HEAD O - MINISTRY OF HEALTH

Head O – Ministry of Health

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

Healthcare Policy and Rising Medical Costs

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, MOH’s mission is to provide good quality affordable healthcare to all Singaporeans. Indeed, over the last few years, we have seen significant improvements in our healthcare system, which have made our lives better even as we grapple with the issues of rising costs due to an ageing population, new medical technology and higher expectations. MOH should be commended for these changes.

I am glad to note that the MOH’s budget for this year has increased by 19%. This is a good sign as our national healthcare expenditure of 4% is way below that of many developed countries and, with an ageing population, it will be difficult to maintain even the current level of healthcare service and quality without any increase in the budget. The burden cannot be completely shifted to individuals who are already contributing 41% to the total national healthcare expenditure.

However, I would like to ask the Minister where these additional health dollars will be channelled to? What improvements and changes in healthcare can we expect with this increase? How will the increased budget improve the lives of patients in the polyclinics and hospitals? How would the quality of healthcare in Singapore improve?

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I would also like to ask the Minister, how have we prepared our healthcare system to meet the challenges of a rapidly ageing population and whether part of the increased budget will be used to further develop the infrastructure, systems and services for the elderly. This is a serious problem as our population aged 65 years and above will increase from 8% today to 18% by 2030. The elderly will use between three to five times more healthcare services compared to the younger population and each episode amounts to about two times more than the average cost.

In dealing with the elderly, the current focus of our healthcare system appears to be still on how to manage episodes of acute illness with intensive treatment. But this is not well suited to manage the medical problems of the elderly. The elderly need continuous low intensity medical or nursing care to manage their chronic illness and to enable them to live good quality lives even if they have age-related disability. New alternative types of cost-effective community-based long-term care, including hospice and home care, will have to be further integrated with health-care financing. I hope to hear the Minister’s response on this as well.

Sir, Singaporeans are concerned about rising medical costs. Last year, medical inflation went up by 6.2%, almost three times the rate of the general inflation rate. Over the last two years, the average hospital bills have gone up by 10% to 30%, and it was the C class wards which had the highest percentage increase. Those who stayed in the C class wards now pay an average of $1,112, 30% more than the 2005 average of $858. Last year, a Tan Tock Seng Hospital survey among 200 patients with chronic conditions found that one in five among them failed to keep up with their medication because they cannot afford it. A 2007 of The New Paper poll among 125 people aged 18 to 65 years revealed

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that two-thirds worry about medical costs for serious illness or accidents.

Sir, addressing these concerns of Singaporeans are important. Equally important is how to help Singaporeans better plan for and manage their own healthcare needs. One great lapse in planning is the absence of insurance coverage or insufficient coverage by many Singaporeans. 200,000 housewives, for instance, are not covered under MediShield and a significant number are under insured as far as MediShield is concerned. This is certainly one area that we need to pay greater attention to in the years ahead.

I would like to ask the Minister what steps are being taken to control increases in medical costs. Efforts are being made to control demand for medical services through means testing and co-payments, for instance, and the supply of medical services, such as through the control of the number of doctors, but the public also need to know what is being done to control medical costs. For even if medical services are highly subsidised, if the portion that people have to pay keeps on increasing, the overall cost to them will continue to go up.

Health Care Costs

The Senior Parliamentary Secretary to the Minister for the Environment and Water Resources (Dr Amy Khor Lean Suan): Sir, while one can discern lifestyle factors like poor diet, stress and lack of physical exercise as the causes behind sicknesses, ill health can strike anyone, male or female, young or old, rich or poor. Hence, healthcare strikes an uneasy chord with everyone. Furthermore, many baby boomers, like myself, now have aged parents who are suffering from some chronic or critical illness. Soon, I too will enter the exalted ranks of senior citizenship. I also need to worry about the state of my own health. What is the

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use of a long life if it is not lived healthily and what is the use of a lifelong annuity if so much of it goes towards paying medical bills.

Recent changes to MediShield to reduce co-payment by patients and Medisave to cover outpatient treatment of various chronic diseases are welcome. Nonetheless, more needs to be done to further reduce co-payment by patients. We should also examine ways to allow claims for other chronic and debilitating diseases, such as dementia and Alzheimer, which strike many elderly and exact a large toll on caregivers. I understand that drugs prescribe to treat these ailments are not subsidised at all, even for Class C patients. Moreover, means testing will soon be introduced. The Health Minister's assurance that MOH will err on the side of generosity has yet to completely allay the fears of the middle-class who expect to be most affected by it.

While many are relieved that they will be allowed to choose the ward class they desire and still enjoy some subsidy, albeit a reduced one for Class C and B wards, they nonetheless have concerns about the actual implementation details. The biggest concern are for those who stay in private property and earn a salary above the maximum qualifying income to enjoy the full subsidy, but who may actually have many dependants and financial commitments. In practice, they may not always be better off than their compatriots staying in public housing.

The question is, how compassionate and flexible would the hospital be in handling such cases? Can an independent appeals board be set up to look into such cases on appeal? For consistency, these appeals board could handle cases from all public hospitals. To allay unnecessary anxiety of the patient and his or her

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immediate family, the appeal should be expeditiously resolved.

Additionally, as a Straits Times article suggested, a fund for bridging loan could be set up for families adversely affected by hefty medical bills and yet do not qualify for Medifund. This will allow them temporary reprieve to sort out their financial problems. There is also feedback of unsympathetic rules relating to transfer of patients from one class ward to another. Recently, a friend of mine shared that his mother-in-law who was suffering from advanced stage cancer was warded in Class C. Towards the end, they transferred her to Class A and then they were told that all their bills for non-ward charges had to be backdated based on Class A ward. The question is, why should the non-ward charges be backdated since they had, prior to the upgrade, not enjoyed any of the high class services and it was only out of convenience for the family members that they had decided to upgrade?

Healthcare Financing

Mr Yeo Guat Kwang: ( In Mandarin ): [For vernacular speech, please refer to Appendix A.] Medical cost and medical expenses have become a cause of concern of our people. Our Health Minister has already announced that this year, he is going to extend the MediShield protection to cover 80% of the high hospitalisation expenses. We hope this can be implemented quickly.

Everybody needs healthcare protection. So everyone must be insured, including their family members, and it is good that our medical insurance is an important part of our social security net. We must let all workers understand the importance of insurance. Therefore, I propose that NTUC, CASE and GIA promote awareness about the medical insurance through a national medical insurance education, and also to insure

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themselves and their families as early as possible. Because of ageing and changing medical conditions, one day our people may become uninsurable and they will be rejected by an insurance company. Also, we must include the housewives under the MediShield scheme.

Just like the Singapore Fire Service, they have adopted a different strategy, that is, they have changed their strategy from extinguishing fire to preventing fire. Similarly, in our healthcare financing, we should shift our focus to promote healthy lifestyle and preventive healthcare measures, because prevention is better than cure. Therefore, it is more effective for us to promote healthcare development and let our people watch out for their health, rather than increase the number of hospital beds and increase the subsidy. So we must help our people monitor their health risk and advise them to be careful of their physical health. According to statistics, the number of diabetes cases has risen from 4.7% in 1975 to 8.2%. Therefore, we should help our people stay healthy so that they will not cause a burden to the society.

*Cols. 1801-1802.

Means Testing

2.30 pm

Mdm Halimah Yacob: Sir, the problem is not with means testing per se , but with the implementation. I urge the Minister to ensure that the implementation of means testing will be equitable, efficient and effective. Let me touch on three points.

First, the cut in the subsidy levels for different categories of patient and ward classes should be fair and affordable. Here, I urge the Minister to err on the side of generosity when he decides on where to draw the line, to ensure that the majority continues to receive the same level of subsidies as they do today and will not be affected.

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Second, ensure that the entire process is seen to be fair and transparent. It should not discriminate against the disadvantaged and add to the financial burden of those in poor health. Rules should be flexible in marginal and exceptional cases.

Third, the testing mechanism should be administratively simple and not time consuming and costly.

But even as the Ministry of Health focuses on means testing for better cost recovery and allocation of scarce resources, I urge the Ministry to also look at other areas to control cost and ensure that healthcare remains affordable. I urge the Ministry to pay special attention to housewives as 200,000 of them are not covered under Medishield.

In conclusion, Sir, I would like to ask the Minister to give us an update on means testing, particularly the details such as the income levels and levels of subsidy for the different categories of patients and ward charges. Also, could the Minister inform this House when will means testing be implemented?

Ms Sylvia Lim (Non-Constituency Member): Sir, on 7th January, Health Minister gave a keynote speech at Changi General Hospital. Means testing for hospitalisation was touted as the way to go to address two issues - one, the issue of fairness in distributing health subsidies; and, two, to meet rising expectation for better services from all patients, rich or poor. Sir, I find the justification for means testing not convincing and somewhat contradictory.

First, the issue of fairness. According to the Health Minister, it becomes unfair when high income patients begin to occupy subsidised beds. An over crowded Class B2 or C ward will come at the expense of low income patients who

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do not have the means to afford an alternative ward. But the question is: if it is expected that there will be over crowding in our subsidised wards, is this due solely to the presence of high-income patients? As our population ages, demand for hospitalisation will legitimately rise. What about the high growth rate of our foreign population welcomed into Singapore to churn our economy? Have our social services, including healthcare, kept pace with these trends? The Government has to address these fundamental issues before asking working-class Singaporeans to go and pay more for such an essential service as hospital care.

The second reason given by the Minister is that in efforts to meet rising expectation for better services, MOH is improving the standard of physical facilities in subsidised wards to be as good as Class B1. Inevitably, by doing so, it will attract more downgraders. Let me quote from the Minister's speech:

'With such marginal difference in ward facilities and while fees in Class B1 are more than double those in Class B2 and four times those in Class C, we expect many patients who would normally choose B1 to now choose B2 or C.'

The question then is: why would MOH want to introduce means testing to address an issue that is itself self-creating in the first place? Since clinical care in all wards is of a high standard, do we need to add non-essential creature comforts for highly subsidised wards? Somebody has to pay for this and, more likely than not, the patient will end up paying for it. Would it not be prudent for MOH to manage expectations rather than to raise them and increase cost unnecessarily? I believe most patients in Class B2 or C wards will understand why they will not

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be getting the same comforts or are not able to choose their doctors, unlike those in other wards.

It has been argued that means testing is already implemented in public housing. So, why not for hospitalisation? There is a significant difference. Households earning $3,000 or less are entitled to a 3-room flat, while those earning under $8,000 qualify for a 5-room flat. Those with higher incomes get less subsidies, but their flats are bigger which they can also monetise and sell for more. Public housing is touted as a way to build up wealth for the future. Thus, means testing for public housing based on market subsidies is still quite acceptable to people.

Sir, the root of this means testing should be about whether there are some baseline expectations which Singaporeans should have of the Government. What essential services should we expect to be available to everyone equally, regardless of means? For instance, when it comes to education, all Singaporeans can have their children educated in the mainstream schools. Education too is a heavily subsidised item, but everyone, rich or poor, pays the same fees for basic primary or secondary education. Why is the Government not pushing for means testing in mainstream education then, with children paying fees on a sliding scale, depending on household income? Could it be because the Government sees education as an investment while hospitalisation is seen as a liability?

