HEAD O - MINISTRY OF HEALTH

Head O – Ministry of Health

The Chairman: Head O – Ministry of Health. Mdm Halimah Yacob.

Mdm Halimah Yacob (Jurong): Sir, I beg to move,

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

Sir, I thank the Government for allocating more funds to healthcare. At 4% of the GDP, our health expenditure is one of the lowest in the world but this cannot be sustained for long because of our rapidly ageing population. While I am happy with the increased budget, I am disappointed that there is no Medisave top-up this year, which would have helped to lighten the burden of our elderly and low-income earners with little or no

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Medisave balances, particularly during these very difficult times. I hope that the Government could still consider Medisave top-ups for this year, which would be a great relief to many. In the meantime, I urge our hospitals and polyclinics to be more passionate and flexible in helping retrenched and needy Singaporeans. I ask them not to be too rigidly tied to some prescribed criteria and conditions when approving appeals for financial assistance.

Sir, healthcare costs have been rising and are a major concern among Singaporeans. Average public hospital bills have increased across all ward classes. For instance, the Class C ward costs $1,112 in 2007, up 30% from $858 in 2006. As for B2 wards, it went up by 17% from $1,094 in 2006 to $1,284 in 2007. Also, although our C Class and B2 wards are highly subsidised, the same level of subsidy does not cover the entire bill. For example, a knee transplant may be done at the C Class or B2 ward, but the patient may not get the 80% or 65% subsidy on the implant used for the knee transplant. I raised the same concern over the lower subsidy for stent implants some years ago, and stent implants now have a higher subsidy, but other types of implants continue to have low subsidies.

Let me cite a specific example from a real B2 bill for a unilateral total knee transplant. The cost of the implant was $2,457, the Government subsidy was only $500. The patient, therefore, had to pay $1,957. The rest of the bill for ward medications and consultations continue to receive the 65% subsidy. I urge the Minister to review this policy.

Mdm Halimah Yacob (Jurong): 4.29 pm

Madam, concerns among Singaporeans have also intensified with the introduction of means testing in January this year,

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especially among middle-income Singaporeans who will not get the full subsidy. When the bills are large, even a few percentage points make a big difference in terms of the amount paid. Much has been done over the last few years to the credit of Ministry of Health to refine our 3M framework to help manage healthcare costs. But I believe that much more can be done to keep costs affordable.

In view of the concerns on ever-rising healthcare cost, I would like to ask the Minister the following questions.

Firstly, what measures are in place to ensure that healthcare continues to remain accessible and affordable to all Singaporeans? Secondly, Singaporeans favour greater flexibility in the use of the Medisave funds than currently allowed. A common complaint from Singaporeans is "I have money in my Medisave but yet I have to pay cash for medical bills which I do not have." And this causes them stress and anguish. So I would like to request that the Minister review the following three areas under Medisave:

(a) Consider increasing the Medisave withdrawal limits for higher ward classes in subsidised patients so that patients will pay less out-of-pocket expenses. With means testing, some people will have to pay more. And if the withdrawal limits are not raised, it will be a great strain on them;

(b) Consider allowing Medisave to be used for overseas hospitalisation. Many Singaporeans I spoke to are in favour of this as they are already heading overseas for cheaper treatments in order to cut down on their medical bills, especially our retirees. Of course, there will have to be safeguards to prevent abuse and to ensure quality care, as the Ministry will have less control over overseas care. But I am sure these are details which the

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Ministry can address once there is an agreement on the principle. Some doctors may also be unhappy over this move because there could be an outflow of patients, but I believe we should put patients' interest first; and

(c) Consider allowing Medisave withdrawal for other outpatient treatments, such as for mental illness and dementia, which I also have raised on previous occasions. The Chronic Disease Management Programme (CDMP) has worked well, so there is scope to extend it to other chronic diseases.

Thirdly, Madam, the Minister has estimated that we will need an additional 600 laboratories per year to cater to the needs of the population. A shortage of laboratories could compromise our quality of care, as people have to wait longer to be admitted or will have to leave the hospital faster. Some may also be forced to seek treatment at private hospitals and incur higher cost as a result. Hence, could the Minister enlighten this House, now that construction costs are coming down, to what extent will the Ministry capitalise on the lower construction cost to step up building or renovation programmes to increase its capacity and ability?

Finally, Madam, even as the Ministry tries to control demand as a way of curbing cost, there is also a need for supply side cost control and other regulatory measures to prevent unnecessary or over-utilisation of healthcare. With the dismantling of the guidelines on fees at the SMA, there is no mechanism for the public to complain if doctors overcharge and this may cause healthcare costs to go up. I would like to ask the Minister whether he is monitoring the situation. If patients today have any complaints against doctors for overcharging, how can they seek redress?

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Cost of Healthcare

Mr Zainudin Nordin (Bishan-Toa Payoh): Madam, I read recently that the United States spends nearly 17% of its gross domestic product on healthcare, while Singapore spends about 4% of its GDP. However, we have been regarded as a healthcare superstar, especially when compared to the United States. Life expectancy at birth in the United States is 78 years; while in Singapore, it is 82 years. The Singapore infant mortality rate is at 2.3 deaths per 1,000 live births, versus 6.4 in the United States. As some have noted, these trends persist despite the fact that the United States has far more care-givers: 2.6 physicians per 1,000 people, compared with 1.4 physicians in Singapore. According to the World Health Organisation, Singapore has one of the best healthcare systems, and the 3M – Medisave, Medicare and Medifund schemes – has often been quoted as best practice in managing the costs of public healthcare.

Madam, our healthcare policies which have been successful in meeting the needs of Singaporeans have also its limitation. Some of it is our efforts in encouraging self-reliance. Keeping healthcare affordable, promoting a healthy lifestyle and engaging the community in the provision of healthcare, have been quite lacking but have improved somewhat lately. Ensuring that Singaporeans continue to enjoy a high quality of healthcare services, to me, is one of the most important things in Singapore. I am glad that we have also put in a mechanism to ensure that healthcare resources are allocated to those in need of them.

However, Madam, with the rising cost of living and inflation, Singaporeans should naturally be concerned with the cost of healthcare. It is likely that the healthcare costs will rise in the future.

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This is largely because of the rise in medical treatment, equipment and medicine as well as the projected increase in the number of senior citizens in our country. Moreover, with the restructuring of hospitals, it could very well mean that higher hospital bills for our patients in Singapore could be a thing that is common in Singapore. And when hospitals are given more freedom to reorganise to meet the needs of Singaporeans, this could possibly lead to a reduction in the amount of subsidies given to hospitals. Medical bills would likely increase and healthcare would not be affordable for Singaporeans in longer term.

With this in mind, Madam, how do we ensure that we are proactively increasing the awareness of affordability of healthcare and prudence in the healthcare spending for Singaporeans? Secondly, will the means testing that has been put in place ensure that Singaporeans know how to manage their healthcare?

To reduce cost of healthcare, like Mdm Halimah has said, there have been requests for Medisave to be used for overseas treatment. What is MOH's position and guidelines on this? What are the concerns if this is allowed?

Human Capital in the Health Sector

Mr Gautam Banerjee (Nominated Member): Madam, I would like to compliment the Ministry of Health for maintaining a very high standard of healthcare and medical services in Singapore.

In some countries, patients have to endure long delays before they can see a specialist. In other countries, one needs to travel abroad when he is down with certain illnesses, because specialist healthcare services are simply not available at home.

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In Singapore, we can take pride in an efficient and readily accessible healthcare system. Here, affordable healthcare and medical services are generally available to all. Our hospitals are well-equipped with the necessary technology, equipment and specialists to deal with various diseases.

But in view of our greying population and the increasingly high level of stress that Singaporeans face, we have to continue to invest in healthcare. I am therefore pleased to note that the Budget has made provisions for additional medical infrastructure in the form of new hospitals.

However, as we build new hospitals, we also need to give sufficient attention to the software in our hospitals. In the quest to build more hospitals, provide more medical services and better serve patients, our health sector will be in need of more human capital. We can train and groom some of these resources locally, but this is unlikely to be enough. We will also need to bring in foreign doctors and nurses not just to meet basic needs but foreign specialists and consultants who can add value to the healthcare standards in Singapore. We should also have a programme to contact Singaporean doctors working overseas and woo them back. We must be wary of leakage of our home-grown talent in an increasingly connected and competitive world.

As we bring in new locally-trained doctors as well as foreign doctors, nurses and other hospital staff, I would like the Ministry to pay more attention to their career development. Due to the growing and pressing needs in our hospitals, I am concerned that our young doctors and foreign medical talents may be thrown too quickly into the thick of action and get burnt out. How are their progress and conditions being monitored? Do we have mentoring and coaching programmes?

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Are pay and conditions competitive not only locally but with other aspiring medical hubs overseas? Madam, I would like to seek an assurance from the Minister that we are doing enough to attract, develop and retain our human capital in the healthcare industry.

Employability and Job Availability

Dr Fatimah Lateef (Marine Parade): Madam, the healthcare sector is one known to be very proactive in the provision of jobs to retirees and also to those starting up with a second career, be it after retrenchment, loss of jobs or staying out of the workforce for some time.

Recently, it has been announced that the healthcare sector will have several thousand job openings in the next few years. To be more precise, 4,500 jobs for healthcare professionals and hospital administrative staff. Can MOH give the breakdown of these jobs in the respective categories, eg, medical, nursing, allied health, administration and other support services? Also, whether applicants should approach individual institutions or whether they can go through WDA or the cluster office. Perhaps the Ministry can give us an update on the Professionals Conversion course which has been introduced.

Strengthening the 3M Framework

Mrs Josephine Teo (Bishan-Toa Payoh): Madam, over the last few years, medical inflation has outstripped general inflation. Medical inflation rate was 7.4% in 2007, more than three times the national inflation rate of 2.1%. Medical inflation has averaged 2.4% per annum during the preceding five-year period (2002-2006), still much higher than general inflation during the same period of 0.66%. Could the Ministry update the House on the medical inflation in 2008, and what more is being done to contain the rising costs of healthcare? Also, in the spirit of

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continuous improvement, could the Ministry consider further refinements to strengthen the 3M framework?

First, on Medisave. The use of Medisave has been liberalised to include outpatient treatment of chronic diseases. As the first liberalisation, to cover diabetes treatment, it has been in effect since October 2006. What is the Ministry's assessment of the effectiveness of the scheme? Are the annual limits adequate?

Madam, the trend for more workers to be put on contract terms will continue, and even be accelerated in these uncertain economic times. For contract workers earning more than $2,000 per month, there is no legal requirement for the employer to provide medical benefits. For those earning below $2,000 per month, if they have worked more than three months, they can claim for consultation but not treatment fees.

While MediShield covers these workers for hospitalisation expenses, they have little coverage for outpatient medical expenses. Will the Ministry expand the scope of outpatient services which Medisave can cover for the benefit of the growing number of contract workers?

The intended use of Medisave, however, is really for hospitalisation bills. And Singaporeans have been heading to places, such as Thailand and Malaysia, for various treatments. Most patients seek overseas treatment because of the lower costs of doing so. In 2007, a Reader's Digest Asian Health Survey across seven Asian cities found that some 36% of 2,000 Singapore respondents would consider going overseas for medical treatment.

Madam, I am aware that the Ministry of Health already approves the use of Medisave for overseas hospitalisation in

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cases of emergency. I would like to ask if the Ministry could consider allowing Medisave to be used for medical treatments in overseas hospitals on a regular basis so that this will allow Singaporeans more choice to stretch their Medisave dollars.

Second, on MediShield. In a downturn, Singaporeans who lose their jobs or experience wage cuts often overlook the issue of medical coverage. They may be unable or simply forget to service their insurance premiums. When they most need the insurance coverage, they find that they are no longer covered. What steps can the Ministry take to minimise such instances, especially since there are no Medisave top-ups this year and we may see more policy lapses? For example, besides CPF Board notifying the member of insufficient funds, can the CPF Board include ways that the member could seek help? Could Medifund consider paying for premiums of those in genuine financial distress? Could it also be an automatic application for 2009?

