POLICIES AND SERVICES FOR AN AGEING POPULATION

Column: 806

POLICIES AND SERVICES FOR AN AGEING POPULATION: 6.01 pm

Assoc. Prof. Kalyani K Mehta (Nominated Member): Mr Deputy Speaker, Sir, I would like to speak on the motion: "Policies and Services for an Ageing Population".

Before starting, I would like to declare my interest as a member of the Board of Council, National Council of Social Service and Vice-President of the Gerontological Society of Singapore.

19 years ago, I applied to do my PhD at the Department of Social Work, NUS, on the subject of "Dynamics of Adjustment of the Very Old in Singapore". The very old referred to those above 75 years. I studied their cross cultural

Column: 807

patterns of ageing – were there similarities and differences between the way a Chinese elderly person ages as compared to his or her Malay and Indian counterparts? The research led me to understand the psychological, physical, emotional, social and spiritual changes that occur in the ageing process, the caregiving load carried by family members as well as the impact of an ageing population on the society at large. I also asked my respondents for suggestions on policies and services.

Hence, what I said today is a culmination of 19 years of reflection and analysis of the views of the end-users of our eldercare and family-oriented services drawing from several research projects. Since older people are frequent users of our healthcare services, ie, polyclinics, hospitals and home-based care, I would touch not only on the social services but the health aspects as well. Given the time constraint, I will only briefly speak on the importance of family caregiver policies. I hope that my input will have some relevance and bearing upon the preparation of next year's Budget as well as the next ElderCare Masterplan by MCYS which will be forthcoming after 2010.

We all know that the speed at which Singapore's population is ageing. It is one of the fastest in the world. What took other developed countries 150 years to evolve, we will shoot through within about 20 years. Currently, people above 65 years form about 9% of our population but they will reach 20% by the year 2030. They will be assets as well as liabilities on the economy. The recent episode of DBS High Notes 5 and Minibonds have highlighted dramatically the retirees' need for financial literacy and how they are easily influenced. At the same time, the Singapore public realised

Column: 808

the political and social ramifications of such incidents.

Not only is our population ageing at full speed but the aged, ie, those above 80 years, are also increasing in greater numbers. The elongated life expectancy of the population is unprecedented! At birth, a woman born in 2006 can expect to live to 82 years and a man till 78 years. What are the major implications of longer average lifespans? While it can be seen as the success of mankind in keeping the human species alive, it is also a drain on family, community and state resources, health services in particular.

Let us take stock at this point, and examine what we have done so far and where we are going in the future. What are the achievements and what are the shortcomings in our efforts to prepare our nation for the full onslaught of a greying population? We have included ageing policies in our national agenda, and we have given some priority to this issue. More than two ElderCare Masterplans have been drawn up, and more than six national surveys conducted by various Ministries on the older population in the last two decades. Relevant changes have been made to the various legislation. Many changes have been introduced to the CPF, eg, ElderShield insurance scheme, and more to come, such as CPF LIFE Annuity. In the light of these structural changes in the political economy of our country, what is the trickle down effect on the ground?

Statistics show that although suicides among seniors have dropped at the turn of the century, they are on the rise again ( Straits Times' article, 6th September 2008). In 2007, the rate was 27.6% per 100,000 population. In terms of numbers, 87 elders killed themselves, the majority being males. The risk of suicides among people above 80 is explained by loneliness, medical problems and physical disabilities.

Column: 809

Let us look at another social indicator – crime against older people. Robberies and snatch thefts targeting those aged 60 and above jumped up 25% according to the January-June statistics to hit 145 cases this year. The statistics for the same period last year was 116. Why are elders being targeted by criminals in a country that supposedly respects its elders? Is it to do with changing mindsets of the public? Or is it related to the economic downturn and inflation? Or is it that vulnerable people will be targeted for crime, given an opportunity? And therefore we will have to step up neighbourly vigilance and educate our elders.

A third social indicator is the rising numbers of elders dying alone, and no one coming forward to claim their bodies. According to a report in the Straits Times , titled "Dying Alone" in 2007, 45 persons' bodies were unclaimed despite police appeals. This is a rise above the 2006 number of 41 and the 2005 number of 32.

This topic reminds me of an Indian elderly man I had interviewed for my Doctoral thesis. He was very poor and on Public Assistance. When I asked him if he would like to return to India, he said he preferred to stay in Singapore. I quote his words, "The Government is like my father. If I die alone, I know the Government will take care of my body and will give me a proper funeral." These words representing the sentiments of the older generation of elders have much significance. The amount of faith that that generated had and still has, leads one to look at whether the Government is living up to their expectations. With the gloomy economic scenario that we are facing in the near future, will the elderly poor be able to manage with their meager Public Assistance of $330 a month?