To paraphrase the words of the Health Minister, everyone needs healthcare most towards the latter part of his life, when he or she is not at the peak in earnings. Means testing for hospitals will create a lot of uncertainties for many citizens at a time in their lives when affordability of healthcare is most critical. Singaporeans should not be subject to such anxieties.

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Mr Siew Kum Hong (Nominated Member): Mr Chairman, Sir, MOH will be introducing means testing this year. I strongly support the principle of subsidies being channelled such that those who need more help will get more. This is a sound principle. It is fair and equitable, and must be beyond question. But as with all things, the devil is in the details.

I would like to touch on two aspects. Firstly, the proposed method for assessing income. To keep things simple, MOH intends to use personal income for those who are working and housing type for those who are not. Sir, I touched on this when I spoke on the Budget Statement. This will effectively penalise households with a low per capita income, in particular, higher income earners with big families and multiple dependants. The Minister has said that the implementation will be flexible and will allow for special deserving circumstances. For instance, hospital medical social workers will review the cases of those with a large number of dependants. But this results in uncertainty and delay, which are the very drawbacks that the simple system was supposed to address. I think most people would agree that, in principle, household per capita income is a better indicator of neediness than personal income or housing type, and I believe that this can be implemented.

Sir, IRAS records data on declared wages as well as all tax reliefs claims. The tax reliefs claim by a person would be objective evidence of the dependants in that household. The declared incomes of all persons with the same address can then be aggregated and used to calculate the per capita for that household. IRAS can do this and maintain a back end system storing the means tested status of Singaporeans, which hospitals can then access to ascertain patients' means tested status. For those who do not file returns or pay taxes, they can be asked to file returns to claim the dependant's tax

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reliefs they are eligible for, for purposes of means testing.

Sir, I would now like to touch on the savings from means testing will be used. It does not seem that the current subsidies for Class C and B2 wards will be increased. Instead, the Minister intends to upgrade the quality of these wards. I strongly urge the Minister to reconsider that decision. Do we really need to close the gap between the different classes of wards so much? I think most Singaporeans would prefer to maintain the current gap between Class C and B2 wards over having means testing. Instead, I think there is a strong case for increasing the subsidy for Class C wards for the lowest income. Using the cost savings to give more help to the neediest Singaporeans is a much stronger justification for introducing means testing. Just as there will be a sliding scale of decreasing subsidy for those above the 50th percentile, we can also introduce a sliding scale of increasing subsidy for those below, say, the 25th percentile for Class C wards. Or if it is difficult to get accurate data for these income groups to identify their percentiles, then perhaps we can simply provide a higher subsidy for those living in HDB rental flats or 1- or 2-room flats. This will maintain the economic principle of co-payment while ensuring that those who need the most help do get it.

Dr Ong Seh Hong (Marine Parade): Sir, I declare my interest as an employee of a step-down care hospital.

I support the Health Ministry's plan to implement means testing in the restructured hospitals to better allocate limited healthcare resources. However, from all that have been reviewed, the new model of means testing in restructured hospitals will be substantially different from that currently used in the step-down care setting of community hospitals, chronic sick hospitals and nursing homes.

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The proposed new model for restructured hospitals will be more generous to allow high income patients from the top 20% to remain heavily subsidised if they choose B2 or C wards, whereas anyone with per capita household income of more than $1,000 now is not subsidised at the step-down care. The new model will have a gradual sliding scale of subsidy with reduction in 1% point from 80% to 65% in a C Class ward, and from 65% to 50% in a B2 ward. Whereas the reduction in the step-down care now is much bigger, at 25%, and the subsidy is set at 75%. 50%, 25% or 0%. The new model will be based on the patient's declared income as the sole criterion, whereas the step-down care currently looks at the income of patients and all immediate family members as well as the ownership of major assets.

Sir, we can see that the new model is simpler, easier to implement and more generous, but yet it remains fair to some extent. Therefore, I urge the Ministry to consider using the new model, if possible, or something similar to this model that we are talking about, for both restructured hospitals and step-down care facilities. This will minimise confusion to the public who see the two hospital systems as one and the same of a public healthcare system. Having one model will also mean that patients need to be tested only once and, hence, reducing duplication or administrative work at the step-down care. One model will also prevent the occurrence of situations where a patient could qualify for subsidy in restructured hospitals but not in the step-down care. When such a situation arises, the patient may refuse to be transferred to the step-down care facilities, and it will result in choking and wastage of acute hospital beds.

Sir, what has been revealed so far about means testing at the restructured

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hospitals has allayed some of the initial public anxieties. The Ministry should now follow through to make sure that the means testing system in our healthcare system is simple, clear and unambiguous, a system that is seamless and allow patients to move between restructured and step-down care facilities easily and readily, and means tested only once.

Mr Low Thia Khiang: ( In Mandarin ): [For vernacular speech, please refer to Appendix A.] Sir, during the 2006 General Election, I asked the Government whether it would implement means testing. The Health Minister's answer then was that he had not thought about the question. However, he has now decided to implement means testing. The questions we should focus on are:

(1) As a matter of principle, is it correct? Hospitalisation is a critical need of the people when they fall sick, which must be assured. It is just like defence which is the security safeguard critical to the people. Thus, all male citizens have to fulfill National Service duties. Regardless of whether one perceives himself to be fit enough or to have the capability to become a soldier, he will be enlisted into NS. Similarly, the Government has the same obligation, based on the same principle to provide a medical safety net to the people.

(2) Who should decide the affordability level of medical expenses? Means testing deprives Singaporeans of the right to determine for themselves what they can afford for hospitalisation. This is a fundamental change. Currently, patients evaluate their own financial situation to decide which class of hospital ward to be admitted to, as the Government subsidies are simply based on different classes of hospital ward . With means testing, even if a patient feels that he cannot afford the medical expenses and decides to be admitted to C class ward, the Govern

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ment will use means testing to prescribe his capacity to pay and determine that he pays higher medical fees.

(3) What is the motive for implementing means testing? The purpose is to allow the Government to justify reducing healthcare subsidies in the name of charging patients based on affordability. The outcome must be that some patients or, in the future, perhaps most patients who are admitted to Class C and B2 wards would be paying higher medical fees.

Presently, a patient can decide which class of ward to be admitted to during hospitalisation and the Government subsidies are in accordance with different classes of hospital ward. This is the last line of defence in our social safety net and a critical safeguard in healthcare for Singaporeans Implementation of hospitalisation means testing will surely increase Singaporeans' anxiety over the lack of social security in life.

*Cols. 1803-1804.

Mr Ang Mong Seng (Hong Kah): ( In Mandarin ): [For vernacular speech, please refer to Appendix A.] Mr Chairman, I want to suggest the repositioning of the means testing survey for the Class C patients. Class C is the focus of the means testing survey. Under Class C, there are basically three groups. For the first group, the Government will subsidise 80%. For the second group, they will be subsidised 66-79%. For the third group, they will only be getting 65% subsidy. So this is a new system and grouping distribution. The Minister has conducted a lot of seminars and dialogues to share with our people the long-term plan, and he managed to get the people's understanding and support.

Now, the Ministry has to reposition the Class C wards. They must have a comprehensive and fair distribution method, in order for people to use it practically and adopt this Class C policy.

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I suggest that the name "C Class" be changed to "E Class" in order to improve its overall image and to get better support.

To some of us, the Class C ward is all right but some patients and their family members are very superstitious and sometimes they do not even mention the letter "C". Recently, I met an old lady whose husband was sick and had to be hospitalised. I asked which ward he was staying in because I might be able to visit him if I had time. She said in Teochew , "A lot of people stay together in the ward." So I said, "Oh, it is a C class ward." She said, "Don't talk about it. The letter "C" in dialect is bad luck." In fact, the implication of this letter "C" in our Oriental society, especially Singapore, is very sensitive.

For example, Japanese car name, like Honda Concerto, in Hokkien , it means "company collapse". Therefore, the businessmen do not buy it and the Alpha Romeo 164 model in Hokkien means "die all the way". Therefore, nobody dares to buy it. Later on, they changed the name to Alpha Romeo 168. It means "prosperity all the way". Similarly, after changing the name, if the cars are selling like hot cakes, it shows that people are generally affected by the names. It is business and cultural sensitivity and we must suit their need and change their mindset. Therefore, I suggest that we change the name "C Class" to "E Class", just like the Economy Class in an aeroplane. So, these are the three categories. It can be set as E1 Class, E2 Class and E3 Class, and each category receives different amounts of subsidies. If you choose a good name for the class, it may help reduce the psychological burden and worries of the patient. If the name is right, people will feel good and it may help them recover faster.

*Cols. 1805-1806.

Mdm Ho Geok Choo: Sir, I agree with the means testing proposal in principle.

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With this proposal, the means test will be less mean. The means test will use the patient's average monthly income as a criterion if he is working. If he is not working, the criterion will be the housing type.

Sir, as for the reduction in subsidy for higher income earners for B2 and C wards, one wonders whether this will really deter them. The overall reduction in cash terms may not deter those in the top 20th percentile of income earners, though it may deter those between the 20th and 50th percentile. Perhaps a better gauge of financial ability would be the household income per head. This would be more accurate in determining if a subsidy is necessary. A patient earning $3,000 a month, for example, may have children and parents to feed as well. He may not even have medical insurance. To deprive him of subsidies because he is not in the bottom half of all workers will be counter-productive to the aims of the subsidies in the first place.

Another problem relates to the choice of criteria for means testing for the unemployed. Housing type may not be the best indicator because some Singaporeans may be asset rich but cash poor. These Singaporeans may also need help from subsidies to get by.

Today, healthcare costs are rising at a time when we are implementing a means testing system. Can the Ministry conduct a study on the cost breakdown in healthcare for us to better understand what are the contributing factors to healthcare costs and formulate cost-cutting measures accordingly?

Means Testing and the Disabled

Ms Denise Phua Lay Peng (Jalan Besar): Sir, I believe there is a need for an overall means testing framework for public

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services so Singaporeans can know what to expect. The framework should clarify the assumptions of what the extent of State responsibility is. How does Government decide when means testing becomes applicable for what are considered traditionally basic State responsibilities? How can Singaporeans be assured that with similar rising costs, other essential services such as education, defence, security and use of public amenities will not one day be subjected to means testing?

Sir, the different ways by which means testing is applied in the various public programmes should also be rationalised and made clearer. Currently, each Ministry decides when and how means testing is applied. Hence, for public housing, only those earning below a total household income of $8,000 are eligible. For MCYS' social services programmes, different per capita income criteria are applied and now the Health Minister has mentioned at a public forum that he is looking at a more lenient income range. Sir, lest it be mistaken that it is up to the imagination of each Minister, a formula by which eligibility and corresponding subsidies are fixed should be developed and communicated in the means testing framework.