Madam, lastly, on Medifund. I am glad that Medifund will receive a top-up of $100 million this year. I thank the Ministry for that. I would also like to urge the Minister to extend a helping hand to workers who may be retrenched during this downturn.

Also, for those who are not retrenched but are affected by wage reductions, they may have other assets, eg, homes, but they could also be committed to loan repayments. In some cases, these Singaporeans may be in negative equity. And when they are hit with big medical bills for their dependants, it could be very burdensome for them. I would like to urge the Ministry that rather than to look for reasons to reject the Medifund applications, at least for this period, please look for reasons to approve the applications.

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Healthcare Financing

Mr Yeo Guat Kwang: ( In Mandarin ): [For vernacular speech, please refer to Appendix A.] Madam, one morning, I was at China Square when I overheard a conversation in Hokkien amongst some elderly people who appeared to be financially well-off. They said, "When you are young, you work to support your children. When you are old, you work to support the doctors." What they mean is that when they were young, they worked to support their children but now that they are old, they need to work to meet the medical expenses paid to the doctors. This reminded me of the movie "Money Not Enough" where two brothers wanted to send their mother to a higher class ward, but they realised that the higher wards would mean higher charges and they were worried that the medical insurance might not be sufficient to cover the hospital bill.

I know the Ministry of Health has been working very hard to reduce the burden of medical expenses on Singaporeans. Would we have a national review to see whether all Singaporeans are adequately covered by medical insurance? We have to ensure that our people start taking up medical insurance from young so that they can protect themselves in their old age. I hope that the Ministry of Health would work with the trade unions and CASE to educate the public so that Singaporeans from all walks of life would make informed decisions to take up a medical insurance scheme that is best suited for them.

Mr Chairman, since 1994, civil servants are placed under the Medisave-cum-Outpatient Scheme, a portable medical scheme. Under this Scheme, civil servants have an additional 1% of his monthly salary paid into the Medisave. Is this sufficient to cover their medical costs? Can this Scheme be extended to

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the private sector as well? We need to look into this. Following means testing, Singaporeans will enjoy the Government subsidies on a sliding scale. I hope that the Ministry will be more flexible in implementing the medical insurance scheme in view of the present economic recession. Some lower and even the middle income Singaporeans may have financial difficulties in this economic downturn. Although we know the 3M schemes are very good, there are always some cases which are not covered by the 3M schemes. I hope that the Ministry of Health will consider having some flexible schemes to help people with special needs. Can our MediShield cover all our children from birth, using an opt-out scheme instead of the opt-in scheme?

*Cols. 2493-2494.

Liberalising Medisave Use

Dr Lam Pin Min (Ang Mo Kio): Madam, over the years, Medisave has been liberalised progressively for payment of medical-related insurance, outpatient treatment and investigations. An example will be the Chronic Diseases Management Programme (CDMP) where Medisave is allowed to be used for the cost of outpatient treatment, up to a cap of $300 per Medisave account per year. The diseases covered under the CDMP include hypertension, diabetes, hyperlipidemia and stroke when the programme first started, and has since been extended to include COPD and asthma. However, many Singaporeans visit their doctors for a myriad of medical problems, many of which are not included in the CDMP. I would like to urge the Minister to consider extending this coverage to all diseases, including mental illnesses, but still subject to similar restrictions of capping the maximum withdrawal to $300 per account per year. This would prevent premature depletion of the Medisave savings but, at the same time, help Singaporeans decrease the out-of-pocket expenditure for medical treatment,

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especially in challenging economic times like this.

Medishield Coverage

MediShield is an important component of our 3M healthcare framework. It is a low cost catastrophic illness insurance scheme introduced in 1990 and has benefitted countless Singaporeans. At present, MediShield covers almost four out of five Singaporeans and PRs. And since 1st December 2007, all newborns will be offered MediShield coverage on an opt-out basis. However, there are many housewives in Singapore who are not covered under MediShield or any form of integrated health plans. This is due to the fact that housewives do not contribute to Medisave and also possibly the inertia on the part of husbands to apply for coverage for the non-working spouses. In addition, current MediShield does not cover newborns for congenital illnesses diagnosed soon after birth.

The cost of treating complex congenital illnesses can be expensive and financially draining for many families. I hope the Minister can consider the following – make MediShield coverage for housewives as an opt-out scheme, just like it has been facilitated for newborns and extending the MediShield coverage for congenital illnesses, to give parents a peace of mind that their newborns will still be covered by MediShield should they be born with any congenital diseases.

Use of Medisave for Mental Illness

Dr Fatimah Lateef: Madam, mental health-related diagnosis can encompass a multitude of problems with wide-ranging variety and different ICD codes. Medisave has now been ingeniously packaged to help Singaporeans with chronic illnesses utilise them for chronic use. It has also been expanded to help cancer patients pay for certain approved

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tests. Perhaps it is time to consider allowing it to be used by patients with chronic mental health illnesses. These patients have a long-term problem and thus the need for long-term care and follow-up. Moreover, some psychiatric medications can be costly as well. One suggestion is to carefully select a few established mental illness diagnosis and have a trial period for Medisave utilisation. This list should initially only include clear-cut diagnosis, such as schizophrenia, manic depressive syndrome, etc. This implementation will then need to be monitored closely with feedback obtained from end users to check for feasibility and need for fine-tuning. If successful, perhaps a new batch of diagnosis can be tried out.

Use of Medisave Overseas

Medisave is a national savings scheme which assists individuals to put aside a part of their income to meet their personal or dependants' hospitalisation needs and expenses. Since its implementation in 1984, Medisave has helped over two million people save on their hospital medical bills. Periodic adjustments are also made to Medisave to help evolve the scheme with changing needs and time. Of late, there has been some discussion on utilisation of Medisave to cover overseas medical care. There can be both pros and cons in this. Certainly, we do not want any relaxation of the policy to go out of hand and miss the main reason as to why Medisave was set up in the first place. Does MOH have any plans on how this can be implemented? There certainly need to be rules and regulations as to how we can use Medisave overseas and which countries will be eligible for it.

The Minister for Health (Mr Khaw Boon Wan): Madam, I thank Members for their comments. Many have noted the extraordinary circumstances which we are now in. The global recession is raging and we are really battling an economic

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tsunami. My job is to ensure that healthcare remains affordable to Singaporeans, even if they should lose their jobs or face wage cuts.

We are in a much stronger financial position for healthcare as compared to all other countries. This is because we have prepared for rainy days like these over the last 25 years. There are more than $46 billion in our "healthcare reserves" in Medisave, Medifund and ElderCare Fund, most of it in Singaporeans' individual accounts. I think $42 billion of the $46 billion are in their Medisave accounts and the other $4 billion are in endowment funds which belong to everybody, which we hold in trust on behalf of Singaporeans. With our healthcare reserves, Singaporeans do not have to forego essential healthcare treatment during the recession.

We have carefully constructed this year’s Health Budget. There will be special schemes to help patients tide over the recession. But our eyes are also on the future when the economy recovers. We are paying particular attention to opportunities which are emerging as a result of the recession and we will seize these opportunities to further strengthen our healthcare system. For this afternoon, let me first elaborate on the strategies which we will implement to cope with the immediate healthcare issues that the recession has brought. Later today, we will discuss the longer term strategies.

To battle the recession, my Ministry has already implemented a number of initiatives during the past few months and I will not repeat them. Instead, let me focus on the new initiatives which we will undertake during the new financial year. They will benefit the healthcare sector directly and some will also have a positive impact on the rest of the economy as well.

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First, as noted by Mdm Halimah, we have increased the health budget substantially, by nearly $1 billion, to $3.7 billion. I am truly grateful to Finance Minister and the colleagues in the Ministry of Finance for their understanding and support. The increase comprises additional operating budget of $700 million and an additional capital budget of $300 million. These are very substantial increases.

Government subvention to our restructured hospitals and institutions will therefore grow from $2.0 to $2.7 billion. Of this, $2.2 billion will directly subsidise the patients’ medical bills. The remaining $0.5 billion will help the hospitals recruit and train more doctors, nurses and allied healthcare professionals.

The additional capital budget will help us expand our healthcare capacity in the form of more beds, new general hospitals, new community hospitals, nursing homes and enhanced IT capabilities. The total new capital commitment is about $4 billion, which we have planned to take probably five years to complete. But because of the recession, I am bringing forward some of the projects to take advantage of the softening construction cost.

Second, we will use the expanded health budget to hire and train more professionals to enhance patient care. This is something we have wanted to do incrementally over the medium term. But given the current recession, we decided to bring forward part of the plan. Over the next two years, we shall add 4,500 more jobs. In reply to Dr Fatimah Lateef’s query, half of these jobs, 50% will be for nurses, one quarter for doctors and allied health professionals, and the remaining one quarter for administrative and ancillary staff. This, as Members can see, is a significant expansion with, of course, long term implication, as it will raise the

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annual manpower cost of the hospitals permanently by more than $500 million per year. This is a major investment on our part and is in response to patients’ demand for better services and longer consultation times. It will have to be jointly funded by the Government, the patients and their families, their insurers and their employers, but the Government will foot the bulk of the increased cost as we will continue to subsidise 80% of Class C treatment and 65% of Class B2 bills.

I thank Mr Banerjee for his kind comments on our healthcare system. He is well-travelled and he has seen healthcare systems elsewhere, both in the third world as well as the first world. So when he commended our healthcare system, I thank him deeply. He asked if the public sector has been competitive in recruiting and retaining our doctors and other human capital. The restructured hospitals have expended a lot of effort and resources to ensure that they have their fair share of talent.

Besides regular wage adjustments to narrow the gap with the market, we also focus on training and research opportunities for our professionals, so as to enhance the value proposition of a career in the public health sector. The point about research opportunities is particularly important because, as he noted and advised, we should, besides training locally, also look out to the rest of the world for recruiting well-trained doctors elsewhere, and we have been quite successful. I will find another occasion to talk about the results of our recruitment efforts in the last three years. It has been wonderful. We have been very successful in recruiting and continue to be successful. In focus group discussions with the doctors who decided to come back and many of them are Singaporeans – our own children, children of our friends and many others as well – who could not enter NUS Medical School, ended up in,

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Cambridge, Oxford or elsewhere, and many now come back, and the reason they gave is because of our last few years' focus on life sciences research. We see them coming back, not just to treat patients but also to have opportunities to take part in research. So that is a very important point in improving the value proposition of a career in the public health sector.

The number of doctors in the public sector, as a result of all these efforts, has grown by 1,000, from 2,800 in 2004 to 3,900 in 2008. Just over a span of four years, we have increased our medical staff by 1,000.

Attrition rate is manageable at 6% last year. I would like to believe that the current recession will help too and attrition will further improve. Similar efforts apply to nurses, pharmacists and the key allied health professionals. Their headcount numbers have also grown by 4,000 from about 11,000 in 2004 to 15,000 last year.

But let me quickly add a word of caution here. These efforts, as I said just now, will increase healthcare cost significantly, if we merely use the extra manpower to reduce the workload for each staff. While this is one objective, it cannot be the sole objective. We must also use the extra resources to help us transform the delivery of our healthcare system, and not merely to do the same things with less staff. For example, we need the extra resources to re-engineer our processes, change the ways hospitals and doctors do their work, support better treatment of chronic diseases. And a very important area raised by several Members – Mdm Halimah, Dr Lily Neo – for several years, is to forge greater integration of services, ie, between hospitals, specialists, nursing homes, GPs, and others. In particular, we need to reshape the traditional healthcare sector built around acute hospitals and acute care and to cope better with chronic illnesses. And in chronic care, we need multi-disciplinary teams based on many more nurses,

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therapists and other allied health professionals.

