on how to better bring it about.

And this is the same for the ElderShield reform that Dr Lily Neo raised. We are trying to make some trade-offs, how to extend the benefits so that it is

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truly meaningful, without incurring too much burden on everybody else. At the end of day, it is about risk-pooling. It is really the rest of the population supporting the small number with mental illness or with severe disabilities. So, these are some of the things that we are looking at, with the help of actuary consultants. Let me assure Mdm Halimah that it is very much at the top of my head because, as she rightly said, she has raised it several times before, and I have not forgotten.

On MAF, I used the word "lower-income". I did not mean low-income. Lower-income is relative. I do understand that even for lower middle-income group, costly medications can be a problem. And that is why I like the Medifund mechanism because that allows us flexibility. This is a group of wise people who will then help us to determine, case by case, who deserves it, who does not. Because we cannot really translate it into an algorithm which we can just plug into the computer and decide, yes, somebody deserves it, or somebody does not.

Home-care, yes, the intention of scaling up, for example, Home Nursing Foundation (HNF) is to make sure that it is a service that will be useful and meaningful to the patients and their families. And we do subvent HNF and I intend to increase the subvention to them. I accompanied the HNF teams on some of their visits to their patients at home. I observed them. Truly, they are doing very good work. Two months ago, I visited two of their patients who happened to be in Mr Shanmugam's constituency in Chong Pang. These are diabetic patients, one leg already amputated and the second leg will soon be amputated, wheelchair-bound, and with diabetic kidney failure requiring dialysis. Fortunately, there is a NKF Dialysis Centre nearby. But nearby for an able-bodied person is truly nearby, but for a disabled person, even 200 metres is like a mile. And the spouse is the one who has to push the wheelchair

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all the way to NKF. So, these are the problems that we can see. But we cannot bring dialysis to the home. Of course, we can go with ambulatory dialysis, but in her case it was not suitable, as she has other problems. So the home nurses visiting her have been very useful. They come, check her blood sugar everyday or every other day, and then remind her to comply. I was a bit sad that day when I visited her. They checked her blood sugar, it was high. So, the nurse asked: "Why? You know your diet discipline, you can eat this, but you cannot eat that." And she said, "Yah, I know." That morning she had some unhealthy breakfast, she thought it was just one meal. As I said, we can only point the way forward, but the patients must cooperate with us. Unless they are engaged, it is very hard for us to really bring about true change in health outcome.

2.45 pm

Under the additional mental health programme, we have funds set aside to work with VWOs, because we know we cannot do this alone, and on the ground, there are many willing VWOs. I have visited some of them in Mdm Cynthia Phua's constituency, they are passionate people. She asked about the Many Helping Hands approach. We could easily say, "All right, we take over, we nationalise it and do everything ourselves as civil servants."

But remember the story of Sister Geraldine – no paid employees can deliver that kind of service. So, it is not a matter of we do it without them or they do it without us. I say, let us do it together. Our objectives are the same, which is to help Singaporeans stay well, live well and, hopefully, end well. But the patients have to play their part too.

Assoc. Prof. Paulin Tay Straughan: Sir, I would like the Minister to elaborate on the point that he had just spoken on. I

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watched "Money No Enough 2" as well and few local movies moved me as much as that movie did, particularly the scene when the elderly mother was moved from one child's home to the other as her health failed. But within the movie, we were also shown the constraints that each of the three sons who clearly loved the mother, I thought, but they were consumed by their own family and work demands. It is easy to trivialise these kinds of barriers in the movie but I think in real life we are going to see a lot more of such families.

Everybody seems to be sharing their age today. So, I am 46. My parents are pushing 70 and, thank God, they are mobile. But when they lose their mobility, I will still be working and there are many, many sandwiched families like that. Can the Minister share with us his thoughts on how to free the sandwiched family? Many of these will be dual-income families. How do we free these families so that they can take care of their dependent elderly at home and rise to the challenge that the Minister has posed to Singaporeans – that we must be filial and we must oblige our moral obligation to our parents.

Mr Khaw Boon Wan: Sir, I find that a meaningful commentary. To respond to it with full justice, I think I will need two hours, which I do not have. But, clearly, it is a major issue that all societies are trying to cope. We are lucky in that our population is still young and we have a few years to strengthen the system, which we will. The bottom line is this. I do not think it is whether you are sandwiched or otherwise. There are barriers, yes. Whether you are rich or poor, there are barriers. But if a person is in the middle-income or higher-income group, in fact, he has more personal resources compared to the lower-income group.

I do, as I said, home visits to patients and, most of the time, I visit the lower-

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income group. These are people much less endowed than the sandwiched groups. But what always struck me was how they still manage because the love is there. They have limited resources, yes, but that did not prevent them from going the extra mile. On the other hand, I have come across people who are clearly pretty well endowed, but they just assume that they can delegate and outsource their love and compassion for their parents away.