Lastly, Sir, whilst I appreciate the Health Minister's desire to keep the means test simple, it must not be so simplistic that it ignores important considerations. The Minister has mentioned about the use of a simple means test that looks at the patient's average salary in the last 12 months or his housing type. Social service experts have long found that means testing based on per capita household income is a fairer formula. For example, the financial burden on a Singaporean with a monthly income of $5,000 supporting three children is clearly heavier than if he is childless or has only one child. Also, on behalf of the disabled community, I ask

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that extra marks be given in the means test to young and old Singaporeans who are disabled and are not eligible for any medical insurance relating to their disabilities. They should not have to suffer the double whammy of being excluded from medical insurance related to their disabilities and then undergo means testing as well.

I urge the Minister to pilot the administration system first before implementing the means test system.

MediShield Coverage for those above 85 years of age

Mdm Halimah Yacob: Sir, currently, MediShield covers only up to the age of 85. I would like to ask the Ministry to consider increasing this age limit for MediShield coverage to be more aligned to CPF LIFE.

In the debate on CPF LIFE, we have heard that Singaporeans are living longer and would therefore have to save more for retirement. But equally urgent is the need to make sure that we are adequately covered for our medical needs during our old age. A person could have a retirement income but that will do him little good if medical bills erode all his savings. This will surely happen if he does not have an insurance covering him beyond 85 years of age.

It is clearly incongruent, in my view, for us to worry about someone's retirement income after the age of 85 but to be less concerned over whether or not he can afford to pay his bills after that age. In fact, a recent Ministry study shows that while Singaporeans are living longer, they will also spend the last eight years of their life in poor health. So, Sir, I urge the Ministry to remove the age cap of 85 years on MediShield.

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Manpower Numbers and Projection

Dr Fatimah Lateef (Marine Parade): Sir, currently, there are about 7,000 doctors or, to be exact, 6,931 from the 2006 statistics in Singapore. This will give us a doctor to patient ratio of 1:650 or we have 1.5 doctor per thousand population. As a comparison, Australia has 2.9 doctors per thousand population; USA has 3; Japan has 2.1; and New Zealand has 2.2 per thousand population. With the annual numbers of our medical school graduates from NUS and a small contribution from the Duke's Medical School, which is more of a research based education, how will Singapore plan to recruit more doctors, including some from foreign sources? I realise there are already efforts going on to bring back some of our own medical students and doctors trained overseas. These projected numbers of doctors will become important in the coming 10 to 20 years as we deal with a population that is ageing rapidly, living longer and with a higher incidence of chronic illnesses as well. Certainly, standards of care and performance will have to be maintained and upkept as well.

Manpower Development

Mr Zainudin Nordin (Bishan-Toa Payoh): Sir, I am glad to note that the Government continues to invest heavily in healthcare. As announced in the 2008 Budget, we are investing $900 million over the next five years to improve the infrastructure and facilities. In addition to that, we have also allocated another $1 billion to be spent over the next five years for the recruitment and training of healthcare professionals in the public sector. I believe this is a step in the right direction, especially when we know that the life expectancy of Singaporeans continues to increase. We have to be ready with infrastructure and medical professionals to handle the increase in the senior population.

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The elderly have many medical needs of varying dimensions and their care requires a multi-disciplinary healthcare team. Our ageing population would have serious implications for the number of healthcare professionals required. In 2003, when the proportion of Singapore's population aged 15 years and below was 21% and that above 65 years was 8%, there were 184 pediatricians and only 32 geriatricians. However, by the year 2015, both Singapore's population aged below 15 and above 65 is projected to be around 19% each, making the proportion of younger persons to older persons equal. This means that we will have a higher demand for geriatricians, nurses, physiotherapists, occupational therapists, speech therapists, dieticians and medical social workers. Are we doing enough to recruit and train the medical professionals to meet this demand. Are our local universities conducting the post-graduate courses in these relevant fields?

I am also concerned that the booming health tourism industry will result in the migration of doctors, specialists and other healthcare professionals from the public to the private sector either within Singapore or internationally. The needs of public healthcare professionals have to be looked at seriously to avoid a shortage in the future. In addition to providing attractive remuneration, we should also look at their career path, training and development needs to retain the professionals within the public sector.

The Chairman: Order. I propose to take the break now.

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

Mr Speaker: Order. I suspend the Sitting and will take the Chair again at 3.20 pm.

_Sitting accordingly suspended at
2.58 pm until 3.20 pm.
_

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Sitting resumed at 3.20 pm

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[Mr Speaker in the Chair]:

[Mr Speaker in the Chair]: Debate in Committee of Supply resumed.

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[Mr Speaker in the Chair]

Head O – Ministry of Health (cont.) –

The Chairman: Head O – Ministry of Health. Mr Khaw Boon Wan.

The Minister for Health (Mr Khaw Boon Wan): Sir, last year, Er Lee Bee Wah nearly brought the House down with a colourful Hokkien proverb. She wanted to stress the importance of forward planning and preparing for the future. In ancient China, the Prime Minister of the State Qi ( chun qiu shi qi qi guo ), Guan-Zhong put it strategically: "yi nian zhi ji, mo ru shu gu, shi nian zhi ji, mo ru shu mu, zhong shen zhi ji, mo ru shu ren. " Guan-Zhong's political thought is that public policies must look far beyond one or even 10 years as affairs of the state impact people's lives and one important public policy is to nurture talent and cultivate people. I try to bring this philosophy into my work.

As Health Minister, my job is to look at healthcare, not just for today or tomorrow, but over a much longer timeframe. Within a few years, I would be retired and potentially become a customer of healthcare providers for the subsequent 20 years, like Dr Amy Khor. To me, health policies are not drawn up in a vacuum or just about focusing on numbers. Health policies are about creating a good healthcare system that is sustainable and relevant to real people, like you and me.

I have some advantage of a long association with the Health Ministry. I had the opportunity to study other healthcare systems and think through

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many issues. There is no perfect healthcare system, but there are positive elements in some which can be incorporated, just as there are clear pitfalls we must avoid. Health policies need a long lead time to see results. And as healthcare is an emotive subject, we need to consult the people widely and patiently with every policy change. So a radical, big-bang complete overhaul approach to healthcare reform is not advisable. Instead, it is through a series of deliberate, carefully considered incremental policy changes over many years that we can build a sustainable healthcare system. And that is how we have built up our 3Ms framework over 25 years and how we are continuing to make it stronger.

As a result, Singaporeans can be proud of our healthcare system. It is far from perfect. But the World Health Organisation has rated it No. 6 in the world. It has enabled Singaporeans to enjoy the high standard of care. With less abuse in the system, our health spending at below 4% of GDP is the lowest among developed countries. And we should try to retain this ranking.

Hence, we continue to build for the future. Last year, I announced a 10-year capital development plan, costing $2 billion. This will expand our capacity further. We are busily implementing this plan.

Like Mdm Halimah, Mr Yeo Guat Kwang and Dr Amy Khor, I worry a lot about rising healthcare costs. Our population is expanding and rapidly ageing. New technology is generating more sophisticated treatment which is almost always more costly. There is a big debate right now in US and UK over this new drug calls Avastin, which is for treating late-stage breast cancer. It is not a cure but some studies show that it could prolong the life of a patient by about a couple of months. But it comes

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at a huge price tag: US$100,000. Many families will be financially ruined just to try to extend the life for a few weeks, with much suffering for the patient. But two weeks ago, US FDA against expert advice approved the drug for late-stage breast cancer. Immediately, on the same day, the share price of the company went up 8% against this current sub-prime concern and possible economic recession.

Back here, in Singapore, we know we need to improve the doctor-to-patient ratio to allow enough time for each patient. Our doctors and healthcare professionals are over-worked, and they need a life too. I know our Director of Medical Services, Prof. Satku, is sleeping less and less, juggling between his surgeries at NUH, meetings at MOH and with international counterparts. And the situation is the same with the other senior consultants – Prof. Tan Ser Kiat at SGH, Prof. Philip Choo at Tan Tock Seng Hospital and Prof. Benjamin Ong at NUH. But it is not just the senior consultants. Our young doctors too are also working day and night to meet the needs of increasingly more demanding patients and relatives. I am sure Dr Fatimah Lateef, Dr Lim Wee Kiak and Dr Lam can testify to this. And some of the parents of these young doctors are in this House too. I doubt you see much of them at home.

Doctors like everybody else would like to enjoy a better worklife balance but the patients just keep coming, and not just local patients. An increasing number of foreigners are coming here for treatment. This is good for the economy, for the hotels, and a testament to our high standard of care, but it does put pressure on manpower. At least two new private hospitals will open in three years' time. We will face a worsening staff shortage. Our specialists are trained at top centres around the world and they are much sought after. We need to ensure our remuneration packages are competitive to retain this key talent.

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And it is not just our doctors we try to retain. This is a point that Mayor Zainudin mentioned. The booming hospitality sector driven by the IRs will put great pressure on other manpower. They are poaching not only from the zoo, but poaching from the hospitals too. Healthcare workers are going to have other opportunities outside healthcare. And we need to keep them at least to retain a fair share of them in healthcare with comparable pay and working conditions.

That is why I have sought a substantial increase in budget. As noted by Mdm Halimah, this Health budget will go up by 19% over the last budget, a significant increase of $421 million.

It will fund both hardware and software and more initiatives to improve clinical outcomes and increase productivity. Our bed-to-population ratio will go up from 1.6 to 1.8 (per 1,000 population) by 2015, but it will still be lower than the rates in other developed countries today. We will also watch over our average length of stay in the acute hospitals which, at 5.3 days, is among the lowest in the world and must remain so. This means that a patient who is medically fit for discharge must vacate his bed to go home or to a nursing home, if necessary. Over the break, I had an interesting conversation with Mdm Cynthia Phua over an incident of a friend or relative who was being asked by a hospital to go home. And this is the reason. We need to price our hospital facilities correctly, so as to discourage unnecessary prolonged hospitalisation.

Dr Fatimah and Mr Zainudin stressed the importance of getting more manpower to cope with rising demand, and I fully agree. That is why we are spending $1.9 billion over the next five years to expand our pool of doctors, nurses, pharmacists,

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physiotherapists and other allied health professionals by 40%. We are actively recruiting from abroad to supplement the local pool, and we have some success to report. Last year, for example, NUS graduated 230 doctors. But we recruited 438 doctors, almost double, who graduated overseas, largely from our approved list. These are good medical schools. The increased budget will also allow us to double the number of scholarships for the allied health professionals to 120 this year. We are starting a new scholarship to sponsor some graduates from Nanyang Polytechnic to pursue a one-year degree conversion course overseas. Many are doing physiotherapy diploma and they want to go to Australia, one year conversion course, and come back with a degree. So I thought, let us offer the best students scholarships each year, say, a dozen or two and we can always ramp up the number later. We can bond them to return to work in Singapore.

These increases should lead to better service levels, but they will also add to our costs. Our health spending will go up from 4% of GDP to 5% or 6% in the medium term. They will also fuel healthcare inflation, which Mdm Halimah, Mr Yeo Guat Kwang and others expressed a lot of concern about.

In the previous Parliament sitting, I have explained the high healthcare inflation in Singapore in the past one year. At 6.3%, updated to 7.4% recently, it was exceptional to the norm of about 2% per annum for several years. And there were several contributing factors to this exceptionally high rate. Huge imported cost increases were a major factor, pushing up prices of medical supplies and medicine, both western as well as traditional Chinese medicine. Those of you who are familiar with cordyceps " dong chong cao" will know how much it has gone up – mind boggling! It just reflects the rise of the middle class in

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China itself so that there is strong demand for this limited supply, and prices go up.