Third, we will help some of the retrenched Singaporeans take up a career in healthcare. We are creating at least 250 mid-career conversion opportunities for those who are retrenched. With the right attitude, they can be trained to become nurses, therapists, radiographers, pharmacy technicians or healthcare assistants. We subsidise the training costs and we pay the trainees quite a reasonable monthly allowance and guarantee them a job at the end of the training. We are prepared to do much more if there is stronger demand, and I hope there will be. We will also increase the number of scholarships and bursaries for students in the various allied health disciplines. This year, we will increase it by 250 but, as I said, budget really should not be the constraint. I hope there will be more demand and we will just grow the number.

Fourth, we are bringing forward some capital development projects, to capitalise on softening construction cost. Khoo Teck Puat Hospital in Yishun is on track to open next year. Because my constituency is in the North. I pass the worksite almost every day and I can see it shaping up. For a long time, it was submerged, for the basement work, but now it is above ground. The last time I saw, it was about Level 4 now. So we are on track. We will open next year. The opening will directly benefit the patients living in the north, many from my constituency, but it will also relieve the pressure in Tan Tock Seng Hospital and Changi General Hospital where patient load has overflowed there.

The proposed Jurong General Hospital is being planned for 700 beds. I think this is in Ms Grace Fu's constituency but I am sure it will also benefit the whole Jurong

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GRC. Elsewhere, the Duke-NUS Medical School is now almost ready, while the National Heart Centre and the SGH Pathology Building are being built at the Outram Campus. The Kent Ridge Campus is just as busy with the development of the National University Heart Centre and National University Cancer Institute. There will also be developments at the Novena Campus, including the new Communicable Diseases Centre.

But it is not just the big ticket items like hospital and Pathology Department. We continue to invest, a point made by Mr Banerjee and reinvest in existing facilities and to upgrade them where appropriate. I give you one example. Last year, SGH debated for quite some time but finally decided to invest $3.5 million in a new hyperbaric oxygen treatment facility to further enhance its capability in treating burns patients. As it turned out, our parliamentary colleague, Mr Seng Han Thong, became a beneficiary of this investment. Daily oxygen treatment, at a concentrated level, at the facility has speeded up considerably his recovery process. For those who have visited him more than once, we can see with our own eyes the speed of the recovery. Our burns unit in the SGH is a major asset that we all can be proud of, and is an example of the excellent healthcare that Singaporeans have access to.

Fifth, I agree with Mdm Halimah, and we will liberalise Medisave use to help Singaporeans further reduce their out-of-pocket expenses. In 2007, we raised the Medisave per diem withdrawal limit to $450. This has helped many patients, particularly the middle income Singaporeans who asked to be admitted to Class A/B1 wards or the private hospitals and those who do not need any surgery. This year, I will focus on helping those who need surgery.

Surgeries, as Members may know, are classified into 21 tables, from Table 1A,

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2A, 3A all the way to Table 7A, 7B, 7C, in ascending order of complexity and, then, we set Medisave withdrawal limits associated with each type of surgical table. For example, for the lowest table (1A), we set a limit of $150 because it is the least complex, charges are the lowest and $150 was enough. For Table 7C, which is the highest, we set it at $5,000. We will raise these limits substantially by up to $7,550 for Table 7C. This would reduce the out-of-pocket expenses of all surgical patients, particularly those who stay in Class A/B1 and private hospitals. Subsidised patients in B2/C do not face a problem because the current limits are already enough to cover their highly subsidised bills.

Let me give some examples. An eye cataract operation is a Table 4A operation. Patients today can withdraw up to $1,400 for this surgery but, after the liberalisation, they can withdraw up to $2,150. So that will save them $750 out-of-the pocket. I think, during a time like this, it is useful. As another example, patients who need a knee joint replacement - an example that Mdm Halimah mentioned - which is a complex operation (Table 6B). They can now save nearly $1,950, when we raise the withdrawal limit for this operation from $3,200 to $5,150. I will try to get this done as soon as possible, but the computer guys need some time to reprogramme the computer. We will get this done latest by June.

Dr Fatimah Lateef and Mrs Josephine Teo asked about our Medisave Chronic Disease Management Programme (CDMP). This programme has helped many patients with any of the six major chronic diseases, including diabetes and stroke. I am pleased with the working of the programme. We are now confident enough to further extend it and to benefit the mentally-ill patients. Mdm Halimah, Dr Fatimah and several other Members have asked for this extension, I know, for

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quite some time. Just like the other chronically ill, the mentally-ill patients also need continuous and often long-term outpatient treatment and the cumulative costs can be high. So I am sure they will find this liberalisation useful but, again, a word of caution.

Please remember the original purpose of Medisave, which is to help Singaporeans cope with costly hospitalisations likely to be at old age. Otherwise we end up "feeding the doctors", as mentioned by Mr Yeo Guat Kwang earlier. It was never meant for outpatient care and we must not allow Medisave to be prematurely depleted through inappropriate outpatient services and that is why I cannot support Dr Lam's proposal to extend it to all diseases. We may eventually get there but I think let us take it step by step. To safeguard against premature depletion, we have set a Medisave withdrawal limit of $300 per account per year, rather than per patient. So for those who have several children, in fact, the withdrawal limit is quite high and we also impose requirements for deductible and co-payment. These are very important conditions and they will also apply to the mentally-ill. But unlike diabetes and stroke, mental illness, as noted by Dr Fatimah, comprises a wide range of conditions, some of which are not easy to diagnose and confirm, nor with clear consensus yet among the psychiatrists on what is the most optimal treatment regime. So if you are not careful, the money may just get depleted and a few doctors "get fat" but the Medisave Account gone and the conditions may not improve. I therefore accept Dr Fatimah's prescription and we will start cautiously with the major conditions of depression and schizophrenia, which affect the bulk of the mentally-ill. The Ministry of Health will also put in place a quality assurance framework with the Institute of Mental Health and the relevant tertiary institutions. This way, I think we can better ensure that Medisave is put to

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proper use, with clear benefits for the patients' recovery. We will begin detailed discussions with the GPs and the psychiatrists on how best to implement this new initiative, but I promise to get it done before October this year.

Mayor Zainudin, Mdm Halimah, Dr Fatimah and Mrs Josephine Teo asked about the proposal to allow Medisave to be used for elective hospitalisation treatment overseas. The unionists asked for this extension when I last met them at a public dialogue. Good competent care for routine treatment is now available in our neighbouring countries, at far cheaper cost, given their lower cost structure. I therefore agree with NTUC and several Members that we should help our patients stretch their savings and reduce their cost if they opt for elective treatment in the neighbouring countries but my concern is how to ensure safety and adequate standards, while guarding against fraudulent claims. It is easier for me to audit our hospitals here but once across the border, our influence does not go that far. So we have to think through carefully the implications of this proposal. In fact, I made a day trip to Johor during the Chinese New Year last week to chit-chat with some of the hospitals and nursing homes there, to do my homework on how to design a stricter scheme which can achieve the purpose without being abused in any way, and I will share our analysis with Singaporeans in due course.

Finally, we will further strengthen Medifund, to make it a robust safety net for the lower income Singaporeans. Last year, we raised the amount of Medifund assistance to $74 million. This year, we will raise it further to $80 million. Medifund assistance is now double the amount of assistance provided just three years ago. I heard the call by Mdm Halimah and Mrs Josephine Teo for our hospitals and Medifund Committees to be

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compassionate and flexible during this downturn, and I am sure they will be. I have been reminding them. But even without the reminder, we selected compassionate people to be in the Committees. For the step-down care sector, our subventions for the elderly will also grow, by at least $25 million this year.

All in, my Ministry will do its best to help Singaporean patients cope with the recession. But we cannot battle the economic tsunami alone. The others have their parts to play too, namely, our patients and the healthcare providers.

First are the patients. I think they have a major role to play. I heard Mr Yeo Guat Kwang say in Hokkien just now –

" lao liao mai chi lo kun " (let us not end up falling sick and feeding the doctors in old age). I remember there is a Teochew expression which the Japanese also have it, and that is " jia chi hoon " which means one should only eat up to 70% of what you need, as the other 30% you eat for the doctors, meaning that if you overeat, you fall sick as you get obese. Therefore, one major role of everyone is to remain healthy and keep a healthy lifestyle. But besides that, patients can do three things: contribute to Medisave and use it carefully, buy the right type of medical insurance, and choose the right class of ward for admission. These are the public education messages that we periodically advocate in the newspapers.

As noted by Mr Zainudin, Singaporeans can stretch their healthcare dollar by being prudent, for example, by choosing the right class of ward. Our restructured hospitals provide financial counselling to ensure that their patients have the proper information to do so. Last week, I was quite glad to read in the Straits Times where it reported one Ms Wee who decided to switch from a private hospital to deliver her second baby in a subsidised ward in Kandang Kerbau

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Hospital. The move, she was reported as saying, would save her about $1,800 in cash, and this is her way of coping with the current recession, and I said, "Well done, here is a smart lady!" Our subsidised ward does not provide a personal choice of doctor, meaning that you cannot choose your own doctor, but the clinical care is of a high standard.

Means testing is now available in public hospitals. This enables the Government to be more targeted in our subsidies to lower income Singaporeans. I am glad that those who could not get the full subsidy, ie, they get means tested out, form less than 10% of the admissions. So more than 90% – nothing has changed with the means testing – are unaffected by means testing. It shows that, by and large, Singaporeans do choose their wards appropriate to their income levels. But we will continue to monitor the situation.

As for medical insurance, I thank Dr Lam Pin Min and Mr Yeo Guat Kwang for highlighting the importance. MediShield is essential for all Singaporeans to take care of major illnesses which may lead to large hospital bills. Now MediShield coverage has reached 84%. When I first started, I remember it was something like 75%. So we managed to push it up 10 percentage points, to almost 85% of the total population. I now set a higher target of 90%, and once we reach there, we will push it up further. I agree with Mr Yeo Guat Kwang that Singaporeans should get insured as early as possible, preferably soon after birth. We introduced opt-out MediShield coverage for children in December 2007, and 98% of parents did not opt their newborns out of the scheme. I thank them for their support. We are now working through the schools to catch up with those who were born before 2008. It will take some years but eventually we will catch up with all. As it is, currently, nearly 70% of Singaporeans below 21 years old are covered by MediShield. So, in fact, our 84%

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MediShield coverage for total population is brought down by the young Singaporeans' lower rate of 70%. As we catch up with the primary school kids and the secondary school kids, we will improve the overall figure.

For the adults, 90% of women aged 20 and above have MediShield coverage, which is actually not bad. Again, when I started this, there were large numbers of housewives who were uninsured and we have worked very hard. So I am personally quite happy with this figure – 90%, not bad. But it can be better because the men are slightly higher, at 93%. Let us raise both rates to 95%, as the immediate target. We are working with NTUC to make workers sign up for their non-working spouses. Mdm Halimah is helping me on this, and I thank her for this. Dr Lam suggested that we have some automatic opt-out for housewives so that unless you opt out, you are in. Actually we do. We have such a scheme. We catch them at the time of marriage, when there is an automatic opt-in. Unless you opt out, the husband has to pay through his Medisave for the MediShield of his wife. Therefore, most women and housewives got covered under this approach. The trouble is that after a few years, some men forgot, which is what they said. So we have to remind them.

Mr Yeo Guat Kwang asked about MediShield’s coverage of large hospital bills. After our reform last year, MediShield now pays up to 80% of large Class B2/C bills, a significant improvement from 60% previously. So by a few dollars increase in premiums, we have now greater coverage and I am quite happy with that. Claim limits for cancer treatment were also raised in the 2008 MediShield reform. However, as noted by Mr Yeo and Dr Lam, coverage for congenital conditions remains a gap in our current medical insurance scheme. MediShield and the private insurers do not cover congenital conditions. The reason

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is financial cost. Including congenital conditions will result in a large increase in the MediShield premiums which the rest of the population may not be willing to shoulder. We will continue to study this problem but, honestly, I do not see a quick resolution as this is clearly not the time to revise premiums. Until then, we will continue to rely on Medifund to help the lower-income patients with congenital conditions. So it is not as if they are left vulnerable.