So, at the end of the day, it is attitude. I am not trivialising – the word the Member used – the barriers that people are facing, but they can be overcome once the attitude is right. "Yes, this is my mother (or this is my father) and I am going to go all out with whatever resources I have, topped up by whatever society is able to supplement."

I visited one couple in my house-to-house visit in Sembawang. She is a Malay lady in her early 50s. The husband, heavily diabetic, both legs amputated, on wheelchair when I visited them. She has been looking after the husband for more than 10 years. When I saw them, she explained to me how she coped with great difficulty, but she coped. At the end of the visit, I told her, "You are a good person." She was all right but when I said, "You are a good person", that was when she broke down. She said, "We knew each other since school. I love him for so many years. We have been married now for 20 years. How can I forsake him, desert him?" And that is how people cope. And for people like that, I will go all out to support them and make sure they can deliver.

The Chairman: Dr Lily Neo, Mdm Cynthia Phua and then Ms Sylvia Lim.

Dr Lily Neo (Jalan Besar): Mr Chairman, Sir, first, I would like to commend Minister Khaw Boon Wan on his good deliverance of the first speech earlier in

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the House. His speech was compassionate, passionate, interesting and explicit, and he also gave appropriate and good personal anecdotal experiences.

Sir, I would like to seek the Minister's clarification on the present acute bed shortages in our hospitals and on the reports that many patients and their family members were unhappy for being put up in the hospital corridors while waiting for their hospital beds. My question to the Minister is whether each of the hospital has put up its best problem-solving practices. For example, should there not be better temporary holding areas rather than hospital corridors while waiting for admissions and whether there should be better customer service in allaying patients' fears and placating patients' family members in such situations?

Lastly, the Minister has not replied me on my earlier question on national healthcare expenditure (NHE) – basically, Singaporeans' concern on healthcare costs. How quickly will the NHE rise in such current servicing, how sustainable it is and how would that impact the population since NHE is borne two-third by the people and one-third by the Government, especially on the low-income and middle-income families?

Mr Khaw Boon Wan: I thank Dr Neo for her comments and compliments.

The national health expenditure in our case is less than 4% of GDP. I have discussed this in this House before. Four per cent is not sustainable, because there is a correlation between GDP growth and health expenditures. As we become richer, we are prepared to spend more on healthcare, and that is why the national health spending will grow.

How much will this 4% grow up to? It is hard to say. A lot depends on how well we manage the cost escalation and

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medical inflation. My own personal target is this. As long as we can keep it to a single digit percentage of GDP, that should be quite an achievement. Many European countries are now at double digits. The US is the worst – 17%, and projecting 20% in a matter of time. And once we go over a tipping point, it is almost uncontrollable. So we must try to keep it single digit – 4% eventually will become 5% and then 6%. Even at the most advanced of ageing, if we can keep it to 8%, I think that would be a huge achievement. How to do it? The key, as I said just now, was to control expenditure. So long as we can keep costs low overall, then who is the one who is responsible for payment is a secondary question. And the way to control healthcare spending is to cut out abuses. The problem in the US and the European system is abuses – what we call "buffet syndrome". The more we can control moral hazards, the more we are able to keep the cost inflation down.

On bed shortage, we had a short discussion last month at a parliamentary sitting. I quoted figures to show that, overall, we are not short of beds, but there are mismatches. Of course, when the media played it up, they will play on those days when it is very high in a particular hospital. Even when a particular hospital is short of beds, I have empty beds in other hospitals. So it is not as if there is a complete shortage of beds nationwide, but there are mismatches. Mondays and Tuesdays are bad in certain hospitals and we are trying to cope.

We anticipated this problem three-four years ago. I remember Mr Low Thia Khiang raised this issue on potential bed shortage coming up in Tan Tock Seng Hospital. Somehow he is familiar with Tan Tock Seng Hospital. He had seen some problem there and alerted me to it, which

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I acknowledged. And that is why in the last few years, we have been increasing beds in every hospital. Over the last four years, we have actually added many beds wherever we can. But we are now coming to the tail end of the construction of the new hospital that is coming up.

Hospital construction is lumpy. There is no increase in beds for years, and then suddenly we have a 500-bed hospital. So, what I have done over the last few years is to progressively add in temporary beds in other hospitals while waiting for this Khoo Teck Puat Hospital to open. When it opens, we can then close all those temporary beds. But as we get close to D-Day, that is when the pressure is at the maximum, and that is why we have these temporary shortages of beds on certain days.

But, as I said in this House, clinical care is never compromised and we will never compromise it, but I accept that service level is unsatisfactory. Yes, our staff could be better at communication, but I have some sympathy for our staff. They are really working their guts out when there are so many patients in the last two-three months. The problem is this, and we know this seasonal factor. With the school holidays in December, many surgeries were cancelled, as people went on holiday. In January, we have the return of Singaporeans and hence the return of the elective surgery cases. Then in February, we had two weeks of Chinese New Year, and everybody shied away. And in the last two weeks and now, we see the return of all elective surgeries. That is the reason why we have all this sudden big increase. It should ease once Khoo Teck Puat Hospital is fully opened in a few months' time. But, meanwhile, I plead for some patience.