The aim of discussing these social indicators and the message they convey

Column: 810

to the public at large, including policy-makers, is that while the country is getting more and more affluent, our social fabric is getting less cohesive and the elderly in the middle and lower-income classes are being marginalised. When an economic downturn occurs, they are the first to be retrenched. When inflation hits, they feel the pinch more because their income has dwindled, and when their children go away overseas, many are left to fend on their own. These are not the minority as figures of Singaporeans migrating overseas are getting substantial.

I now move on to shortcoming or gaps in policies, after which I will discuss the gaps and services.

I wish to highlight four gaps in policies. But before I move on, I wish to mention that the appointment of Mr Lim Boon Heng as Minister-in-charge of Ageing Population at the PMO's Office last year was a very important step. The setting up of the Ministerial Committee on Ageing, which Mr Lim chairs, signals the Government's recognition that a coordinated approach is necessary.

The first policy I want to address is a National Registry of Elders living alone or living as a couple. This has been mentioned in the past but, to my knowledge, it is still not a reality. In the study of four countries by Prof. Hermalin of University of Michigan, those considered vulnerable in Singapore are elders living alone, childless, poor, above 70 years, and those who are frail. Women tend to be a substantial proportion of this group; hence, this term "feminisation of poverty".

We need a Registry of vulnerable older people that includes referrals from the Ministry of Health, MCYS as well as community-based agencies such as CDCs, Resident Committees and FSCs. Targeted

Column: 811

help such as financial assistance, health screening, help-in-kind such as transport and meal vouchers, could be efficiently rendered to these Singaporeans who have sacrificed their lives to help build our nation.

Second policy – the formulas of means testing are currently inconsistent between MCYS and MOH. MCYS sets two tiers, ie, 50% and 75%, while MOH has three tiers, ie, 25%, 50% and 75%. For example, someone who is eligible and receives financial assistance at a Day Rehabilitation Centre, when he is moved to the Social Day Care Centre, he may suddenly find that he has no more financial aid. It is strongly recommended that the means testing formulas between these two Ministries be streamlined so that the schemes are more user-friendly.

Third policy – the current Many Helping Hands approach has served us well for the past few decades but it has its shortcomings. One of the main limitations is that the delivery of services is fragmented, piecemeal and not easy to navigate by end-users. There are many hotlines, such as ComCare hotline, to help alleviate the situation to some extent. However, there is an urgent need to standardise and centralise the services so that the public can use them without experiencing the 'passing the parcel' syndrome. In 1989, the Report of the Advisory Council of the Aged recommended that a National Council on Ageing be established to co-ordinate policies and services for the older population. However, this recommendation was not taken but the National Council for Family and the Aged (NACFA) was set up.

In the recent 2004 study which was commissioned by MCYS to the Gerontological Society of Singapore, titled "The State of Gerontology in Singapore"

Column: 812

(in which I was involved as a co-Chair), we consulted international experts, Singaporean professionals and reviewed the agendas and approaches of six countries towards tackling the challenges of an ageing population. These countries were UK, USA, Canada, Australia, Japan, and India. One of the key findings was that we lack a national level, cutting-edge Institute or Centre on Gerontology.

When the Council for the Third Age (C3A) was set up last year, I thought that it may fulfil the functions of such a National Centre. However, looking at their vision, mission and focus on Active Ageing agenda, I feel that it does not have the iconic focus unless it expands its role in the future.

The solution to the multi-faceted and complex challenges ahead is, in my view, a National Council or Institute which will maximise our resources and avoid duplication. We should look at this, in a sense that policy practice and research need to be combined as a major approach in Singapore. It would not only serve to address the issues of fragmentation, but also be a Regional Institute representing South East Asia on the world map. It could be set up by joint funding from MOH, MCYS, MOM and even MTI, for the entrepreneurial activities of the baby boomer generation of the future would possibly be of interest to MTI!

The last topic under policies is on family caregivers. We lack a holistic and integrated approach that includes mandatory family leave, informational resources and incentives.

Now, I move on to the gaps in services. The first gap is in relation to our community-based care. We have to work towards a system of chronic care that is integrated and comprehensive – medical, personal, social and rehabilitative aspects. In a recent study of Perceptions of Primary Healthcare by older persons in

Column: 813

Singapore by Tsao Foundation, it was found that many older people in Singapore dread falling sick. They say "falling sick is worse than death in the Singapore context". The spiralling medical costs, long waiting hours in polyclinics, lack of proper explanation or guidance by the doctors who are rushing against time (like me!), and the inconvenience of seeing a different doctor at every visit – all these make the visit to the polyclinic stressful and frustrating. Caregivers also voiced their need for support from the State. So the first gap is in relation to home health and home help services.