Mrs Josephine Teo has wisely advised all Singaporeans to continue to contribute to Medisave and maintain MediShield coverage even during current bad times, and I echo her call. 3Ms is important and is effective, but provided you are within 3Ms. So, please, stay within 3Ms – do not walk out of the 3Ms' giant umbrella. You will be exposed, you will be vulnerable. Basic MediShield premiums are very affordable. Given that Singaporeans have substantial Medisave balances, most would have no problems with maintaining basic MediShield coverage. In cases where the individual has insufficient Medisave balance, that is when the immediate family members must chip in to take over the premium payment to ensure continued coverage. Family members should take care of one another, especially in times of hardship. I took a look at the latest MediShield subscription data, it continues to rise. So it is not as if people have been cancelling their policies because they are unable to do so. Of course, the main reason is because we have Medisave. So Medisave enables the payment to continue even though your salary may be cut or you may have even lost your job.

The second group pertains to the healthcare providers. They play an important role in helping patients save money. Saving patients' money is an important responsibility of all healthcare

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providers both during good and bad times, but it is especially critical during bad times. They have to help deliver better health outcomes at lower cost. Singaporean healthcare providers have largely been productive and cost efficient. But there is still scope for greater efficiency and higher productivity.

Let us look at the computer industry. For years, they focus on adding more features, more capabilities to their products, tempting consumers to buy higher priced products, never mind if they may not need the frills, the bells and the whistles. This strategy of paying more for added capabilities is now under severe stress in the current downturn. And that is why the electronic sector is hardest hit. Consumers are now demanding that manufacturers go back to basics and offer lower priced products, without the frills. They are demanding new technologies that do the same for less money, rather than more for the same price. They prefer computers to get cheaper, rather than more powerful. Small, low-cost laptops, called netbooks, are now "good enough" for many consumers. The same "good enough" approach is also being demanded in the software and many other industries. The Indian manufacturers are particularly innovative on this front: they are shooting for radical breakthroughs like a US$20 laptop and a 1 lakh (US$2,500) car. And not just in manufacturing. Indian ophthalmologists have pioneered the provision of cataract surgeries at less than US$100 per eye when practically everywhere, including Singapore, it is above US$1,000 per eye.

We need more of such disruptive innovations in the healthcare sector. Four years ago, I published hospital bill sizes to show the wide variation in cost among our hospitals, with a view to push our hospitals on this effort to "do more with less". And indeed there were some successes as lasik prices dropped by more than $1,000 per eye and the price wars

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continue. If you look at the newspaper advertisements, the volume has come down but lasik advertisements remain prominent. The competition has brought great benefits to consumers. But this "lasik effect" does not seem to extend to other surgeries. There are still many surgical procedures where prices vary widely. For example, the median bill size for cataract surgery varies from $2,900 to $4,200 at the high end – a range of more than $1,000. Why? Some people get it for $2,900 and some, for $4,200. Even for the subsidised patients, the variation is from $875 to $1,000 – a few hundred dollars difference – the same thing for hip replacement. The median bill size for Class B2 varies from $4,100 to $5,100 – a range of $1,000.

These bill sizes are easily accessible by patients and we update it every month with actual data but, regrettably, we do not experience the same "lasik effect". Why do patients continue to go to higher-cost doctors and clinics when competent lower-cost providers are available? If patients are indifferent, then why should hospitals try hard to save money for them because there is no reward. I think this is partly because the "lasik effect" has been blunted by third-party payment. For lasik, most consumers pay out from their own pockets – insurers and employers will not cover. But for cataract, knee replacement – employers chip in, insurers chip in, Government chips in with heavy subsidy. Yes, patients do some co-payment but to many, they can afford a couple of hundred dollars. So they just stick with whoever they are comfortable with. There is no incentive to shop around. But, surely, the third-party payers, like employers and insurers, will have an incentive to require the patients they sponsor to shop around?

As a major third-party payer for subsidised patients, my Ministry has a strong incentive to economise. We will want to create the right regulatory

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framework and conditions for providers to compete and innovate, like in the case of lasik operators. For surgeries with well-defined conditions and measurable outcomes, like delivery of babies (you cannot fake it), cataract surgeries (I do not know whether it is possible to fake cataract surgeries), knee joint replacement or hip replacement, I am going to tweak our Government subvention to reward the lower-cost providers and pressure the high-cost providers. We will try this out for several common surgical procedures, and see if it is effective in getting our hospitals to work harder to save money for their patients. This recession is a good time to apply this pressure, and will position our hospitals well in terms of offering cost-effective treatments when the economy recovers.

Prof. Clayton Christensen, Harvard Business School’s guru on disruptive innovation, has devoted his latest book "The Innovator’s Prescription" to a thorough discussion on applying disruptive solutions in the healthcare sector. This is now one of my bedside reading materials. He is emphatic that the solution to the US, and indeed the global healthcare challenges, is a complete reform of the traditional healthcare system and a disruption of the business model centred on the general hospital. His book makes for both optimistic and pessimistic readings. It points a way forward that will improve quality, accessibility and affordability by changing the way hospitals and doctors work. In other words, healthcare can be better and also cheaper. Who will not want that? But it also highlights the many obstacles and the ingrained self interests of the stakeholders to preserve the status quo . They will fight to avoid or delay the transformation. Maybe President Obama can do some miracle and lead the world in healthcare transformation. We will see, even as we attempt our own disruptive innovations here.

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5.30 pm

Madam, the economic tsunami is with us and we cannot wish it away. But there are opportunities to transform our healthcare system, even as we implement measures to battle the recession. If we apply our mind, we can help Singaporeans tide over the recession and also make our healthcare system even better when the economy recovers. My Ministry will play its role diligently, Singaporeans and our healthcare providers have equally important roles to play.

I thank Members for their advice and support of our economic tsunami battle plan. This will enable Singaporeans to continue to enjoy healthcare that is amongst the best in the world.

Healthcare for An Ageing Population

Mdm Halimah Yacob: Madam, we are facing a tsunami of healthcare challenges for the elderly. A 2006 NUS study shows that disability rates here are on the rise, much faster than other countries such as the US. Two decades ago, about 14% of those aged 75 and above could not do simple things such as move around, bathe or eat. By the time of the 2006 study, this had risen to 20%. To tackle this problem, we need policies and programmes which will provide an integrated and holistic approach in providing for the healthcare needs of our ageing population. We have to help our elderly live a life free from pain, be in good control of their faculties and are mobile.

A rapidly growing number of our elderly are suffering from dementia. The MOH estimates that there are about 25,000 dementia patients in Singapore, up from 21,000 in 2003. Despite this increase, there are only five subsidised

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dementia centres catering to them, offering a total of 177 places although it is estimated that about 5,000 would need institutional care. Fewer than 10 of the 59 nursing homes have specialised dementia care wards which offer subsidised care. There is also a shortage of centres taking patients in the early to moderate stage of the illness.

We also need to better develop our home healthcare services so that our elderly who are ill can stay at home instead of being hospitalised. There are nearly 70,000 people aged 65 years and above who even live alone or live with another elderly spouse. A Monash University study in 2000 has shown that maintaining a patient at home can lead to better quality of life and be cheaper as well by as much as 40%. Major concerns of home healthcare providers are lack of funds and shortage of manpower. MOH funding is tied to the number of visits a doctor or a nurse makes to a homebound patient, and therapy services are not funded at all. There is also a shortage of manpower to provide safe and competent care at home. Most doctors and nurses see homecare as less glamorous, less lucrative and physically more demanding than working in hospitals.

As women outlive men in our society, we need to worry about their healthcare financing as they suffer a longer period of disability compared to men. And many women, as we also just heard, are still not covered under MediShield.

I would like to ask the Minister the following questions:

First, what are the Ministry's plans to meet the needs of our fast growing population? Has the Ministry studied the experiences of other developed countries in tackling the health care needs of a greying population and what can we learn from them?

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Second, what are the key areas needing critical improvement in the provision of healthcare services for the ageing, including funding and greater support for caregivers? Also how are the special healthcare concerns of older women being addressed?

Third, what steps has the Ministry taken to improve the quality of step-down services, nursing homes or community hospitals, and the various centres catering to the needs of the elderly, including also home healthcare services?

Fourth, what is the progress made in training our doctors, nurses and para-professionals for geriatric care?

Fifth, could all our hospitals provide free geriatric screening for elderly patients that are currently provided at the Tan Tock Seng Hospital so that appropriate intervention can be mapped out as part of the strategy to cut down disability among our elderly?

Finally, what are the measures to ensure, on the part of MOH, that step-down care for the elderly remains affordable and accessible to low-income families? I think this is a major concern for many families, particularly those who have to put their elderly parents in institutional care. Affordability of nursing homes and other places for putting the elderly is a major concern. I hope the Ministry can address that as well.

Elderly Care and Support

Mdm Cynthia Phua (Aljunied): Madam, to those of us who have been living with an elderly person in our home, we know the joy and the bonding they bring to a family unit. Something as simple as a misstep that results in a fall would cause the family to be in difficult time, the cost of medical care can pose a heavy burden on a family and the additional support needed to take care of the family and the patient. Of course, we would be worse

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off without MediShield and Medisave. We need to look at an overall plan on how we can help families to cope with unexpected needs from the elderly in the community.

What is the status of the Master Plan for the Elderly? Do we have enough hospital beds by 2020? I am glad that we have proceeded to build the Yishun Hospital. Do we need to build more to cater to our elderly? How about our community hospitals? Many a time, the appeal on the ground is to allow the elderly to stay longer so that arrangements can be made to bring them home. The urgency of turnover at the main hospitals and the community hospitals is being executed by the medical staff compassionately, so it seems, because of the way the funding of the hospital is given. Is the Minister reviewing the funding formula so that the end result, the medical staff does not need to be so compassionate and turn the beds around? Can the Minister elaborate on the funding method as it has an impact on the residents?

The devils are in the service delivery on the ground. Firstly, we must have enough supply of geriatric doctors on the ground who can understand the elderly patients. In the hospitals and clinics, the bedside manners of doctors and nurses can be improved. Elderly patients may only be able to speak dialects but not English or Mandarin. They would have difficulty to communicate their basic needs. Many who serve in our hospitals come from the Philippines, China and Myanmar. Coordination between clinics can be improved.

The other aspect is coordination between the hospital and within its specialist support services and the polyclinics is critical. Let me give Members a real example. My father-in-law was warded last year and was asked to leave the hospital on a Sunday, despite

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the fact that he was unable to swallow properly and had a scheduled test to determine if he could swallow properly on the following Wednesday. If he could not, a tube had to be inserted. I had to make a few frantic phone calls to ensure that the test be completed before he was discharged because if he could not swallow, he would be dehydrated and needed to be warded again. Such basic coordination is important for the well-being of our elderly patients and not cause undue stress on the family units.

Are we to set up more support services in the heartlands to help families who have to provide aftercare for the elderly? How many elderly daycare and medical and rehabilitative centres do we have in Singapore to support our elderly?

Affordability of Community-based Long-term Care

Assoc. Prof. Kalyani K Mehta (Nominated Member): Madam, the demographic ageing of Singapore's population and the challenges that it brings for policymakers, service providers and family caregivers have been reiterated by my hon. colleagues.

I am glad the Ministry of Health intends to spend $500 million over the next five years on community-based long-term care such as new community hospitals and capabilities to run the facilities. However, my question is: are the services affordable for the average Singaporean?

Long-term or step-down care includes a wide range of services such as day rehabilitations, hospices, home nursing, home medical and even ambulance services. The increasing physical disability among people above 65 years, women in particular, as revealed in census data from

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1990 to 2000, emphasises the importance of these services.

Let me share some statistics that I have found. Sunlove-Hougang Senior Citizens Day Rehabilitation Centre and Ang Mo Kio Thye Hua Kwan Day Rehabilitation Centre charge about $40 per day and these charges exclude transport cost which could range from $15 to $20 per trip. The charges are usually subject to means testing which is viewed as mean by clients.