The Chairman: Mdm Cynthia Phua, keep your intervention brief. We do not have much time.

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Mdm Cynthia Phua: Yes, Mr Chairman.

I would like to thank the Minister for his care and love for the people of Singapore on healthcare issues. I just want the Minister to elaborate on the mobile care service for the mentally ill. Are they only taking care of the active Institute of Mental Health (IMH) patients or do they allow the residents to call them when mentally-ill residents are identified in their home who need attention? Do they answer to our call for service?

Mr Khaw Boon Wan: The hotline for IMH is for their ex-patients. There is no problem, because we know the patients on our database. Whether they also respond to new fresh calls, I have got to check. As the hotline is 24 hours, and if somebody calls up and explains what is the problem, I am sure they will be able to, there and then, provide the necessary counsel and advice. But I need to check on this point.

Ms Sylvia Lim: Sir, three clarifications on my cut on Medisave for outpatient treatment for chronic illnesses. First, earlier, the Minister mentioned that he spoke to some elderly who told him that they deliberately chose not to use Medisave for their outpatient treatment. But I wonder whether the Minister is also aware of some feedback being given to him that the deductible has been a problem for some. The man I mentioned earlier hand wrote a letter to the Minister but he received a reply from somebody in the Ministry of Health. So I do not know whether the Minister is actually aware of this feedback that the deductible is causing hardship to some elderly sick.

The second point is, does the Minister agree that with the caps already in place of $300 withdrawal every year plus the co-payment requirement, is there really a need for the deductible to check on over-consumption and to protect the Medisave savings?

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3.00 pm

The third point is the Minister earlier mentioned that to get over the deductible some clinics are offering package deals. Could the Minister clarify whether this package deal means that the patient is paying for consultations in advance? Not just the medication, but consultation as well, because patients need to go back every few months. Secondly, whether this option is something that the patient can insist on at the polyclinic.

Mr Khaw Boon Wan: The beauty of our system is diversity, so I have heard of different packages from different general practitioners (GPs). They package it up – some patients pay in advance or at the end of the year or by instalments or other ways. There are all sorts of packages in town. I will advise the Member to advise whoever who gave her the feedback, to shop around in the neighbourhood. I am sure there are different GPs and they should be able to respond to that.

I want to stress that this packaging is not to get around the deductible. The packaging serves a purpose. A package for chronic disease is no different than our motorcar maintenance package. Many motorcar workshops have maintenance packages for their customers – 5,000 kilometres do this; 10,000 kilometres do that; 20,000 kilometres please come back to check engine. The maintenance of motorcar and of the human body is similar. The package deal serves that purpose and the problem that the Member mentioned can be easily overcome with this package scheme.

As for the person who hand wrote the note on his problem with $30 deductible, I vaguely recall the incident. But as I said, the right solution is to get a suitable package. Chronic disease is not a one-off acute attack. Payment is not just one visit for $30. The patient has to do it for the rest of his life. Very importantly, the

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programme has to be packaged, to ensure compliance.

With the capping of $300, the Member asked why there is an additional need for deductible. I have explained that just now. The deductible is a very important part of controlling this morale hazard we talked about. I would advise or suggest that the Member read up on some of the commentaries which are floating around on the Internet in US over their healthcare reforms. Serious economists are all coming to the same conclusion that the only way to tame this beast – ie, runaway healthcare cost – is health savings account coupled with a high deductible insurance scheme. Drop the comprehensive first-dollar coverage and all other means which have been incentivising wrong behaviour.

Dr Lam Pin Min: Mr Chairman, Sir, on behalf of the GPC and Members of the House who have spoken so passionately on various health issues, I would like to thank the Minister and Senior Parliamentary Secretary for their comprehensive, yet emotional, and at times moving responses. There is a Chinese saying, "医者父母心 ( Yi zhe fu mu xin )", which basically means, as doctors, we treat patients with the heart and good-intent of a loving parent. Similarly, the Minister and his team shoulder a heavy responsibility of looking after the health needs of four million Singaporeans. This is by no means an easy feat and requires a even bigger heart than that of a parent. I am optimistic and confident that with a big compassionate heart and astute leadership, our healthcare system will undergo this quiet healthcare revolution successfully to remain relevant to the needs of all Singaporeans. On that note, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

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The sum of $3,537,809,800 for Head O ordered to stand part of the Main Estimates.

The sum of $643,606,300 for Head O ordered to stand part of the Development Estimates.

The Chairman: Order. I propose we take a break now.

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

Mr Speaker: Order. I suspend the Sitting and will take the Chair at 3.30 pm.

Sitting accordingly suspended at

3.06 pm until 3.30 pm.