In the social services for older people, the VWOs play a major role. The demand for home help services which include personal hygiene, home management such as laundry and housekeeping, escort for medical appointments, meals delivery and befriending has increased. In a report titled "Wither Home Health Care?" in the Straits Times , the demand for such services was noted to have risen from 1,300 in the year 2002 to 1,900 this year. Social and health services are required by frail elders who live alone or they

live with family members who are working and therefore unavailable in the day time, or those whose spouses are also handicapped and sick. VWOs have many problems in continuing to deliver these much needed services due to funding and manpower constraints. According to one provider, the funding formula by MCYS and NCSS is not keeping up with the current circumstances such as higher manpower and transport costs.

So, the community-based health and social care services are in great need for more support from the Government. Studies abroad have shown that home-based care saves the State thousands of dollars, and it is preferred by the elderly patients as well. The families find it less straining on their savings and time as well. Readmission rates to hospitals also

Column: 814

decrease when the continuum of care from acute to home care is smooth.

Next, I want to look at reaching out to the lower income elders.

This House has debated on the widening income gap and schemes such as Workfare Income Supplements, Growth Dividends, Medisave top-ups, etc. It is the reality that with globalisation, inflation and crisis such as the current downturn, this will aggravate the situation further. In such times, it is the older people who will be hit the hardest. Their medical costs continue to rise, their problems get exacerbated and their mental health deteriorates, for example, they may suffer from depression or anxiety disorders.

I wish to recommend the setting up of a fund to be called the Senior Pocket Money Fund, a counterpart to the School Pocket Money Fund. A start-up initial amount could be allocated by the Government and philanthropists, foundations and individual donors could contribute to it. Singaporeans are generous and I am sure there are many who will come forward if it is for the low-income elderly. It could be managed by a private/independent body, for example, C3A, and referrals could be from VWOs, FSCs, CDCs and medical social service departments of hospitals. This Fund would be for the needy older people above 70 years, especially to meet their daily and medical needs. A Committee could be set up to review all applications and the process could be made user-friendly. The Fund would symbolise our society's gratitude to the past contributions of our seniors whilst simultaneously respecting their dignity. I sincerely hope that a champion or organisation takes up this idea. And, here, I quote David Gutman who said: "We do not have elders because we have a human gift and modern capacity for keeping the weak alive; instead, we are human because we have elders."

Column: 815

The third and last gap in the social services is in relation to social and health services for people with dementia. The Asia-Pacific report, titled "Dementia in the Asia Pacific Region: The Epidemic is Here" (September 2006), was an eye-opener. It rang an alarm bell for countries in this region to wake up to the need for developing social and health services for this group of people, who are usually elders. Currently, there are 22,000 dementia patients in Singapore and annually 7,000 are being diagnosed with this debilitating illness. In addition to the suffering experienced by patients, their family members also undergo emotional and physical exhaustion.

More day-care centres catering to dementia patients, especially those at the early and moderate stages, are needed. More custom built residential institutions will be required in the future, and a good model is the Apex Harmony Lodge. As a first-world nation, we have to be concerned about quality of care offered in our residential institutions. Singaporeans travel more and they visit other countries and their expectations of holistic care, ie, physical, psychological, social and personal, are increasing. This is reflected in the survey conducted by Tsao Foundation on retirement destinations reported ( Today , 14th August 2008). Almost two-thirds of the sample said they would consider migrating overseas for retirement.

Mr Deputy Speaker: Order. Dr Mehta, your 20 minutes is up.

The Minister, Prime Minister's Office (Mr Lim Boon Heng): Mr Deputy Speaker, I thank Prof. Kalyani for her suggestions, which are meant to be taken as inputs for policy formulation. I am sure that our agencies will study them as they review their policies and services.

Column: 816

Let me first briefly explain our philosophy towards policy formulation and what we do for the people.

We want all citizens to be well prepared for old age. As they age, they should continue to lead active, secure and meaningful lives. Government policies will enable them to do so. But the individual must take personal responsibility on how he lives his life. When he needs care, the family should provide the first line of support. Then comes the community and the State. The role of the State is to support the individual and the family. With this philosophy, we have four strategic thrusts and they are: first, enhance employability and financial security; second, enable ageing in place; third, provide holistic and affordable healthcare and eldercare; and fourth, promote active ageing.

We have paid a lot of attention to ensure that people have enough money for old age. The CPF is the bedrock of our system. We save for our old age. Recently, we have made improvements to the CPF with the introduction of CPF LIFE. Most CPF account holders will get a stream of income for life. The low income are helped to accumulate CPF savings through the Workfare Income Supplement.