For community hospitals, the average monthly bill including treatment cost for an eight-bedded room without air-conditioning is $2,040 for Ang Mo Kio Community Hospital, $2,079 for Saint Luke's Hospital, $2,746 for Saint Andrew's Community Hospital. The cost works out to be about $90 per day. For someone from the middle and lower middle class who may have other dependants such as children, the fees are very high. While Medisave can be used for part payment, we must understand that the CPF account holder will need his Medisave for his own healthcare needs.

For ambulance services, an emergency call to SCDF is publicised on the internet to be free provided that the person is hospitalised. If not hospitalised, cash payment of approximately $80 to $100 is charged. For a non-emergency call, the charge is minimum $60, maximum $80, for a one-way trip. If the family has to call an ambulance for a frail grandfather to go for a medical checkup, I estimate that the appointment and the transport cost would run up to at least $400.

I would like to link the issue of affordability with the fact that people in the lower-income groups are at higher risk of poor health. This has been researched widely in other countries. In Singapore, a study by the Singapore Heart Foundation concluded that almost 50% of the people in one- and two-room rental flats had at least two chronic diseases. This included

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needy elders who had no source of regular income. It is logical to assume that for low-income people, steep costs of healthcare are a barrier to healthcare utilisation. Many of them avoid healthcare screening for fear they may find something sinister and that would create higher monthly cost.

To summarise, if community-based long-term care is made more affordable and means tests are conducted with flexibility, especially in this time of recession, many families would find immense relief. Of what good is the construction of more concrete structures, highly trained staff, if the ordinary man-in-the-street cannot afford to pay for the services?

I would like the Minister to consider waiving the GST for all transport fees and community-based long-term care services. This could be for one year to recognise the financial difficulties families are facing, renewable after one year. Regarding families which have multiple serious problems, the maximalist rather than the minimalist approach towards subsidy should be applied.

Long-term healthcare is a necessity, not a luxury. Therefore, the Ministry is urged to take a humanitarian approach in this very extraordinary time.

Healthcare for the Elderly

Mr Ang Mong Seng: ( In Mandarin ): [For vernacular speech, please refer to Appendix A.] Madam, with Singapore facing an ageing population, by 2030, out of four Singaporeans, one of them would be aged 65 and above, and our people's life expectancy is getting longer and longer. When people get older, the chances of getting sick is greater. So we must be prepared for a solution to help our aged folks deal with their medical problems.

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Every week during my MPS, some older folks will come to me and ask me to help them write to the hospitals to waive their medical expenses as they are not able to pay. They have no savings, no CPF, no insurance and, faced with the spiraling medical expenses, they just could not cope. Furthermore, when a Singaporean is more than 65 years, it would be very expensive if he were to buy medical insurance. But with life expectancy at 85, how are they going to cope with the medical expenses for the next 20 years?

I would like to ask the Government to consider buying insurance for them as a one-time exercise. These old folks do not have medical insurance. Can the Government buy the insurance for them? Although it may cost the Government a lot of money, I feel that the medical insurance would ensure that they would have the coverage to help them defray their medical expenses and this would be a sign of respect for these old folks for their contributions they have made to our nation in their younger days.

*Cols. 2595-2596.

5.45 pm

Secondly, I would like to ask the Minister whether he would consider having more polyclinics in the housing estates for the convenience of these older folks.

Finally, I would urge the hospitals to set up some special service counters to serve these older folks. Some senior citizens can speak dialects and if, for example, they have asthma, and if the staff at the counter do not know what is " hay ku " (asthma in Hokkien) then they would not be able to get the doctor to attend to them quickly. That could give rise to a potentially fatal situation. We also need people who have a better understanding of the health issues faced by these older folks so that they would be able to serve them better.

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Step-down Care

Ms Sylvia Lim (Non-Constituency Member): Madam, last year, I raised the issue of affordability of nursing homecare and the means test for Government subsidy. The Minister replied that the means test is reviewed from time to time. As the cost of nursing homecare continues to rise, I believe now is the time to look at the financial impact of such charges on families and to review how we can assist them.

Currently, Government subsidies for step-down care are means-tested, based on household per capita income. The rate of subsidy is tiered at either 75%, 50% or 25% subsidy depending on per capita income. And for those whose per capita income is more than $1,000, no subsidy is given.

Under the current framework, the impact of nursing home bills on families can still be very drastic.

I know of one family whose father has dementia and is in a commercial nursing home. The household has four persons. The two adult children together earn about $4,400 in gross pay. According to the means test formula, the family does not qualify for subsidy because the household gross income of $4,400 divided by four members means that the per capita income is $1,100. But the net income which the children have, after deduction of CPF, totals only about $3,500. Each month, they are paying the nursing home fee of about $2,000, which is more than half the household income. The per capita income left for the remaining three family members is about $500 each. Considering that the two adult children need to travel to work daily, is this not a very high burden on the family?

One aspect of the means test that is hard to understand is why it is computed

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based on the gross pay of the household, including the CPF component? After all, under the current policy, CPF balances cannot be withdrawn to pay nursing home charges.

Will the Government review the means test to take into account only the net or take home pay, or raise the cut-off incomes for Government subsidies?

Earlier the Minister mentioned increased subventions to step-down care institutions of $35 million. I would like him to clarify how much of this amount is going to the nursing homes and whether it is meant to defray expected inflation in wages and operating costs. Or will there be enough money for the homes to reduce the amount payable by the non-affluent families based on the current bill size?

And lastly, Madam, what are the options do such families have to take care of their aged sick besides the nursing home care?

Homecare and Caregivers Support

Dr Lam Pin Min: Madam, with Singapore's rapidly ageing demographic profile, the prevalence of dementing illnesses and physical disabilities will inevitably increase correspondingly. This phenomenon affects not only the individual but can also have devastating effects on the family.

Former First Lady of the United States, Rosalynn Carter, once said, "There are only four kinds of people in the world – those who have been caregivers, those who are currently caregivers, those who will be caregivers, and those who will need caregivers."

The family has traditionally been the main source of support for the elderly in Asia, and Singapore is no exception. Singapore is not a welfare state and

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individual responsibility is the mantra underlying most, if not all, policymaking decisions. There are obviously two choices when the family is encountered with caring for the elderly sick and disabled. They can either place them in the nursing institution or provide home-based care.

Many elderly sick patients would definitely prefer to stay in the comfort of their homes. Home care, however, will not be possible without the dedicated participation of the caregiver, who is usually a family member most of the time.

In Singapore, the Government has strongly upheld the belief that familial support of the elderly is ideal. However, are caregivers given the necessary support, both financially and emotionally by the Government? I think we are still far away from the ideal.

Caregiving is a challenging task that can impact a caregiver physically and emotionally. The caregiver's role for a family with an elderly relative or persons with disability can be very demanding and could be a long-term or even lifelong responsibility.

The medical fraternity is beginning to recognise the psychological and physiological changes experienced as a result of chronic stress due to on-going care giving activities. This condition has been coined "Caregiver Syndrome". Caregivers tend to be so immersed in their role that they neglect to take care of themselves.

In addition, caregiving can result in new financial burdens, as many have to give up their careers to look after their loved ones. Many families with elderly sick or disabled family members would require special care and attention. Home-based care not only provides the ideal cost-effective long-term care of the

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elderly frail and disabled in the family, it also helps free up limited vacancies in rehabilitation centres, daycare centres and old folks homes for families who genuinely require such services.

As the population greys, the infrastructural support such as nursing homes and step-down care facilities must grow in tandem. One complementary alternative would be to enhance the homecare support where the dependent elderly can receive optimal quality care and family love. Unfortunately, the structural support for caregivers in Singapore is insufficient, many a time, it is not available when it is needed most.

Caregiver to the elderly dependent is like the conductor to an orchestra. In all cases, the caregiver is the elder dependent's link to the world of a completely independent life that he or she once had. The caregiver is just like any one of us, a human being, with physiological and emotional needs. Often times, caregivers start from the deep end of the water, not knowing what lies ahead and struggling to keep their heads afloat.

I would like to suggest the following to the Ministry:

Consider setting up a one-stop caregiver resource centre to provide a range of supportive services, including information, educational programmes and emotional support for family caregivers.

Formation of caregiver support groups to allow caregivers to ventilate, share and support one another.

Formation of dedicated homecare medical teams to provide medical review services of stable patients at their homes so as to minimise the hassle of frequent travels to healthcare institutions, especially when most of them are non-ambulatory.

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And, lastly, consider the provision of monetary allowances for caregivers to compensate family caregivers for their unpaid effort and stress. This would definitely help alleviate the financial burdens faced by these families.

Quality and Affordability of Healthcare

Ms Jessica Tan Soon Neo: With the ageing population and lifestyle in Singapore, we can expect to see the increase in the risk of Singaporeans impacted by chronic illnesses, for example, diabetes or high blood pressure. Can the Minister share on the measures in place to drive greater synergy and proactive healthcare management for quality of health among Singaporeans?

Statistics have it that Singapore has the fifth highest incidence of kidney failure in the world with about 20.1% Singaporeans suffering from hypertension and 8.2% from diabetes. With people living longer, this underscores the importance of effective chronic disease management programmes to prevent the worsening of the medical condition to provide quality of health and life. With the current economic downturn, many will find the cost of treatment and medication for their chronic illnesses challenging as they will require treatment on a long-term basis.

In some instances at our Meet-the-People Sessions, it is really sad to see middle-aged and older residents trading off seeing a doctor or getting early treatment for their illnesses for other more pressing needs to manage their financial situations. This may not be the most rational decision but, given their situation, this happens. The on-going course treatment for chronic illnesses will make it harder for some people to pay for needed medication and they may not stay on them or skip doses, worsening their medical problems.

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As we all know, the best way to manage the course of chronic illnesses and the quality of health and life is preventive management of the disease. Those in their 50s, 60s and 70s are in that segment that need attention. They have the potential for undetected chronic medical conditions and, if not managed, will lead to complications and disabilities. Many of my Parliamentary colleagues have touched on the point that those who do not have Medisave and CPF contributions, how would they manage the cost of treatment for medication for chronic illnesses as this can be unaffordable given the long-term treatment.

I must commend the Ministry for the high standard and the continued focus of the quality of healthcare in Singapore. But I would like the Minister to also share on what more can be done to help patients manage the cost of chronic illnesses in this difficult time. It is good to see that Medisave now allows patients to use life supplants for disease management programmes for the illnesses, including outpatient services. And I do also understand the concern of depleting and overusing the Medisave. But given the long-term nature of treatment and medication for chronic illness, the cost can be hefty. So as we talk about disruptive innovation, I would also ask us to be disruptive in thinking of how we can look at managing the cost of chronic illnesses. Because, seriously, I have seen too many trade-offs and it is really heart-wrenching to see people making those trade-offs.

There is no easy answer to addressing the challenge of balancing the quality of healthcare and managing the escalating cost of treatment. However, given our ageing population and our somewhat sedentary lifestyle, the continued risk of chronic illnesses, proactive and preventive management of diseases as well as cost

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management will need constant attention. This difficult economic time makes this even more challenging. I am heartened to hear the Minister speak of the focus of the Ministry on doing more for less and ensuring that there is quality of healthcare treatment for patients.

Use of Generic Drugs

Dr Fatimah Lateef: Madam, in restructured hospitals, use of generic drugs is encouraged. At SingHealth, for example, there is a group purchasing office which negotiates on the purchase of drugs for the institutions with significant cost savings annually. Can the group purchasing office of this be expanded and extended to Government facilities and institutions such as nursing homes and other VWO-run facilities and homes for the elderly and disabled? This step can certainly help with, first, cost-cutting; secondly, regulating use of non-standard drugs; and thirdly, having more competitive choices of non-standard drugs, if necessary.

Already now in many nursing homes, inmates have to utilise Medifund to help with their payment for care, and we heard today that Medifund utilisation has doubled in the last three years. This may become a more prominent cause as the number of elderly is only expected to escalate in the coming years.