The imported cost increase have affected the private sector. Last week, I heard Dr Ahmad Magad relating a personal experience when his daughter was hospitalised.

He said he almost fainted when he received the bill – more than $2,200 for a two-day stay. I did some mental calculations. It cannot be a public hospital. So I queried him during the break and asked him, "Which hospital did she go to?" "A private hospital", he said. Public hospitals are not spared such imported inflation. But part of the cost increases is also due to higher public expectation and their demand for higher-end care. Just now, Ms Sylvia Lim said that we should not raise public expectations. I agree. As a strategy, I would be the last one to want to fan up public expectations. But I cannot ignore rising public expectations. Her message to me just now was to keep still. Enough Class C, remain like today, or even scale back so that it is absolutely no frills, very basic. Do you think Singaporeans will agree and say, "All right, let us do it, scale back, and we go back to the Class C of 1970s"? I do not think that would be the case.

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So, while we should be the last one to want to fan up public expectation and will constantly remind Singaporeans: please moderate your expectations because the higher your expectation, the higher must be the cost. While we will bear most of the cost, you have to co-share, too. So, it cannot be just keep on raising public expectation and demand without wanting to pay something for the additional cost that will be incurred.

Let me give Members an example: attendances in our Emergency Department. I have been tracking this number

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because it has been worrying me for quite some time. Last year, the number went up 11%, a very high rate. In the previous three years, the rate of increase was 7%, which had already alarmed us because it was higher than the previous 10-year average of 4.5% per annum. What is happening? Our population is not growing at 7% or 11%. Are Singaporeans getting sicker? Are we getting into more accidents? Or are we now rushing to Emergency Departments too readily and perhaps unnecessarily? There is therefore a need to price our services properly so that we do not inadvertently attract non-emergency patients to our Emergency Departments. Non-emergency patients should go to their family GPs. Every Singaporean must have a family GP to whom they consult all the time, who knows their whole family well. They should not rush to Emergency Departments and compete for the resources which are really meant for the critically ill.

We will do our best to manage cost escalation, difficult as it is, and during this period of high inflation, our public hospitals will be particularly careful. They cannot freeze their charges, because imported inflation will have to be passed through. So for expensive drugs - unfortunately, the tender price has gone up - the fees have to go up. But they will not add to other cost increases unnecessarily. They will also play their part by promoting greater use of generics instead of brand name medicines, and standard medical supplies instead of non-standard appliances like stents or implants. And they will help the patients to get treated at the right settings. For these, our hospitals require the cooperation of our patients.

Indeed, in healthcare, patients have a big part to play. How?

First, stay within our 3Ms framework. Contribute to Medisave. All employees

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do, because it is compulsory. Otherwise, we will take the employers to task. But many self-employed and casual workers are still not regular contributors to Medisave or are not contributing enough. We must persuade them to do so and do more for their own good and the good of their families. And let us not forget the housewives too. Husbands should help contribute to their Medisave accounts. CPF Board has a voluntary contribution scheme and, now, there are some tax incentives that go along with it. I urge all husbands to top up their wives' Medisave accounts, especially if they are full-time homemakers. I think this must be one of the basic duties of husbands, and we should remind them.

Second, subscribe to MediShield. I totally agree with Mr Yeo Guat Kwang that all Singaporeans should subscribe to MediShield. It is as simple as that. Every one should have MediShield at least. Nearly 80% of Singaporeans do, fortunately. But what about the remaining 20%? They must come in too. Big numbers of uninsured are young kids. So, last December, we changed the rule. Now, all newborns are automatically covered. We are working with the CPF Board and the Ministry of Education, and we will proceed to sign on all the students who are in schools. In addition, we are working with NTUC, especially with Mdm Halimah, to get workers to buy MediShield for their spouses. This is the second basic duty of husbands. Get them MediShield. Through these efforts, we aim to raise MediShield coverage, first, to 85%, and when we arrive, we will shoot for 90%.

Third, the middle and high-income Singaporeans should top up their basic MediShield with riders. Basic MediShield is not enough for the middle and upper-income group. So, buy MediShield but also top up with a private rider, which is

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provided by so many private insurers, because that will then enable you for admission to private hospitals, Class A/B1 wards. MediShield is designed only for Class B2/C. It is not designed for private wards. Many Singaporeans are still under-insured, probably due to inertia or possibly ignorance. So we will continue to educate them.

The Government, of course, will do its part.

First, we are strengthening Medifund and Eldercare Fund. This year, the $600 million top-up to these funds will provide our hospitals, community hospitals and nursing homes with more funds to help patients who need additional assistance.

Second, I am finalising the details of the next reform to MediShield, to further improve its coverage of large B2/C bills. I welcome Mr Yeo Guat Kwang's strong support for the proposed reform. This is taking some time as we are trying to keep premium increases as affordable as possible, while increasing the payout to cover, I hope, nearly 80% of large bills. But these are two contradictory objectives.

For most of the age groups, balancing these objectives is not too difficult. But for the very old, especially those above 80, this is simply not feasible. We are making our actuarial consultants earning their consultancy fee by doing many iterations. I want to see whether we can find an optimal point for the trade-offs. But no matter what, the old will have to face a larger premium increase. To help them cope with this, the Government will be topping up the Medisave Accounts of elderly Singaporeans. With this top-up, combined with the MediShield loyalty discount, an affordable package may be possible. I target to finalise the details next month. We will time the Medisave top-ups to precede the implementation of the MediShield reform.

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Mdm Halimah suggested that we raise the maximum coverage age for MediShield. It was raised to 85 in 2006. We will review this periodically. But we do need time to gather more local data to correctly establish the premiums for those in higher age groups, taking into account the prevailing life expectancy. Later, during clarification time, if Mdm Halimah would like to, we can have some discussions over this very difficult topic. It is not simple. It is not straightforward like, "Let us just raise the maximum age." It has to do with critical size, ie, the size of the risk pool. When the risk pool is too small, the premiums will have to be very high. I have checked the numbers. Those who are more than 80 today, in MediShield, number only a few thousands and they are largely the very sick ones. That is the problem.

Above all, the main strategy to help lower-income Singaporeans cope with rising healthcare cost is our heavy subsidies for Class B2/C patients. At 65% or 80% of cost, these are very large subsidies. Last year, direct subsidy for these patients was $1.5 billion. This year, very likely, it should exceed $1.7 billion. Indeed, the bulk of the budget increase will go towards caring for subsidised patients.

The question is: who should constitute "subsidised patients"? Who are Class B2/C wards created for? I put these questions forward during my public dialogues recently. The vast majority of the participants were clear in their reply: Class B2/C should serve the bottom 20% or at most 30% of Singaporeans. In fact, this used to be the case when I started my career in the Ministry of Health exactly 30 years and three days ago. When we first started, Class C beds were clearly for the poor, at the bottom 10% or 15% of Singaporeans, and they were furnished as such. But over the years, with rising public expectations, we

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improved Class C wards and services, more lower-middle income patients choose them. Today, the bottom half of Singaporeans form the bulk of Class C and B2 patients. It is now a very different scenario from the days when Class C and B2 wards were first conceived.

And budget permitting, I would like to continue to upgrade the subsidised wards in response to rising expectations. But as we raise their service levels and narrow the differences between the subsidised and the private wards, we must expect more and more higher-income Singaporeans to be attracted to them, because there is no barrier to entry. Today, any Singaporean who wants a B2/C ward can just put up their hands and they would be admitted to Class B2/C and they would enjoy the high subsidy. This must mean greater competition for the same health subsidy. This is the rationale why we need to introduce means-testing in the subsidised wards now.

Over many dialogues, I have explained this to a good cross-section of Singaporeans. The concerns raised by various MPs were similar to those I have heard during the dialogues. I am heartened by the people's understanding and support for this policy, after hearing my explanation and clarification. I have assured Singaporeans - and I give them my word - that we will take a practical approach to means-testing. We will be flexible at the margins to help those who may appear to be high-income but who may have exceptional financial liabilities, either because of large families or maybe some family members with congenital complex illnesses. We have decided to set the criteria more loosely so as to mitigate the impact on those who may be affected.

The Clerk of Parliament will now distribute the parameters which will define our means-testing framework. [ Copies of

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Annex A* distributed to hon. Members. ] Please refer to Annex A of the handout.

Members will notice that the criteria and income thresholds are more generous than was discussed during the public dialogues. As Members can see, the vast majority of patients will not be affected by means-testing. All those who earn below $3,200 per month - individual income, not household income - will continue to enjoy the full subsidy. All housewives, retirees and children, in other words, non-working, living in HDB flats and lower-Annual Value private properties will similarly be unaffected. We have taken such an approach after taking into account the feedback from several MPs, including Mdm Halimah, Dr Amy Khor, Dr Lam Pin Min, Ms Jessica Tan, Dr Maliki, Dr Fatimah Lateef and Mayor Zainudin, who have helped me to conduct some of the public dialogues.

Mdm Ho Geok Choo asked if means-testing will deter the higher-income patients from continuing to use B2/C. I will not be able to forecast how individual patients will respond to the change. But what I hope will happen is a greater awareness on the part of Singaporeans that we all should subscribe to MediShield, and that those who earn more than, say, $3,000 or $4,000 per month, should top up with a rider which would enable them to use the higher ward classes. And if they do so, there is no reason for them to go to Class B2/C to compete with the poor patients. So, this means-testing is as much about getting Singaporeans to get a proper level of medical insurance. That, to me, is the key motivation and a very important motivation.

Mr Siew Kum Hong suggested even more subsidy, higher than 80%, for the very needy patients. In fact, we do so today.

*Cols. 1797-1798.

Through Medifund, patients who

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cannot afford the current Class C subsidy get additional assistance. Many end up paying nothing - we just waive the whole bill - which means a subsidy of 100%. But, of course, they have to be properly means-tested. So there is nothing wrong with the concept of means-testing in healthcare at all.

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We are now working out the implementation details and we are confident that implementation can be automated and hassle-free. Like Mdm Ho Geok Choo, we want to keep the cost of implementation low. Some cost in computerisation has to be incurred, but the incremental cost should be manageable.

I agree with Mdm Halimah that we should simplify implementation. That is why we adopt a simplified approach to means-testing, just by looking at personal income, rather than per capita household income. I agree totally with Mdm Ho, Ms Denise Phua and Mr Siew Kum Hong that per capita household income is a more correct gauge of financial ability, but implementing such a scheme for acute hospitals with very high turnover, large numbers of patients, short stay, will be extremely costly and, of course, intrusive to every patient, when the majority will actually not be affected by means-testing. So you are subjecting people to a lot of hassle for nothing. However, if specific patients feel that the simplified approach has been unfair to them, we will then do a thorough means-testing on such patients upon their appeal. So, in a way it is a hybrid system, a simplified approach - a first cut for everybody - and for those who feel aggrieved, we will look at them individually.