Work provides both income and active engagement for seniors. We encourage re-employment. Legislation will be in place by 2012. We are also enabling Singaporeans to unlock the value of their homes if they need more funds in their old age through lease buy-back or change to smaller homes.

A few years ago, we started to modify our environment and public transport so that they are barrier-free. The lift upgrading programme is well underway, and so is the programme to enable buses to take the wheelchair-bound. New HDB apartments adopt universal design.

Column: 817

Private developers are required to follow the new design code. Beyond the physical infrastructure, we are setting in place support systems to enable the elderly to stay with their families in their homes. This includes daycare services, home-help services and caregiver training and respite care. We will be guided by the principles that services should be people-centred, something that may be missing in the Many Helping Hands approach, as mentioned by Prof. Kalyani. For example, a centre for information and referral is being actively studied. And we should encourage various organisations that are providing services to the elderly not to be too narrowly focused.

It takes transport and manpower to deliver a meal. It takes transport and manpower to do home-cleaning services. If they can be combined, I think at least we save on transport. So, I think there is a scope of things that we have to look at when we talk about the people-centred approach to servicing the elderly.

On holistic and affordable healthcare and eldercare – will the elderly be able to pay for medical bills? The 3M framework for healthcare is in place, comprising Medisave, MediShield and Medifund. It is sustainable. Improvements have been made to the system in the past few years and further improvements can be expected. Patients can tap on Medisave to pay for treatment of chronic diseases. The poor are supported not just by polyclinics but also by GPs under the primary care partnership scheme. Currently, polyclinics handle 20% of primary care cases, and GPs handle 80%. We should keep these ratios, and enable the GPs to handle the health problems of the elderly well, so that they do not have to queue up at the polyclinics.

For long-term care, we have ElderShield. ElderShield was enhanced last year to provide better payouts in the event of severe disabilities – $400 per

Column: 818

month for six years. ElderShield is a sound scheme which allows for risk pooling. It allows the elderly and the family to decide how best care is provided. I know that some Members have in this House asked for a caregiver's allowance. This deserves careful study. In an ageing population, many of us will be caregivers. Who should provide such an allowance? We have to be careful about putting a price tag to what is traditionally a family duty. It may lead to unintended consequences. The way forward may be to build on ElderShield. We will study this; in fact, we are studying this.

With respect to caregiver leave, it is not a simple matter. It has to be arrived at with consensus of the employers because quite apart from childcare, eldercare can actually be a more costly item if we provide eldercare leave. So, it is something I would not rule out but we should not rush into.

We are reviewing the provision of rehabilitative services and social daycare, nursing home and caregiver training, taking into account rising demand, and including dementia which is rising in demand as well. I need to mention that home-help services are expensive. There are several service providers, but none have sufficient critical mass to be efficient and that is why the cost is so high. So, I think the way forward is consolidation.

There is a need to change our perception of ageing. According to an international survey, people in Singapore sees 67 as the age when someone becomes old. In the US, the age is 77 or 10 years later. If we remain healthy, there is no reason why we cannot be active until 80. We are old when we think we are old. Having a reason to wake up every morning or leading a meaningful life contributes as much, if not more than a healthy lifestyle. Each of us has to find our reason for waking up – be it work, family or friends.

Column: 819

We set up the Council for Third Age (C3A) to change public perceptions. I think the work is important and therefore the C3A should focus on this task in the next few years.

We are working on a pilot wellness programme. It is aimed at keeping our seniors socially and physically active. It encourages seniors to take charge of their own health and join social interest groups. Such groups can be funded on sports, hobbies or even study. The wellness programme will connect seniors to other seniors and help them lead active and healthy lives. We plan to roll it out to all constituencies after the pilot programme.

With respect to Prof. Kalyani's point about a register for elders living alone, we can do this through the wellness programme and working together with the CDCs. In fact, this is what some of the pilot sites are now doing. I need also to say that if we have seniors engaged with their neighbours, then the incidence of

Column: 820

loneliness and therefore suicides will be less, and the incidence of people dying alone will be less.

But I need to correct Prof. Kalyani who said that the rate of elderly suicides in Singapore has risen. In fact, I mentioned to the press after the Straits Times' report that if we looked at the rate over the past few years, we actually see a gradual decline. So, I think, we should not compare one year versus the next and say that there is an increase. We should look at it over a longer period of time.

Mr Deputy Speaker: Order. The time allowed for the debate has expired.

The Question having been proposed at one minute past Six o'clock pm and the Debate having continued for half an hour, Mr Deputy Speaker adjourned the House without Question put, pursuant to the Standing Order.

Adjourned accordingly at
Twenty-Nine minutes to

Seven o'clock pm.