Policy Matter

Dr Lily Neo (Jalan Besar): Madam, I would like to request somebody to review one policy related to women today. I am not gender biased but there are inherent problems that happened to women here that require our attention.

Singapore will see a significant increase in female population among the elderly population referred to as feminisation of the elderly population. Women tend to outnumber men. In the

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older age group, women tend to be younger than their spouses and have a higher life expectancy at birth. This has now emerged as a new challenging issue. This is viewed as problematic because it reflects high levels of widowhood and the various difficulties associated with it.

Older widows are likely to live alone especially with the trend of declining number of children. Traditional means of family support are being steadily eroded with our declining fertility rate. Older women are more likely to suffer from weak health and have financial difficulty as women tend to have shorter working years and smaller earnings. They may therefore turn out to have lesser Medisave savings to support themselves at old age. We therefore may need policy to incentivise Medisave saving for this group. There is also a need for a better postulation and planning of the future healthcare needs that this group will require with regard to community hospitals, daycare centres and tertiary hospital beds.

There are also a whole set of diseases that are more prone to older women such as obesity, diabetes, osteoporosis, hip fractures, just to name a few. These are preventable diseases that can be reduced in incidence with the adoption of correct lifestyles and preventive medicine. Prevention in them will save patients pain and burden.

Feminisation of the elder population poses serious challenges for economic and social support and healthcare. There is an adage, "our duty is not to add years into our lives but to add life into our years". I am sure MOH believes in preventive medicine and this is one area that needs MOH's immediate attention to mitigate future healthcare needs. A well planned policy calls for enhanced awareness and early intervention to try to cushion this explosive demand on the healthcare needs in the years ahead.

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6.00 pm

Mr Khaw Boon Wan: Madam, last year, the American Geriatrics Society coined the term "silver tsunami" to sound the alarm of the enormous healthcare challenges facing the United States as their post-war baby-boomer generation enters retirement. The ageing of the baby-boomers combined with a rise in life expectancy and the drop in birth rate will place tremendous strain on the US healthcare system which is already under a lot of pressure. They concluded that the US is ill-prepared to meet the silver tsunami.

As noted by Mdm Halimah, Singapore will face a silver tsunami of our own as the elderly are more likely to be hospitalised and consume more healthcare resources.

And I noted Dr Lily Neo's point about many of these elderly patients, who will be females. It left a deep impression in me when I visited Okinawa where there were quite a few who were more than 100 years old; over 90% were females, less than 10% were men. And the only man who is above 100 years old is in the nursing home with dementia, and cannot communicate with me.

In fact, our hospitals are already facing the first wave of the tsunami – a relatively smaller wave as our baby-boomers turn 60. In 10 or 15 years' time when the baby-boomers turn 70 or 75, we will feel the real pressure of the second and the larger wave of the silver tsunami. We have been served notice. We must protect Singapore against the silver tsunami and we have started the preparation.

We are expanding our healthcare capacity and adding beds, training more staff. But preparing for the silver tsunami goes beyond simply expanding the

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hospital sector. Most of the elderly would have health conditions that require long-term chronic care – a point highlighted by Ms Jessica Tan just now – rather than short-term acute hospital care. This means that a large part of the burden will fall on the primary, intermediate and long-term care sector. GPs and polyclinics will play important roles in the care of the elderly sick. We have to grow the long-term care sector, both quantitatively and qualitatively, to meet this new and expanding demand. Obviously, we need many more doctors, nurses and allied health professionals.

Failure to strengthen the long-term care sector will end up in the elderly patients seeking treatment in more costly hospital care and often with worse health outcomes, less satisfactory service level and larger bills, ending up receiving more expensive but, in many ways, inferior service level.

I believe one reason for the US spending 16% of the GDP on healthcare is that many of their elderly patients get treated in the wrong place, in a more expensive, costly acute sector, when lower cost and, in fact, better care should be rendered in the long-term care sector. And we must avoid this. We have 10 to 15 years to put the policy, system and infrastructure in place so that we can face the silver tsunami with confidence. I highlighted this issue last year. After a year of analysis, I now have a better sense of what we need to do. There are gaps in several important areas and we need to fix them.

First, we need to have enough funds to support the long-term care sector, of a quality which Singaporeans will demand. Unlike our parents and grandparents, the elderly baby-boomers of 2020 will demand and they will expect a much higher level of care. Many will not be satisfied with the current level of care

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rendered in some of the nursing homes. I think many will expect and will be able to afford, if we help them save up while they are young, a higher standard of care run by professionals and better trained staff – this is the future which we must prepare for. To help Singaporeans prepare for this future, we can take a leaf from how we prepare Singaporeans for their anticipated hospital care in old age.

Over 25 years, we have carefully constructed a comprehensive 3Ms framework to ensure its adequate funding. Singaporeans save regularly in Medisave; MediShield ensures efficient risk pooling; and Medifund provides the ultimate safety net.

As wisely noted in this House by the Prime Minister's Office Minister Lim Boon Heng last week, we need to construct the equivalent of the 3Ms for the long-term care sector. He called it the 3Es – Eldersave, ElderShield and Elderfund. I support his call.

I was part of the Ministry of Health team, led by Senior Minister Goh Chok Tong when he was Health Minister, which 30 years ago carefully thought through and constructed the 3Ms framework for acute hospital care. 3Ms did not come about overnight. It was a carefully thought through plan which we knew politically we have to take our time to slowly explain and implement it phase by phase. So, after 25 years, we now have a fairly robust 3Ms framework – not perfect and there is still room for improvement but, I think, largely it has ensured Singaporeans being able to afford a very high standard of acute hospital care even if you belong to a low-income group. And I think this is what we should do for the long-term care as well. We need to do the same for the long-term care sector. The work has actually already begun.

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Former Health Minister Lim Hng Kiang drove in a key piling – ElderShield – in 2002. Mr Lim Boon Heng's Elderfund is what we called Medifund Silver, and was introduced in 2007. I am now able to build on these two elements. We need Singaporeans to regularly save for their anticipated long-term care while they are young and working. We can either create an Eldersave or we save more in Medisave so that it can also be used to fund long-term care. The question is how much will be needed for long-term care.

We are studying the experience in more mature societies such as the US, UK, Europe and Japan. And preliminary analysis suggests that they spend less than 2% of their GDP on long-term care. There is an outlier – Sweden. Sweden spends higher than 2% but still less than 3% of their GDP. And this gives me a lot of comfort. I was initially very worried that this sector will be a bottomless pit. And potentially it can be a bottomless pit and I was worried that it may suck in a lot of resources which society may not be able to afford. But the figures from these OECD countries give me some comfort – that the funding problem may not be insurmountable. But there must be a conscious effort to ensure that Singaporeans save regularly for their long-term needs, just as they do for their hospitalisation needs.

Of course, this is not the time to talk about raising CPF contribution rate, and we have no plans to do so. But when the economy eventually fully recovers, we should re-visit this issue of saving for our long-term care. But meanwhile, we have allowed Medisave to be used for some aspects of long-term care – the community hospitals, chronic sick hospitals and hospices, and also to pay for ElderShield premiums. But we must remember that the current Medisave contribution rate is based on the projected needs of hospitalisation. It has not priced

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in the additional needs for long-term care. So, we need to compute how much Medisave should be enhanced to finance this expenditure going forward.

As for ElderShield, I have restructured the industry to incorporate ElderShield supplements in their product offerings, but we need to do more. Half of Singaporeans above age 40 are now enrolled in basic ElderShield. Not bad – I suppose like half-empty or half-full glass. Now we must persuade the other half to join in and we must persuade everyone to also top up with ElderShield supplements as basic ElderShield only pays $400 per month for six years to the successful claimants. This will fall short of the monthly cost of about $1,800 in a private nursing home and will require a sizeable out-of-pocket monthly payment by the elderly or the family. Singaporeans' understanding of this insurance product remains poor. And we have to work harder to raise awareness of ElderShield supplements and their benefits.

As for Medifund Silver, we will continue to top it up whenever the Budget position allows it. This year, despite the pressure on the Government Budget, I am grateful to the Finance Minister for topping up Medifund with $100 million, of which a significant portion will be allocated to Medifund Silver. And we would definitely put it to good use.

Dr Lily Neo and Mdm Halimah highlighted the larger portion of female among the elderly population. The reasons are straightforward because they live longer and they do have higher incidence of some chronic diseases such as arthritis and osteoporosis. So women would have greater need for long-term care, incurring higher medical expenditures, and that is why it is so important that all working females should stay within 3Ms and eventually 3Es, contribute regularly to

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Medisave and subscribe to both MediShield and ElderShield. For housewives, husbands should do their duty by contributing to their wives' Medisave accounts. I discussed this at some length earlier, so I will not repeat the point.

I noted Dr Lily Neo's point about prevention, and that applies to both female and male patients, adult or young. I agree totally with her that prevention is truly the best option. Many things are within our control but if you are not willing to do your part – do the exercise, eat less (eat 70% rather than 100%), and wait until the parts are falling apart and you start looking to us for solution, it is a bit tough. Really, the key to healthcare reform is, besides disruptive innovations, "disruption" to your lifestyle; and make sure for those with unhealthy lifestyle, "disrupt your lifestyle". It is easy.

I go to the gym every lunch time. Before coming here, I am busy preparing the last minute speeches, but I still set aside one hour to go to the gym, did my treadmill – a few kilometres of it – and as a result, I eat less too. So, my BMI, I think, is all right.

But many are not, and we just have to persuade more people to do so. And regular screening is another. There are many types of screening, but we know that effective screenings are really inexpensive, such as simple blood test after fasting. And these only cost a few dollars; in any case, we heavily subsidise them. So Singaporeans need to play their part. The silver tsunami requires you to take part in this battle. It cannot be just the Government and the hospitals alone.

Prof. Mehta asked if current community-based long-term care services are affordable. For the vast majority of Singaporeans, they are. The lower income patients are assisted by MOH subvention, Eldercare fund and donations raised by VWOs, and Medifund Silver provides a

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safety net. Subsidised services include home medical, home nursing, home rehabilitation, dementia day-care services and also renal dialysis. But as the population further ages, we expect to do more and we will.

For the vast majority of the middle and higher income population, if you regularly save, as you do in Medisave for your acute hospitalisation, you do not have to worry about long-term care when you eventually reach retirement. Voluntarily, some people are doing that but it is not sufficient. That is why it is so important for this 3Es framework to be eventually in place to help Singaporeans develop the discipline to save, and ensure that they can afford their long-term care services.

6.15 pm

Ms Sylvia Lim asked about the means testing framework for long-term care. The current formula assumes that we subsidise the lower 50% of the population. It therefore includes part of the middle-income group. Whether we use gross income or net income, it does not really matter because if you use gross income, then the threshold criteria must be based on the gross income percentile; if you use net income, then the income threshold will also be based on the net income percentile. So it does not really matter. But the important thing is to be consistent, ie, we cannot use gross income data and then, the threshold is set at net income percentile.

With the increased budget that we are pumping into both acute and long-term care, I will expect that money to flow down to the patients to help them during this difficult period. Do not forget that many of these long-term care services are run by charities which also raise their own funds. They would be able to also top-up with whatever that the Ministry of Health routinely supports. But I know that this may be a difficult period to raise money

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through charities and that is why the Finance Minister has kindly set aside a special budget for both MCYS and the Ministry of Health. With that fund, we will help those charities, who, for various reasons this year, are not able to raise enough donation funds to cover their needs. But let me assure Ms Sylvia Lim that we will continue to refine the means testing framework and the assessment process so that it remains fair and relevant for Singaporeans.

Second, we need to build up capacity, including new community hospitals, nursing homes and train more skilled manpower. Community hospitals play an important role in helping some patients transit from their acute hospital stay to their return home. Timely and appropriate community hospital care results in lower re-admission rates and improves quality of life for patients especially our elderly. With an ageing population, demand for community hospital services is bound to increase further. We now have six community hospitals with more than 800 beds in total. This includes the new Ren Ci Community Hospital which I visited last month. It is still empty but I expect it to be filled up eventually.