Dr Ong Seh Hong asked: why not have this seemingly better means-testing approach extended to the stepdown care? He comes from the stepdown care sector,

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so he knows how intrusive this more correct per capita approach is, which Mr Siew Kum Hong and a few others are advocating. It is troublesome, but I do not believe that there should be one common formula that applies across the board, for the simple reason: what are we trying to achieve? We are trying to make sure that fees are affordable to different income groups. And whether fees are affordable or not depends on what is the quantum of the fee. If it is just $10, $20, or less than $100, it is quite different from if it were a few hundred or a few thousand dollars. And I generally would err on the side of generosity for large bills. That is why, although we say Class C ward subsidy is 80%, in ICU, the subsidy actually is way above 95%, as a rule, because I know very few people, except Bill Gates, can afford unsubsidised ICU charges. And that is also why regularly, when patients get into serious trouble in private hospitals who requires prolonged ICU stay, especially babies, neo-natal premature babies, we take them, because we know they just cannot afford those charges unsubsidised. Therefore, any standard approach to means-testing that is applied across the board, may get the patients into trouble. The charges will then be either too high for many or unnecessarily low for those with small bills.

Mr Low Thia Khiang made some comments about means-testing. He mentioned it during the last General Election, which is true. The media approached me and I gave my reply and said, "Yes, it is not urgent on my agenda". That was the last GE in 2006. I said it was not urgent on my agenda because I had got so many urgent issues to do and I listed some of them: I wanted to further reform Medisave for out-patients and I wanted to reform the MediShield to allow a larger payout. Those were the urgent issues that I wanted to do and they were hot on top of my head. So I said, "Well, at some stage,

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we will probably do means-testing but it is certainly not urgent (then)." I think I might have even offered an answer to say that I do not see myself implementing it during the first year. That was in 2006, and "the first year" would have been 2007; this is now the second year, 2008. And we have decided that we will implement the simplified approach as set out in Annex A in January 2009. So I have not contradicted what I said during the GE.

He made a second point, which is that means testing is unfair because you would then deprive Singaporeans of choices. Are we? Are we depriving them of choices? I am not saying that if you are in the higher income group, middle or upper middle income group, you cannot access Class C wards. Nobody said that. If you look at Annex A carefully, everybody, so long as you are a Singaporean, put up your hand, if you want Class C wards, you may be admitted to Class C ward. But what we are saying is that it is fair of you, because of your high income, that your subsidy does not have to be as high as somebody who is earning a fraction of your income. If you look at the finalised subsidy rate, it is still a very heavy subsidy. So somebody earning $10,000 a month, high income group, if he insisted on going to Class C, we will treat him there and the subsidy is 65%. So he only needs to pay one-third of our cost.

I am a thorough man. We went through several rounds of simulation of bills to assess the high income patients: their Medisave balances and the bill sizes, not only average but also 90th percentile large bills. And I can confidently say that, despite the reduced subsidy for the upper middle income group who go to Class C, it is totally affordable. In fact, if their medical conditions are not serious, they do not even need to use their MediShield, their Medisave will be able to pay for it. Even basic MediShield without rider, they

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could pay for it, without having to pay out of pocket, and this is what I expect largely will happen when we implement it early next year. So, bills will remain totally affordable to all different income groups. But what we are asking Singaporeans is: if you are lucky, you belong to the higher income group, perhaps you should accept a lower subsidy than those who are much poorer than you. And, better still, check your CPF statement: have you bought MediShield? If you do not have MediShield, please subscribe to one and, if you are earning more than $4,000 per month, please, buy a rider immediately.

Mr Ang Mong Seng mentioned C Class ward as he is unhappy with the title "C", because Hokkien means "dead" or "dying". This is not the first time that we named it as Class C: it has been around for 40-odd years. In fact, this is the first time I received such a feedback. We are not using it for means testing to scare away people from Class C! If anything, the Class C ward is over-crowded and there are many patients who do not mind this. But I thought most patients, if their relatives asked, will talk about their ward number, eg, ward 32 or ward 36. They really do not ask in terms of whether they are in a Class A or Class B ward.

This Budget will raise our heath spending to a new level. It will improve clinical care and go towards meeting part of the higher public expectations for shorter waiting time. It will raise cost for both patients and the society. We should be mindful that this does not trigger further expectations, and here on this point, I totally agree with Ms Sylvia Lim, and hence greater cost escalation.

Managing expectations and moderating expectations require full understanding by Singaporeans. At the clinical level, what is standard healthcare can be

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more objectively determined. There are established norms for, say, how diabetes ought to be managed, how speedily heart attacks ought to be handled. To keep cost affordable, we have experts who advise us on what constitutes standard care, what constitute standard drugs and what are non-standard. And if patients demand non-standard treatment when standard medicine or appliances are available, we will have to ask them to pay for it.

However, for the non-clinical aspects of healthcare, say, the number of days or weeks of waiting by non-emergency patients for a new clinic appointment or waiting time to see a doctor at the clinic, clinical care is unaffected by improvements in such service standard. If such enhancement is pursued too vigorously by Singaporeans, it must lead to huge increases in health spending. We have to be cautious on this front. Our 19% increase in health spending this year will bring about some enhancement in such non-clinical service standard, but we should be realistic that it will not be on-demand service like what you get in five-star or even four-star hotels.

I will do my part to ensure that Singaporeans will continue to enjoy healthcare that is among the best anywhere in the world. But higher spending often does not guarantee better health. Indeed, as noted by Mr Yeo Guat Kwang, it is the basics that we must continue to focus on which will bring about healthcare improvement: prevention and better management of chronic diseases.

Just as an example, please refer to Annex B of the earlier handout. It shows the rapidly-growing obesity problem in the US and in Europe. The colour chart: as the colour darkens, it means that the population there is getting more obese. As Asia modernises and embraces fast food, we will not be spared. Obesity is

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becoming a global epidemic. In terms of human cost, it is worse than SARS. It will kill many more but in a silent way.

Singaporeans like to eat, so we are vulnerable. We are not yet as obese as the Americans or Europeans, but we may soon be, if we are not careful. If you look at the chart: how quickly a population can become obese within 10 years, 15 years. After cigarettes, obesity is the most important cause of global mortality and morbidity, and like cigarettes, it is preventable. We did a good job fighting cigarettes and our smokers’ rate is among the lowest in the world. We should try to beat obesity like we beat smoking. We must win this war against obesity and, yes, we can!

Step-down Care Services for the Elderly

Mdm Halimah Yacob: Sir, the current state of step-down care services for the elderly is not satisfactory. As a result, many elderly continue to remain in hospitals although it may be cheaper for them to be taken care of at step-down care services such as the community hospitals or nursing homes.

Some elderly prefer to stay in hospitals long after they have recovered because they can tap into their Medisave for in-patient stays. Home-care services for the elderly is lacking and, if available, is not affordable to many. There are also not enough people trained in geriatric care at all levels among healthcare providers.

Another problem is that the services are rather piecemeal. Coordination between the hospitals and step-down care services can be improved. There is also some concern whether there is adequate number of places in nursing homes as the population is ageing rapidly but the number of places has not gone up as fast.

I would like to ask the Ministry of Health to do a thorough review and

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enhance our step-down care services in Singapore to better provide for the needs of our ageing population.

Health Issues and Ageing

Dr Fatimah Lateef: Sir, the Policy Study Workgroup under REACH was revamped in October 2006 and re-launched in September 2007. There were five major areas that they had to look into and one of the focuses was actually health and ageing. The group allocated this topic was to brainstorm and design a health package for the different segments of society in Singapore and how they could stay healthy. Are there any updates on the reports and progress of the group? I do hope the programmes would include preventive health recommendations for the average Singaporean, suggestions for community and primary care screening, rehabilitative care and community integration of those affected by long-term illnesses, such as psychiatric illnesses.

Ageing Population

Dr Lam Pin Min (Ang Mo Kio): Sir, the filial daughter-in-law looking after her demented father-in-law made the mistake of leaving him alone at home while she went downstairs to run some errands. She was only going for no longer than 10 minutes. What harm can possibly happen? She did not bring the keys to the flat and spent the next three hours trying to coax her father-in-law to open the door to let her back into the flat. Welcome to the world of reality and dementia.

The risk of developing degenerative mental problems such as dementia and Alzheimer's disease increases with age, doubling every five years after the age of 65. Given that 20% of Singapore's population will be 65 and older in 2030, we will be facing a potentially serious problem in the future. If our current population remains constant by 2030,

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that is four million, we are likely to have 800,000 above the age of 65 and a significant proportion is likely to be suffering from some forms of mental degenerative diseases.

The number of people suffering from dementia and Alzheimer disease is set to grow, as our population greys. Medical science can help slow down the degeneration but it cannot cure. More programmes must be put in place to get us ready to deal with this disease. It can be overwhelming for family members confronted with a member suffering from dementia. Yet, family members, as carers, are the most cost effective and conducive. Towards this line, I would like to ask if the Ministry of Health is prepared to step up its programme for families of demented patients.

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Secondly, the ratio of medical professionals, especially in the fields of geriatric medicine, psychological medicine and allied health, such as physiotherapists and occupational therapists, to the population appears inadequate. What strategy is the Ministry taking to ramp up the supply of medical professionals to cope with our rapidly ageing population?

Lastly, I would like to urge the Ministry to embark on research programmes in the prevention of age-related mental degenerative diseases.

Ageing Society and Ambulatory Community Care and Support

Dr Fatimah Lateef: Sir, with our rapidly ageing population, the incidence of dementia and psychological illnesses is bound to increase significantly, as we have heard the numbers. Given the finite number of community hospitals, acute hospitals, nursing homes and rehabilitative institution beds, it will become necessary

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to be able to manage many of these people on an ambulatory basis in the community. They may have to be cared for by their family members, their neighbours, the community around them, and certainly inputs from professionals offering auxiliary services in the community become very important. To be able to handle the caring of such persons, these people may require some training, empowerment and understanding of the nature of these illnesses. Would MOH be able to consider some form of care-giver support package, which may include subsidies, recognition, facilitation for domestic, which may have to be a tie-up with MCYS and MOM perhaps and, of course, simple training.

Age-Friendly Primary Health Care

Assoc. Prof. Kalyani K Mehta (Nominated Member): Mr Chairman, the concept of age-friendly primary health care was developed by the World Health Organisation in 2002. An international research was conducted using focus group methodology in the following countries - Australia, Canada, Jamaica, Malaysia and the Philippines. According to their report, which I have here, published in 2004, Active Ageing Towards Age-Friendly Primary Health Care , the general principles guiding the practice of age-friendly community-based practice were described in detail.

Singapore participated in the second half of the study when doctors and nurses were interviewed for their views. The Tsao Foundation represented Singapore in this study. There are three major categories included in these general principles:

(1) Information, education and training. All clinical staff should receive basic training in core competencies of elder care;

(2) Community-based health care management. All relevant stakeholders,

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including older persons, should be part of participatory decision-making mechanisms regarding the organisation of committee-based care systems; and

(3) Physical environment, safe and affordable transport to the health care centre should be available for all, including older persons whenever possible, by using a variety of community-based resources, including volunteers.

The importance of primary health care in an ageing society today is an under discussed topic, especially at national levels. Global ageing has shown the prevalence of chronic diseases over infectious diseases. World wide, it is estimated that 60% of all deaths are attributed to chronic diseases, such as hypertension, diabetes, stroke and dementia. Compared to neighbouring countries, Singapore has a higher prevalence of diabetes.

Sir, recently, an expert in geriatrics, Prof. Bergman, visited Singapore, and he said in one of his presentations that "the daunting challenges of adopting health care systems to the complexity of managing and tracking chronic diseases requires a multi-dimensional approach. More resources have to be pumped into primary health care as prevention is better than cure." His opinion was that the Singapore primary health care system is fragmented and could be strengthened.

The primary health care system in Singapore consists of ageing polyclinics and GPs. The private GPs handle 80% of the bulk of primary care while polyclinics handle the rest. Other players are the community-based day rehabilitation centres, mobile health clinics, senior activities centres and free clinics run by religious and ethnic-based organisations.

The HPB has done many programmes, such as oral health promotion and so on. However, preventive education is a

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marathon task. Hence, it has to be undertaken by all the players in the primary health care system in a planned and systematic manner. Since MOH is the central policy making body, it is important for MOH to ensure that all the players move in a similar direction for preventive health care as we are facing an ageing population.

Now, I move on to another study conducted in Singapore, and I would like to declare my interest here as a principal investigator of this research. Older people and care givers were asked about their views on the primary health care system, and their suggestions for improvements. This primary care study revealed barriers faced by older persons in accessing health services. These were: (1) distance - here, primary care partnership scheme helps but it has many conditions; (2) cost; and (3) physical access. The last was emphasised by frail, dependent and physically disabled elders.

Recommendations included shorter waiting time, choice to see the same doctor on every visit to the polyclinic. The recent move by MOH to introduce the scheme of family physicians does meet the last recommendation to some extent. However, the increase in cost is a barrier to many. Sir, I wish to ask the reason for this extra charge. Is it really necessary?

The doctors and nurses mentioned two main issues. Doctors who were interviewed expressed their focus on curative medicine rather than preventive medicine. They regretted that they did not have more time to spend with older patients due to the work load at polyclinics. The social workers and case managers voiced the lack of integration between health and social care services. An example: community health care providers could not access medical data of patients. Hence, the delay in helping clients in critical conditions.

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Some suggested solutions:

(1) Assign older patients to a particular day in the week for polyclinics, eg, Fridays. I know that there is a pilot scheme in Delhi doing this, and realistically rostering their appointment times, such as 10 minutes or 15 minutes instead of the standard five minutes; and

(2) Obtain the permission from patients to share their medical data with community-based health care providers for an added level of efficiency in meeting their needs. It would mean time saved and less frustration.

I would like to ask the Health Minister whether MOH has any plans to promote age-friendly practices in the polyclinics. There are older persons who cannot keep an appointment because they have no one to escort them. I would like to suggest perhaps a resource help line to be maintained by polyclinics. If a patient calls, say, two days ahead of time that he or she needs such an escort, a health senior volunteer from a nearby senior activities centre could provide the service with a small transport allowance. In addition, not all polyclinics are accessible to wheelchair-bound patients, eg, Clementi Polyclinic. Can I request the Health Minister to look into this important issue? Addressing this barrier could lead to more elderly patients keeping their appointments as well as disabled patients.

Finally, I would recommend that the holistic approach be adopted to ensure an integrated age-friendly health care system, looking at hardware and software that prevail in Singapore. Short-term gerontology training could be given to all staff in community-based agencies serving older people in the community. This would help them understand the needs of older people and appreciate their strength. With technology, such a training

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could be even done on a website, and GPs could be encouraged to also do this training.

The Chairman: Mdm Halimah, take your two cuts together. You have two minutes.

Allow Subsidies for Home-based Medical Care of the Elderly

Mdm Halimah Yacob: Sir, currently, there are no subsidies for families who take care of their elderly sick at home. This is further exacerbated by the limited access to Medisave for home-based medical care. I urge the Ministry to rethink the current strategy as it seems to be designed at keeping the elderly in the hospital rather than at home, as it disincentivises those who opt for home-based care.

Taking care of a sick elderly person is a serious physical, emotional and financial strain on families, particularly for those with limited resources. Small wonder then that we often hear that the elderly occupy a lot more of the subsidised hospital beds and also stay long, which is a cost to our society because hospital care is expensive. Although one may argue that the elderly stay longer in hospital because they are sicker, it could also be because families with little support at home drag their feet in bringing home their elderly relatives. I urge the Ministry to consider granting subsidies for home-based care of the elderly, so as to ease the burden of families and to help to keep more of the chronic sick at home.

Extend Subsidies for Treatment at Private GP Clinics

Sir, I now move on to my second cut. Judging from the long queues, polyclinics are finding it difficult to cope with the increasing number of patients. The problem will not go away even if we build more clinics and deploy more manpower.

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Conversely, an SMA survey shows that GPs now have fewer patients and face higher costs, forcing some GPs into aesthetic medicine resulting in 20 of them being scrutinised by the Ministry arising from complaints of botched cosmetic jobs. This is the kind of supply generated medical service that we can do without, as it causes health care expenditure to balloon.

On average, a doctor in a big polyclinic sees about 62 patients per day, which is much higher than the average of 40 patients per day at a busy private GP clinic. From a national perspective, this mismatch in capacity and demand between polyclinics and GPs is an inefficient allocation of resources. I would like to ask the Ministry to consider allowing GPs to claim the same amount of subsidies for treating subsidised patients as that given to polyclinics, subject, of course, to conditions or protocols to prevent abuse.

The Chairman: Mr Chiam See Tong is not here. Dr Fatimah.

Chronic Disease Management Programme

Dr Fatimah Lateef: Sir, under the Chronic Disease Management Programme (CDMP), which comprises diabetes, hypilipidemia, hypertension and stroke, the number of patients enrolled has increased from 7,000 when the programme was first implemented in October 2006, to 91,000 in December 2007. This resulted in the annual drawdown on Medisave of approximately $17 million in 2007.

With the coming introduction of the CDMP for asthma and chronic obstructive lung diseases, what will be the additional draw down projected annually? Only about half of the general practitioners, ie, 734, have to date signed up and participated in the programme. What are

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the main concerns and the reasons for the rest not joining the programme?

Finally, will there be future plans to include other chronic illnesses, which are confirmed by doctors, such as rheumatoid arthritis, SLE or lupus and long-term confirmed psychiatric illnesses into the programme?

Health Policy

Dr Lily Neo (Jalan Besar): Sir, the concern of many Singaporeans is on the sustainability of pay-as-you-go healthcare financing here. The rate of population ageing in Singapore is among the fastest in the world. The elderly will use between three and five times more healthcare services compared to the younger population. While the 3Ms are intended to increasingly cover a larger share of the health financing pie, the fact remains that they cover only less than half of overall national expenditure at present, leaving still a large portion of expense as out-of-pocket payment. Thus, any reduction in healthcare cost will lessen an individual's cost substantially. Could MOH look into the policy of reducing the burden of healthcare of Singaporeans in the following areas:

(1) Promoting active elderly citizenry based on Okinawa's population on healthy living;

(2) Promotion of independent living at home with the support of family and community;

(3) New alternative types of cost effective community-based long-term care;

(4) Home care;

(5) Home hospice care; and

(6) Public-private-people partnerships in new models of elder care.

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Increase Payout under Basic ElderShield

Mdm Halimah Yacob: Sir, with last year's increase of the ElderShield payment to $400, this scheme has now become more attractive. However, even with this increase, the cost of taking care of a highly dependent elderly family member is a huge financial drain on many families. This amount does not even meet the income per capita of $450 set by MCYS for eligibility to our financial assistance schemes. Unlike many developed countries, we do not have a scheme which covers the needs of the elderly sick from a common pool funded by tax, individuals and companies.

Hence, the ElderShield scheme will increasingly become an important source of help for the elderly sick, complementing CPF LIFE. Although families wanting a higher payment can now opt for enhanced ElderShield, the premiums may not be affordable to many because the base is smaller compared to basic ElderShield. I urge the Ministry to consider increasing the basic ElderShield scheme, so that ElderShield will become a more effective financial scheme for our elderly sick.

4.15 pm

Mr Khaw Boon Wan: Sir, last week, I came across an article with a seductive promise: "Five easy steps to living long and well". It is a serious article quoting the evidence gathered from a study on more than 2,300 healthy men over many years. When the study began in 1981, their average age was 72. At the end of the study, 970 men or 41% had survived into their 90s. The study was published last month in The Archives of Internal Medicine. "The take-home message", said Dr Laurel Yates, a geriatrician at Brigham and Women's Hospital who led the study, "is that an individual does have some control over his destiny in terms of what he can do to improve the probability

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that not only might he live a long time, but also have good health and good function in those older years."

The prescribed five easy steps are: abstain from smoking, manage weight, control blood pressure, regular exercise and avoid diabetes. I score 5 out of 5, but I believe that good genes and good karma play an important part too. The study focused on men but the prescription is probably applicable to women as well. In fact, in the same issue of the journal I read another study which monitored 500 women and 200 men ranging in age from 97 – so the youngest was 97 – to 119. This study showed that a large proportion of people who lived that long, with minimal or no assistance, did so despite long-term chronic illnesses. In other words, some of the oldest of the old survive not because they avoid illness, but because they were able to delay or even prevent disability.

As life expectancy grows, there will be many more such studies and articles. Dr Lily Neo mentioned Okinawa and how they deal with longevity. I went there last year and I spent several days there. I visited a village called Ogimi with 3,500 villagers. Seventeen of them are above the age of 100: 16 female, one male. And the man, with dementia, lying in a nursing home, I visited him. I have never, in one sitting, met so many over-90 years of age, mostly ladies.

I have met many Singaporeans in similar age groups here, but they are largely in nursing homes or chronic sick hospitals. The Okinawans are different. They are active, they are busy, they are happy, fun loving. I did folk-dancing with them. And they live independently. They still cook their own meals. Very few are bed-ridden in nursing homes – they do have nursing homes there – but when I spoke to them, they said they came from other villages, not from this village. And they were quick to share their secrets

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with me. Less scientific and more anecdotal, their prescription is: sleep well, meaning have a good night's sleep, not necessarily at night, it could be during the day, but have a good sleep. Be happy, eat lots of vegetables, very important, and they eat fruits too, but they treat fruits like vegetables, they cook their fruits into their dishes and, of course, stay active.

These are some positive aspects of ageing. But ageing of the population is not all bed of roses. Dr Lam Pin Min's comment on dementia is just one illustration. Indeed, the ageing of the population is the greatest challenge confronting healthcare systems around the world. Just look at the US. They spent 16% of their GDP on healthcare and you look at the component called Medicare which funds the medical care of the elderly, anybody more than 65 years, that takes up 3% of the US GDP. So 3% of US GDP just to look after those who are more than 65, and we spent 4% treating everybody. And one quarter of Medicare spending goes towards supporting the last year of the patients' lives. And, of course, this naturally raises many questions about the appropriateness of such spending.