Over the next 10 years, we will add more community hospital beds. We estimated the need to add an additional 60%. Our immediate plan, and this is confirmed, is to build two new community hospitals with 200 beds each, one next to Khoo Teck Puat Hospital by 2013 and another next to the being planned Jurong General Hospital by 2016. Our target is to raise the current ratio of one community hospital bed per eight acute beds, to one community hospital bed per five acute hospital beds by 2020. That should be sufficient but we have time to review and update the data.

Similarly, we are expanding the nursing homes' capacity by half, or 50%, over the next decade, from 9,200 to

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14,000 beds. This will be in both the private and VWO sectors. We are working with several existing nursing homes to increase their bed capacity and help those with expiring land leases relocate to larger venues. Over the next two years, we will help the private and VWO sectors to set up five new nursing homes. We will also work with URA to reserve more sites for nursing home development to meet longer-term demand.

Where appropriate, we are blurring the line between VWO and private nursing homes by allowing means tested patients access to private nursing homes through the Portable Subsidy Scheme. This is one way to help raise professional standards across the industry. Last year, 750 beds in private nursing homes came under this Scheme. So, it is quite significant. I am ready to do more if there is demand. In addition, from this year, the Ministry of Health will extend Medifund Silver to needy subsidised patients in private nursing homes on the Portable Subsidy Scheme. Separately, I agree with Mdm Cynthia Phua that we need to increase the number of community rehabilitation and dementia daycare centres and we will do so.

Third, we need to upgrade the capabilities of the long-term care sector. For example, we need to raise nursing standards in the nursing homes to deal with increasingly complex needs of the elderly, including care for elderly with dementia. For community hospitals, they need to develop stronger medical capabilities to manage more complex sub-acute cases so that we can discharge the patients over there, saving patients' money and also freeing up the expensive beds in acute hospitals. Similarly, the public will expect a greater degree of accountability from the healthcare VWOs as they receive more Government subsidies and public donations. Beyond

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delivering good long-term care to patients, sound corporate governance and financial accountability, must be established in the VWOs. We have extended the Health Manpower Development Programme which is a Government-funded training programme to the long-term care sector. Many healthcare professionals from the sector have benefited from both local and overseas training. We have further revamped the programme to provide higher level of support.

I agree with Mdm Halimah, Dr Lam and Mdm Cynthia Phua that we should also enhance the homecare sector. My Ministry currently supports several homecare services but as a next step, we are working with the stakeholders to develop viable models to deliver more coordinated and more integrated healthcare services to the home. We certainly recognise and acknowledge that the caregiver is the key and the pressure on them, which Dr Lam talked about – the caregiver syndrome – is real. We have friends and relatives who experienced that, so we can see with our own eyes. It is easy for us, visiting a patient with dementia once in three months. But for somebody, day in, day out, 24 hours, living and staying with a loved one who does not even recognise you, and constantly forgets that you have just fed him. To call this stressful is an understatement. So we will certainly do as much as we can to support. Much of the time, it is about training, awareness, how to cope and tips on what to do. I am not so sure about caregiver allowance. This is not a topic under the Ministry of Health and is traditionally under the Ministry of Community Development and Sports (MCYS). My own view is, let us do as much as we can to try to support and put the 3Es in place. At the end of the day, it is money. We have carefully constructed ElderShield. Practically, in all other countries, including Japan, their insurance scheme for long-term care is – if it is confirmed that you require long-

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term care, then go to the long-term care facility approved by the insurance policy and as charged, you can stay there for as long as you can and, therefore, tremendous abuses, over consumption and over servicing. And the patients lose their freedom of choice. Many of them we know would prefer to age at home.

What we do for our ElderShield is quite unique; once you are confirmed an ElderShield beneficiary, we just give you the money. With the money, it is up to you on whatever you want to do – to keep the patient at home with additional home help or admit to a nursing home or whatever. Our ElderShield structure, I believe, we have got it right. So do not deviate from that. But what is a weakness today is the amount is too small. So from $300, I raised it to $400 per month. From five years, I raised it to six years – a significant increase. But I think we need to raise it further. My own view is that for basic ElderShield, maybe we should push it up to $800 for basic, and those in the middle-income group, they should buy a supplement, so that they can afford private nursing homes. We discussed earlier about lower cost possibilities in the neighbouring region, especially Johor Bahru. Let me talk about my day trip during the Chinese New Year to Johor Bahru. I visited one site where a Singaporean investor is going to put up 200-bed nursing home. I asked him, "How much would you be spending on your capex (capital expenditure)?" It is mind-boggling, the construction cost and land cost are so low, that my cost of just putting up a polyclinic is probably more than his cost of putting up a 200-bed nursing home. So the cost of keeping a resident in a private nursing home in Singapore can easily pay 2.5 months of nursing home care in Johor Baru. If the connection is easy and if there is any urgent problem, you can always ambulance in the elderly to Singapore. The family members can get to visit the elderly on weekends. As this nursing

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home's CEO told me, even in Singapore, when they put the elderly in the nursing home, they also only visit them once a week over the weekends. Of course, many visit daily but quite a significant percentage just visit on the weekends. So, what is the difference with putting them in Johor Baru?

But we need to recognise that there are limitations of homecare, brought about by smaller family sizes and frailty with increased life expectancy. We have to be realistic and recognise that homecare may not be for everyone, given that homecare can be relatively expensive and skills intensive.

Mdm Cynthia Phua highlighted the major challenge posed by dementia. We need to do more on prevention, early detection and treatment. We will expand our programme to help improve the mental well-being of elderly and we will scale up targeted public education on signs and symptoms of dementia. This is an area which is bound to increase with greater numbers as we go along. We certainly need to train many more geriatricians. But I would like to emphasise that it is neither sufficient nor sustainable to solely rely on geriatricians to take care of the sick elderly. There needs to be general levelling up of capabilities of our healthcare professionals in caring for the elderly. I agree with Mr Ang Mong Seng that we must be elderly-friendly in our institutions. I do not think we need to set up special counters for elderly. Elderly patients are visible to us, so proper use of language that they are comfortable with, and so on, that ought to be common sense.

Fourth, we need to achieve greater integration amongst the various healthcare providers. Our objective is to enable our patients to move seamlessly across different institutions. Integration of care is critical so that we can care for patients in the most appropriate setting

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and at the lowest cost. To facilitate smooth patient transitions, we need to strengthen collaborative partnerships between primary care hospitals and the long-term care sector. For the frail elderly in particular, a multi-disciplinary approach, with close collaboration between doctors, nurses and allied health professionals, is essential, given their multi-faceted needs. Last month, Tan Tock Seng Hospital signed a clinical governance agreement with the new Ren Ci Community Hospital. We will encourage more such win-win collaborations.

We are also building up various support services and mechanism to integrate care. The Agency for Integrated Care (AIC) was set up last year to strengthen discharge planning and facilitate the movement of patients from hospitals to the various long-term care services. I have received good feedback on the good work done by AIC where discharge planning is a lot better now. Of course, there is always scope for further improvement and we will. Affordable drugs are another important means to integration as this lowers our financial barrier to right siting. In reply to Dr Fatimah, our restructured hospitals and polyclinics have established drugs supply partnerships with some VWOs running community hospitals and nursing homes. We support these partnerships and we will expand such partnerships to more VWOs.

6.30 pm

Finally, we need to tap technology much more smartly to help us fight the silver tsunami. Information technology is an important infrastructure. President Obama's Stimulus Package includes a programme to computerise the medical records nationwide, although over the weekend, I read that this item has been

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cut. Even if it proceeds, we are already ahead of the United States because for many years, we have had our hospitals –public hospitals, at least, and private hospitals follow suit – computerise their records. But our problem was, and which was our priority in the last few years, that they remain "silos". So if you are in the same hospital, if you go back to them, you are fine. But once you cross hospitals, there is trouble. So in the last few years, we focused on getting the computers to talk to each other so that we can transfer records electronically even if you start off from different hospitals. And we have done it. It is now possible for public hospitals. It is quite a major achievement. That is something to celebrate. But that is not enough. In parallel, the Ministry of Health has begun reaching out to the general practitioners (GPs) so that we can exchange electronic medical records with the community hospitals and the GPs. These building blocks have provided basic capabilities and health information exchange among public hospitals, polyclinics, GPs and step-down facilities.

As the Finance Minister mentioned in his Budget speech, Singapore is in a unique position to be among the first in the world to implement electronic health records nationwide across the primary, acute and step-down care setting. This is made possible through the strong foundations built in our public hospitals. The Ministry of Health will see this initiative through, to benefit our patients. We are spending nearly $180 million over the next two years to complete this project. Healthcare providers would then no longer need to shuttle individual paper records to and fro, can reduce unnecessary repeat tests and ensure improved safety and continuity of care for the patients. We will not disappoint the Finance Minister. Singapore will be among the first in the world with a nationwide system of electronic health records, bringing real benefits to our patients.

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On Ms Jessica Tan's point on chronic diseases, I totally agree with her. A big priority for me during the last few years is to enhance chronic disease management to make sure that it is better, improves healthcare and lowers cost. A number of initiatives have been done and I am sure there will be new initiatives coming along.

Madam, confronting the silver tsunami cannot avoid a discussion on death and end of life issues. This used to be quite a taboo subject but I am quite glad that after many months of public discussion on this morbid subject, Singaporeans are now able to discuss this with less emotion and more logic. I thank all Singaporeans who have offered their views and insight on this difficult subject. Some of the discussions focused on euthanasia, which was not the Ministry of Health's intention. What we wanted to do was to get Singaporeans think about the necessity to prepare for a good death. One concrete way of doing so is to introduce broader, what we call, the Advanced Care Planning (ACP) amongst healthcare professionals. We are really trying to find a middle ground between a scenario where families insist on treatment at all cost, contrary to clinical opinion and a situation where families opt for non-action due to ignorance on the option palliative care. There was a recent article in the New England Journal of Medicine by three American ICU doctors on their experience with the terminally ill. It was a moving article on how the dying suffered unnecessary pain, akin to torture as their children insisted on fighting on and refusing to let go. The authors ended the articles with this rhetoric: "Those of us on the frontline can't but wonder for whom do we fight on and why do we do it?"

An important part of end-of-life care is the Advanced Medical Directive (AMD). The Directive provides an avenue for people to think about and make a choice

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about their end-of-life care in advance while they can. You just look at this poor lady in coma in a hospital in Rome, who has been so for 17 years. And during this long period, while in a completely vegetative stage, the family has to fight lawsuit after lawsuit with the courts to just let her die. And now, the politicians jump in. I suppose because they think that it win them votes. But you have the Prime Minister and the President on opposite sides of the debate while the poor lady remains in coma.

Madam, the silver tsunami is definitely coming and we must gear up so that we do not end up overwhelmed by it. We have some time to fix the gaps in the current system. There will be fundamental changes and disruptive changes which we will take care to implement progressively. Change is necessary for the long-term sustainability of our healthcare system and we should not shy away from these changes, even as we cope with the short-term challenges of the current economic tsunami.

School Health Services

Dr Fatimah Lateef: Madam, amongst medical staff many still perceive the school health services division as rather archaic and few young doctors voluntarily choose to work there now. Will there be plans to rejuvenate and invigorate the "school health" on a more exciting and stimulating front so as not to engage the staff but also the youths and students that we are reaching out to? Will there be any increase in funding and programmes we can look forward to in terms of outreach? In July 2008, the Health Promotion Board organised the Championing Effects Resulting in Improved School Health (CHERISH) conference. The objectives were to empower local schools and enhance school health promotion efforts and programmes. Can we have some details and update on this programme?

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Health Education for the Young

Mr Ong Ah Heng (Nee Soon Central): ( In Mandarin ): [For vernacular speech, please refer to Appendix A.] Madam, young people nowadays do not seem to care about their health. Because they are young, they think they can jump, they can eat, and they will not fall sick. However, according to statistics, one out of 10 school children is overweight. In other words, among our 500,000 students in Singapore, some 50,000 of them are obese. I am talking about this, because obesity is very closely linked to heart diseases. People who are obese tend to have heart problems much more than people who are not overweight.