One reason is that current healthcare systems largely skew the practice of medicine towards high-tech medicine, a point Prof. Mehta made just now, and therefore at great financial cost and often poor quality of life for the patients. Someone showed me this book, "Slow Medicine" written by a geriatrician at Dartmouth Medical School. He promotes a different approach and I quote him, "a family-centred, less expensive way", as he puts it. He felt that for many elderly patients, "modern medicine in its hospital-based, medication-obsessed, high-tech impersonality may hurt more than it helps".

He has many practical tips for children of elderly parents and they are worth

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sharing. First, while the parent is still vital and lively, children must not fool themselves that this happy situation will last forever. This is the time to re-insert themselves back into the parent's life, to accompany them to doctors' visits, and at the right moment raise unpleasant topics like the advanced medical directive or living will. And I see a cut on this by a Member later today.

After a few more years, this geriatrician said, it is time for the children to address the "can you still manage at home?" issues and to help create routines that compensate for the elderly's slipping memory and slightly wobbly balance. And then, inevitably, medical crises will arise. The children should then be vigilant to protect and "rescue the elderly from standard medical care". By that, he meant medical care should, all the while, favour the tried-and-true, over the high-tech. For example, instead of a yearly mammogram, a manual breast examination for the very old may suffice. And home tests for blood in the stool may replace the draining routine of a colonoscopy. Very practical tips.

He added that the pace of care should be slowed to a crawl, and hence the title of his book. For doctors, that means starting the medications at low dosage and increasing them gradually. And for children, that means learning not to panic and yell for an ambulance on every apparent bad day. Though both comforting and worrying, it is a valuable contribution to the global discussion on ageing and how best should families cope with it.

Indeed, modern healthcare systems are not well-designed for the demands of ageing. They are geared towards acute care in hospitals, that is, treatment for only brief but severe episodes of illness, sometimes requiring high-tech care. But insufficient thought has been given to long-term chronic care. Good models are

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rare and far-between anywhere in the world. Proper chronic care should be carefully designed for the long term, with appropriate level of resources, usually low-tech care, and most critically with strong cooperation, participation by patients and their families. Chronic care is a very different care regime from acute care. But when high-tech acute care is mindlessly extrapolated to cover long-term chronic care for the elderly, it is not at all surprising that problems in the US and the West have arisen.

Everyone is searching for a better model to handle long-term chronic care of the elderly. We too are evolving our model. So I agree with Mdm Halimah that there are gaps, many in our current step-down care sector, and we must fix them. Fixing them, however, requires careful thought. Some elements or operating philosophies are better researched and appear sound, but we cannot be sure until they are tested through time and actual experience. This calls for carefully-planned experimentation and small-scale pilots, close monitoring and review, and if proven, scaling up. Such initiatives include, among many others:

(a) Greater emphasis on preventive medicine;

(b) Better management of chronic diseases at outpatient level;

(c) Better integration of care between hospitals and step-down care facilities; and

(d) Right-siting of patient care in more appropriate and lower-cost settings.

Many Members have shared their thoughts on this important subject and I thank them. I have noted Dr Lily Neo's comments on possible public-private-

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people partnership as a model of providing eldercare. And indeed, we should widen participation, both in provision as well as in funding. Ageing of the population is a growing problem, and we should not underestimate its impact. The Japanese are well-known for doing very careful research and wide consultation before they launch any new scheme. Yet, when they launched their national long-term insurance scheme just a few years ago, they found that their initial projection of demand and funding needs were off by a wide margin, just after one year of implementation! They have since been trying to curtail demand and raise premiums. I think this is a very important lesson for us who are involved in the planning of eldercare services. Do not underestimate demand, especially if it is going to be subsidised generously. And make a strong distinction between demand and what is genuine need. Demand does not equal need. If service is provided, heavily subsidised or provided for free, demand will grow, much more than the actual need. Better think through, start small, test the market, rather than rashly committing to any long-term financing that our society may not be in a position to afford. Let us discuss some of the points raised.

First, I agree with Dr Lily Neo that we must promote healthy living and healthy ageing. But Singaporeans must participate actively in order to benefit. This is a continuous and often uphill endeavour. But we persevere.

Healthy living starts with awareness. This year, HPB will roll out the nurse educator programme. This is a new programme which we are starting. We will place some of these nurse educators at community centres where they can hold classes for patients and their families on how to manage their chronic conditions. We will work with PA and the grassroots to promote these programmes.

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We will leverage on screening. Many MPs, I remember during the early years Dr Lily Neo actively championed community screening, and a lot of work has been done promoting this. We are consolidating the programme and we will raise it to a new level. From this year, HPB will roll out what we call an Integrated Screening Programme. All Singaporeans above the age of 40 will receive a letter from us, a reminder to go for screening for some of the major chronic diseases.

We are embarking on preventive efforts to promote healthy ageing. Last year, we embarked on a pilot "Wellness Programme" at six constituencies. This came under the framework of the committee chaired by Mr Lim Boon Heng. We are trying out at six constituencies, and if it works, we will scale it up. This includes a platform for health agencies and service providers to encourage positive changes in seniors' lifestyles and health behaviour.

Second, I agree with Prof. Mehta, that when medical care is needed, primary care is the best first point of contact for the chronically ill and elderly patients, unless of course, it is genuine emergencies. Good primary care is particularly essential to meet the chronic disease challenge. Medisave can now be used for outpatient treatment of four chronic diseases. As noted by Dr Fatimah, half of GP clinics are now participating in this scheme.

4.30 pm

Overall, we are pleased with the progress. So, from next month, we will extend the scheme to the remaining two major chronic diseases: asthma and chronic obstructive pulmonary disease (COPD), and we will extend it under similar terms. This will benefit up to 180,000 more Singaporeans.

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Dr Fatimah asked if we would extend this scheme to other illnesses, for example, mental illness. We keep our options open, but for the moment, we focus on the key chronic diseases with established treatment protocol and measurable clinical outcomes. We also must not forget that Medisave at current contribution rates are only designed for inpatient care. It was never designed for outpatient care. Extension to expensive outpatient care is an exception, and we should resist any temptation to broaden its use liberally, or it will surely be depleted prematurely.

Mdm Halimah proposed that we extend the Primary Care Partnership Scheme (PCPS) to cover some chronic diseases. Currently, it does not. It only covers acute care, coughs and colds, but chronic care, it does not. Any extension to chronic care will raise the risk of over-consumption and over-servicing. But a case for extension can be made if we can manage the potential problem of abuse. So I am studying this very carefully.

Dr Lam Pin Min and Dr Fatimah described the problems faced by caregivers of patients with dementia. And it is a real problem. Talking to them in nursing homes, you cannot help not to be affected when the loved one can no longer recognise them. Sometimes, it is easy for outsiders to say, "You terrible children: never visit your parents in the nursing home after dumping them there." But when you go there, one month, two months, three months and then six months, the patient cannot recognise you at all. It is heartwrenching.

So for caregivers, we will try to support them as much as we can in a professional way, in a technical way, how to cope with all these difficult problems, forming them into support groups so that they can support each other. But whether we should pay them, I think let us think

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through this carefully. This is part and parcel of the children's duty, this is family duty. I think if the Government steps in to turn children into employees, we are walking backwards.

Third, I agree with Mdm Halimah, Dr Lily Neo and Dr Fatimah that we must better integrate the healthcare system with the community to provide appropriate care for the elderly. From next month, we will upgrade the Integrated Care Services into what we call Agency for Integrated Care (AIC) with upgraded capabilities. Starting with Changi Hospital and National University Hospital, the AIC will equip our hospitals with additional resources, including additional care coordinators. This will cost us $20 million over the next four years. These coordinators will help ensure that patients who are fit for discharge but, who have multiple complex care needs, are transferred to appropriate step-down care providers and that they will receive the necessary medical or social services.

Another key focus for MOH is to ensure patients get the most appropriate treatment in the right place, or what we call "right-siting".

Mdm Halimah and Dr Lily Neo suggested that we subsidise home-based care for the elderly, including home hospice care. I think we do but of course we can always do more. But we have to study the implications: what does it mean? Last year, the Ministry of Health provided $3 million in funding these providers. We will do more, but we are taking a careful approach, as the direct home care model actually is very expensive. So I am at a dilemma. We know that the elderly prefers to age at home. And to strengthen family bond, treatment should be at home, instead of in an institution even if it is a day-care

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facility. But between the two, it is a lot cheaper to do it at an institutional level because you can have economies of scale, rather than at home. So these are the balancing acts that we have to do. We need to study the underlying patient needs carefully.

Mdm Halimah commented on ElderShield. We have enhanced it last year, as she noted. Those who require more payouts, they can subscribe to supplements. Unfortunately, partly because the product is not an easy product to market and public awareness is not good, only a single percentage point of ElderShield policy holders top up with the ElderShield supplements. But we will study this problem.

And of course, we will have to expand the step-down care infrastructure. Much of this may be care that is not medical in nature. In fact, in this area, we should be careful that we do not "over-medicalise". If it is just simple care, just keep it at that level. We will work with MCYS to see how we can develop new services here.

Dr Lam Pin Min commented on the manpower strategy to cope with a rapidly ageing population. And I agree with him that the current numbers will not be sufficient. We will study and we will try to increase them. In the earlier speech, I mentioned about wanting to step up the training as well as recruitment of many of these allied health professionals. In this sector, really, they are the most important resource.

Sir, everyone wants to live long and live well, without being a burden to the family. In Okinawa, the ladies told me, when I asked them what is their top wish: "pokkuri shinu" . It is a Japanese word. Pokkuri means pop, like bubble that pops. In other words, they want their lives to be like a bubble – bubbly, active, happy and then, one fine day, in the sleep, just "pop" and die in the sleep.

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My father led such a life. He worked hard, loved the family, had no vices, and one night, in front of the TV, went into a coma and drew the last breath a few hours later. I missed him by an hour because I was not in Penang.

Not everyone is so lucky. My mother suffered nearly three years of cancer pain. We had to try high-tech medicine first. When the poor prospects became clear, we went for "slow medicine". She was able to die peacefully at home in familiar surroundings. This time round, I was able to return to Penang in time and be there as a loved one passed on.

As we busy ourselves with our work and our family, we should sometimes take a pause and reflect on how people spend their last moment. Death is not a taboo subject to be left unspoken. In fact, the more we think seriously about death, the more likely we will know how to live life to the fullest and to make each moment and each day the most meaningful possible.

Mental Health

Mdm Halimah Yacob: Sir, one in six people here suffers from some form of mental illness and, based on trends in other developed countries, the numbers are set to go up especially dementia with an ageing population.

Mental illness causes terrible anguish to the sufferers. It carries with it a terrible stigma, results in loss of economic independence and is a great burden to caregivers.

The current approach adopted by our healthcare system in the treatment of mental illness is still very much focused on medication. There is also an over reliance on institutional care and insufficient attention given to community-based care, which can play an important role in the treatment and care of mental

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illness as it helps in the integration of the individual and is less expensive.

Sir, I would like to ask the Minister for a review of the current framework and to put in place a more holistic and comprehensive healthcare framework for the treatment of mental illness. I would also like to ask for an update on the $88 million fund that was set up last year. Could the Minister enlighten this House on what was this fund utilised for and how has it benefited and helped to improve the lives of those suffering from mental illness?