According to a recent survey on the health of young people in Singapore, about 9% of our youths are smokers, compared to 11% in 2005. Smoking is now the fourth leading cause of death in Singapore. What is of concern to us is that some of our young people who are actively involved in sports are still smoking. I do not know what we can do about that. I think it is important that we encourage our young people to be careful with what they eat, control their diet so that they do not become obese.

*Cols. 2497-2498.

State of Health of the Different Communities

Dr Muhammad Faishal Ibrahim: Madam, I have met a few residents who shared with me how they have successfully managed their health situations by having regular health screenings. Therefore, it is important that we continue to encourage Singaporeans to conduct regular health screening, as it will enable them to detect any forms of illnesses, in particular, chronic illnesses and address them immediately. I would like to ask the Minister on the trend of Singaporeans conducting health screening as well as the relevant demographics, such as gender,

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age and race of those who have gone for their health screening over the last five years.

Relating to this issue, I would like to ask the Minister on the state of health of the different communities in Singapore. What are the types of chronic illnesses suffered by the different communities? What efforts are undertaken by the Ministry in managing the issues of chronic illnesses in the different communities. As the people in the different communities have different eating habits and culture, it is important that any effort and engagement process take these factors into account. How do these efforts and engagement process vary?

Madam, allow me to continue my speech in Malay.

( In Malay ): [For vernacular speech, please refer to Appendix A.] Madam, I would like to know, what is the state of health of the Malay/Muslim community? What type of chronic illnesses do they face? Can the Ministry share with the House the patient demography, like age and gender, related to the Malay/Muslim chronic patients?

How does the Ministry plan to engage the Malay/Muslim community in facing and managing health issues related to these chronic diseases?

In a Berita Harian report on 26th January 2009, which obtained information from the NKF, the statistics showed that the number of Malay/Muslim kidney patients rose by around 36% compared to three years ago. There are 513 kidney patients in December 2008 compared to 377 in the year 2005. How will the Ministry tackle this issue?

Related to this topic, I would like to ask the Minister, what is the level of the Malay/Muslim community's support towards organ donation under HOTA?

*Cols. 2499-2500.

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The Chairman: Mdm Halimah, take both your cuts together.

Chronic Illnesses

Mdm Halimah Yacob: Madam, allowing the use of Medisave for chronic diseases is actually a very good initiative. It has greatly helped the elderly as well as the low-income Singaporeans to manage their chronic illnesses much better. It has also encouraged the better use of family physicians amongst those suffering from chronic illnesses.

I would like to ask the Minister whether he could give an update on the number of patients that have made use of their Medisave to pay for their outpatient treatment. What was the total amount withdrawn and how many doctors are now participating in the Chronic Diseases Management Programme (CDMP)? I have received some feedback from doctors however. They said that the paperwork and the process sometimes becomes a little bit too cumbersome and tedious, I would like to ask the Minister whether there is any way where we can try to streamline some of the procedures, make it a lot easier, so that the doctors will be a lot more encouraged, motivated and incentivised to take part in CDMP.

I would like to ask the Minister whether he would consider increasing the cap of $300. I know he has mentioned that it is important that we do not deplete our Medisave resources. But bearing in mind that the Ministry has enlarged the use of outpatient treatment using Medisave, there is therefore a need to look at the annual limit. I do not think this is a popular thing, at least not currently, but at least I would like to register that point.

My final point is to urge the Ministry to step up preventive efforts because it is

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absolutely critical that in dealing with chronic illnesses, we just do not deal with the end part of it but that we deal with upstream measures and issues, which is really dealing with helping people to better manage their own healthcare needs. One very important area is the importance of healthcare screening. People now go for screening after they have fallen ill but not before they fall ill. So how do we encourage and raise public awareness to educate people to make them understand the importance of going for pre-illnesses screening? Apart from awareness, there is also this issue of affordability. A lot of the low-income Singaporeans and elderly Singaporeans I spoke to are prepared to go for screening once they are made aware of it but they are concerned about the cost. Could the Ministry look at ways to make screening a lot more affordable to low-income Singaporeans and the elderly.

Mental Illness

Let me come to my next cut on mental health. There have been a lot of changes, improvements made and a lot of funding, and that is really good. But there are still a lot of gaps, and I hope the Minister could address these gaps. First, there is a lot of concern among those who are mentally ill and their family members on the cost of psychiatric treatment, including medicines for psychiatric treatment. I hope the Ministry will continue to look at ways to make psychiatric treatment affordable and accessible to all Singaporeans. This is a major concern because this is a long-term illness.

Secondly, I would like to urge the Ministry to consider including people with mental illness under MediShield. For a long time, many of us have raised it, but the Ministry felt that it was not opportune to include them at that point of time, but mental illness is a long-term illness. So I

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would like to ask the Minister to review this policy of not including people with mental illness under MediShield.

Finally, I would also like to urge the Ministry to provide a lot more support to VWOs who run partially-funded or non-funded programmes for the mentally ill. They are doing a wonderful job but they lack resources. So they need a lot more support, but a lot of them are not included in the funding.

Community Support for Mental Patients

Mdm Cynthia Phua: Madam, I have spoken on support and help for mentally ill patients during the debate on the Budget Statement. I will repeat again as these patients are really in need in the community.

I would like to appeal personally on behalf of a group of residents who are mentally unwell, as we have not attended to their needs for a long time. Also, we have not helped their families who look after them. Many have been left behind to cope with their dependants on their own. Many families have difficulties seeking help, as they are either embarrassed or do not want to face the stigma of the illness. I have checked and found that there are only three day care centres in Singapore, although the Minister had earlier revealed to me that there altogether six centres for mentally ill patients.

I made a cold call and spoke to one of the occupational therapists who is taking care of one centre. He has two other colleagues who are helping him to take care of about 40-50 clients daily, and they are understaffed. The average age of the clients is 30-40 years old. Basically, these are healthy men and women in their prime, and yet they need long-term medication. I understand that

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the medication is very expensive as well. The burden on the family is heavy, and it is really for 365 days. It is not short-term but really long-term care. I can empathise with them because, as I said earlier in Parliament, I have actually stayed with relatives in a kampong area, and I felt the gloom and the doom in the day.

We have done well in community support for the elderly. Can we have similar networks for our mentally unstable patients? Presently, many of our community leaders and volunteers do not understand the various ailments relating to mental health, let alone how to help and support them and their family members. I really hope that the Ministry will make an effort to share this knowledge with the ground. I would also like to appeal for more VWOs to set up community support centres, so as to support these mentally ill residents and their families with the help of the Ministry of Community Development and Sports.

However, there is a limit to what the VWOs can do both in terms of manpower and resources, especially on trained personnel. I understand that it takes at least a good five years of post-graduate study to be trained in this area of medical specialty. So I hope that the Minister could put in effort and resources to train these specialists on the ground.

Funding for Institute of Mental Health Services

Ms Sylvia Lim: Madam, the Institute of Mental Health maintains the Woodbridge Hospital Endowment Fund to raise public donations. The purpose of the fund is stated as providing welfare and medical care for needy patients.

In explaining the need for public donations, the IMH website states, "Although there is the Medifund, there are some patients from the lower-income group who do not qualify because of the

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stringent criteria." Examples are given of programmes supported by public donations. For instance, IMH highlights that mental patients need not only medicine but also psycho-therapy sessions. However, noted the hospital, "Some patients do not seek treatment because they cannot afford to pay for this service." It is worrying that IMH needs to ask the public for money to provide essential treatment for its low-income patients. Should the Medifund criteria not be relaxed for mental health services?

Mental Healthcare

Mr Zainudin Nordin: Madam, in a study done several years ago, it was reported that more people in Singapore die from suicides than from road accidents every year. And conditions, like schizophrenia, major depression and alcohol use disorders, are increasing significantly. The burden of disease attributable to neuro psychiatric disorders is expected to rise, with depression being the second most common cause of disability. The effect of major depression on the quality of life is as great or greater than that of chronic medical condition.

In 2005, the Ministry of Health had tasked a committee of policy makers and mental health professionals to formulate the first national health policy and blueprint for the year 2007-2010, to try to improve the mental healthcare system in Singapore. It has been several years since then, and I would like to enquire on the progress of the recommendations that were made. More specifically, I would like to know how much has been allocated to carry out the recommendations made in the blueprint. Is the amount provided sufficient for our current and future needs? Has there been much improvement in the way we care for mental patients? Is there a comprehensive epidemiological research done to gauge the extent of psychiatric mobility in Singapore? The

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findings will allow us to target population sub-groups at increased risk facilitating prevention, early intervention and treatment for psychological mobility in the community.

Madam, have we managed to address the issue of stigma of the illnesses? Are there efforts to develop community support for patients released from IMH and assist them to integrate back into society? And do we have support resources and system in place in the community to assist caregivers?

Breast Cancer

Dr Lily Neo: Madam, breast cancer is the most common cancer in women with 110 women here diagnosed each month. In the years from 2002 to 2006, breast cancer cases here were the highest with 6,626 patients. The next highest number was for colorectal cancer, the commonest cancer in men, with 3,790 patients. Since the start of the national screening programme in 2002, there has been a definite shift over the past few years towards discovering breast cancer at the earlier stages, when it is easy to treat and the chances of survival are higher. However, a survey last year found that only 41% of women aged 50-69 go for breast screening every two years as recommended. Many women are afraid to find out thinking that a diagnosis of cancer is a sure death sentence.

In 2004, a survey found that a third of women did not think breast screening was needed as they appeared healthy. But the fact is that there are no symptoms in early breast cancer; so even women who think that they are in the pink of health might have it. About 15% did not go for mammograms because they feared the pain, and 12% said that it was inconvenient.

It is time to address all these issues and adjust our policy accordingly,

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especially on public education and raising awareness in order to get more women to go for screening. May I urge MOH to place more emphasis on breast cancer, and definitely not reducing the budget or removing the subsidy for women at age 40-50? Currently, about 280 women die of breast cancer in Singapore each year, or more than five per week. This is set to rise, with breast cancer cases here up roughly at 4% a year. A successful national screening programme with participation by at least 70% of the female population can cut breast cancer deaths by 20%-40% after 10 years. The reason is that breast cancer is one of the easiest cancers to beat, if detected early.

Primary Healthcare: Making Consultation at GPs More Attractive

Mr Ong Ah Heng: ( In Mandarin ): [For vernacular speech, please refer to Appendix A.] Madam, I was told that there was a man who is paralysed from his waist down. He had to go regularly to the polyclinic for treatment and it was very inconvenient for him. Most of the time, he went there just to change the dressings on his leg. Whenever he had to go to the polyclinic, he would have to wake up at 4 am so as to arrive at the polyclinic before 6 am to be ahead of the queue just to go in and have his dressing changed. If he was unable to beat the crowd, he would have to wait for three hours in the queue to get his dressing changed.

Since there are many patients like this old man who go to the polyclinic just to change their dressings and not to see the doctors, why can we not have a different queue for them so that they do not have to wait so long? It would also shorten the queue for those who are going to consult the doctors.

On way of alleviating the long queues at outpatient polyclinics is to make

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primary health care at local GPs more attractive. Local GPs are close to the residents who are also their patients. It makes sense to provide the support and encourage the residents to visit the GP near to his home, under the Primary Health Care scheme. I would like to know what is the progress of this scheme. How ready are our local GPs to respond to this scheme?

*Cols. 2501-2502.

Affordable Dental Care for Low-income Families

Mr Chiam See Tong: Madam, the cost of dental care has been escalating steadily over the years. It is such that low-income Singaporeans cannot afford to see the dentist. I will just give a few examples of the charges. One filling is now $80 and a capping is $2,000. One root canal procedure is $3,500. The cost of dental care is very high these days. I wonder whether the Minister is willing to open up Medisave for poor workers to use their Medisave for dental care. And if not, whether some kind of subsidy can be arranged for them?