More specifically, I would like to suggest that the Ministry consider the following:

(1) Extend MediShield to cover mental illness;

(2) Develop more trained manpower such as psychiatrists, psychologists, counsellors and medical social workers, to deal with the increasing number of people suffering from mental illness;

(3) Do more to educate and raise public awareness about mental illness, as a recent study found that one in three people believe that the mentally ill are dangerous and half the population thinks that the public should be protected;

(4) Expand more community-based step-down care services for the mentally ill to help them re-integrate into society; and

(5) Review the funding support given to VWOs who are running facilities or providing care and support for the mentally ill, such as the Action Group for Mental Illness and those providing residential care, such as the Singapore Association of Mental Health.

In fact, according to some of these associations, there are now more numbers

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of people being picked up from the streets by the Police and being referred to them because as the population ages, those who are mentally ill are also ageing but, unfortunately, their caregivers are not in a position to take care of them, especially they themselves are growing much older. It is, of course, a tremendous strain for caregivers also, as they financially have to take care of the needs of the mentally ill.

I have a resident in my area, for instance, who lives with his mother and only the two of them are living in the house. The son has to go to work and the mother has no one at home to take care of her. And the problem with people with mental illness is that when they feel a bit better, they do not take their medication, and that is when they start having problems. Neighbours begin to complain. But when they speak to the son, he says, "I have to work. If I don't work, I stay at home to take care of my mother to make sure that she takes her medicine regularly. There will be two mental patients and not one." So I think that really points to the fact that we need a lot of support in the community for those suffering from mental illness.

I would also like to urge for more support to be given to caregivers who suffer physically, emotionally and financially in taking care of their loved ones who are mentally ill.

Preventive Healthcare

Dr Lily Neo: Sir, Singaporeans live longer but suffer eight years of poor health. Japanese women have an average of eight years more good health compared to women here. Japanese men have four more years of good health compared to Singapore men. MOH study shows that the main causes of sickness of men and women here are diseases that could be prevented earlier on. These

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diseases are heart disease and stroke, cancer, diabetes and even mental illness. May I ask MOH what can be done to reduce the years of disability amongst Singaporeans? What further preventive measures are useful to reduce such disability?

Preventive Health Measures

Mr Zainudin Nordin: Sir, during the World AIDS Day in December last year, a survey on basic knowledge about HIV AIDS was conducted in Singapore. It is shocking to note that despite public awareness campaign about the disease, one third of the 705 survey respondents said they believe HIV can be transmitted through mosquito bites and kissing. More than half of the survey respondents also said they did not know HIV can be transmitted through breast milk. The survey also found that one in 11 people said he or she would not take an HIV test even if being HIV positive was a possibility. The findings of the survey worry me. Knowing how much effort we have put in to educate and create awareness about the disease, there is still so much ignorance about it in the public.

This led me to think about the effectiveness of current healthcare awareness programme and the ones that we held in the past. We have to look at the effectiveness of the current efforts, especially those dealing with health promotion and disease prevention. I know that the Health Promotion Board is currently doing a lot in these areas. But are we actually getting better?

Sir, based on what I see on the ground, I also observe that Singaporeans, young and old, are more obese and prone to health problems. Not only is obesity preventable, it could lead to multiple other conditions and could place a large burden on healthcare use and cost. We all know that prevention is the key to controlling obesity. Furthermore, the treatment of

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obesity is often difficult and frustrating to the patient and doctor and if weight loss is difficult, maintaining it is even more difficult.

Sir, we need to enforce the importance of living a healthy lifestyle with focus on nutrition and exercise.

I would like to know if there are any plans by the Ministry of Health to prevent obesity from threatening Singapore and what is the Ministry doing to prevent it from escalating.

4.45 pm

The Chairman: Dr Lam Pin Min. You have two cuts. Take them together. Four minutes.

Management of Obesity

Dr Lam Pin Min: Sir, obesity has reached epidemic proportions in some countries like the US. While the prevalence of obesity in Singapore has not reached such alarming levels, it is still a matter of concern, as statistics have shown that the prevalence of primary school children with obesity is about 12%-14%.

A 32-year study published in the New England Journal of Medicine reports that obesity spreads within social circles. Interestingly, we base our idea of appropriate body size on people we trust. We have a 100% increase in our risk of obesity if we have an obese best friend, 44% if our brother is obese, and 37% if our wife is obese. Therefore, the latest doctor's advice is - choose your friends carefully!

In our looks-obsessed society, lots of people think that being overweight is only an appearance or aesthetic issue. But being overweight is actually a medical concern because it can seriously affect a person's health, both physically and psychologically.

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The association between obesity and cardiovascular diseases is well established. Other health problems that can affect obese individuals include arthritis, diabetes, depression and lower self-esteem. In addition, European researchers report in a recent study also link obesity with certain cancers, such as thyroid and kidney, among others.

Prevention is one of the best strategies to address the long-term effects and high costs of treating the co-morbidities of obesity. I would like to ask the Minister the following questions:

(1) What measures or programmes are put in place to educate Singaporeans the ill effects of obesity?

(2) Is the Ministry working closely with MOE and MCYS to prevent obesity at its early stage, in the childcare centre and in the schools?

(3) Can the Ministry implement incentives to encourage Singaporeans to stay trim, such as lower premiums for health insurances, something to the likes of no claim bonus in motor insurance?

Let me switch from fat to sex now.

Teenage Abortion

Sir, our teenagers' cavalier attitude towards pre-marital sex is a cause for concern. According to some of the surveys conducted, it is a matter requiring immediate attention. "It just happened," said one teenage girl who engaged in unprotected sex after one drink too many with a casual friend.

Teenagers are adopting a more liberal attitude towards sex. A poll of youngsters between 16 and 23 years found 13% of them were sexually active. A survey conducted by pharmaceutical company Bayer Schering, Pharma Singapore and Youth.sg, an online portal,

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revealed 23% did not use any form of contraception. In the first nine months of last year, 657 young people sought help for sexually-transmitted diseases. In addition, the rising number of teenage abortions strongly suggests that sex education amongst our teenagers is inadequate. Of the 12,000 abortions in 2006, teenage abortion accounts for 11%, with 19 cases performed on girls under the age of 15.

Abortion should not be used as a form of contraceptive. Frequent abortions can result in possible medical complications, such as womb infection, bleeding problems and even sub-fertility. Not surprisingly, the increasing number of young people engaging in pre-marital sex has resulted in more teenage abortions, teenage pregnancies and sexually-transmitted diseases.

Sex education has been shown to be effective to correct the ills of pre-marital sex and teenage pregnancies and abortions. Teenagers should be educated on the moral values and virtues of abstinence from pre-marital sex. However, I understand that times have changed and the society and younger Singaporeans take a more liberal view about sex. It is, therefore, more important to educate teenagers on the importance of safe sex.

I would like to ask the Minister what additional efforts will be put in place to address the issues of teenage abortions in Singapore, and what indicators or targets will be used to monitor the effectiveness of such initiatives.

The Living Will

Dr Fatimah Lateef: Sir, the Advance Medical Directive has been introduced in Singapore. Guidelines have been circulated. However, many are still not

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aware, not interested, as it may represent a rather taboo subject or are not taking any action, thinking that perhaps it is still too early to consider their last days. There exist skepticism and barriers to discussing such a subject and, of course, there are issues of religion and culture to be taken into account as well.

Will the Ministry be doing any further publicity, roadshows, dialogues and so on to enhance awareness and understanding of this very important subject? We need to safeguard the rights of the sick, the aged and the dying with the same enthusiasm we show for the young and the healthy in our society. Treatment decisions can be difficult. We need to think about our wishes and expectations in advance to discuss with our family, friends and healthcare professionals and make plans for our future healthcare needs. I am sure, Sir, everyone will come to realise the positive impact such a period of reflection will have on us all.

Skin Donation

Mr Sam Tan Chin Siong (Tanjong Pagar): Sir, thank you for allowing me to speak on this issue.

This issue is relatively obscure, and for good reason. The issue of concern is that many people do not know that there are not enough skin donors in Singapore. Skins are donated when we die and, last year, only one person did so. Every year, the average number of skin donors in Singapore is between two and four people. This is way below other developed countries. For example, Australia has 57 donors in the first eight months of 2007. In the New York metro area alone, there were 173 skin donors in 2006. Each year, up to 20 people in Singapore die because there is not enough skin to save them.

Sir, skin is not covered under the Human Organ Transplant Act (HOTA).

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Nurses and doctors have to ask families of the person who has died whether they would like to donate the skin. Very often, they are turned down. Perhaps people are just leery of this topic. They may think that their loved ones will be stripped of all their skin, leaving behind a muscled raw mass for burial. But this is simply not true. For skin donations, doctors shaved about 0.25 mm to 0.4 mm from flat surfaces like the thighs and back. And the body still has a layer of skin remaining. The affected areas will appear slightly pale and, when fully clothed, should not affect the donor's appearance.

What happens to the skin after that? They are harvested in pieces and packed individually. Unlike organs, donated skin can last for a long time. After harvesting, they are frozen at -196 degrees Celsius and can be stored up to five years in this condition.

Members may be wondering why I am talking about this topic. Are skins a matter of life and death? In a word, yes. We would probably remember that, last year, seven Singaporean soldiers were injured in a foreign place when a fighter jet crashed into the room they were in. This accident killed three Singaporeans and injured the rest. One of the injured was flown back to Singapore for treatment. He suffered 45-degree burns on his hands and body. Donor skin probably saved his life.

Sir, Singapore has to import skin from Australia, US and the Netherlands. And Singapore has the only comprehensive burns unit in this region and, in the event of terrorist attacks, we are likely to receive many patients. For example, after the Bali bomb blast in 2002, SGH received and treated 16 patients. After the Jakarta bomb blast in 2004, SGH treated 15 patients. And if the terrorist attacks had happened in Singapore, the number of patients would be much, much higher.

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Sir, it is time that we took greater note of this medical resource and encourage Singaporeans to donate their skin on death. I myself have signed up and pledged my skin to be used after my death. And I will take this as a final spa treatment before embarking on the next journey.

Like organs, skins are truly a gift of life to our fellow human beings. I hope that one day it can be included in HOTA when the idea of skin donation has become much more widely accepted.

Sir, I would like to continue my speech in Mandarin.

( In Mandarin ): [For vernacular speech, please refer to Appendix A.] Sir, first let me quote a Chinese saying: "人死留名，豹死留皮". It means that when a man dies, he leaves behind a good name, a leopard leaves behind its skin. I would like to ask: why can a man not leave behind his skin when he dies? In Singapore, we have almost about 20 burns victims dying of complications every year and, many times, these victims die because they are not able to undergo skin transplantation. Every year, the Singapore General Hospital's Burns Unit treats about 300 burns patients. These victims are warded because of industrial or family accidents. About 15% of the patients suffer extensive burns and 30%-40% of the bodies are severely burnt. So, if these patients do not receive skin transplants, their lives would be in great danger. We often say that money is not everything. We do not bring it to this world when we are born, therefore, we cannot bring it with us when we die. This is the same for our physical body. Therefore, why not treat it as a good deed? When we die, leave behind our skin and give it to those who need a skin transplant.

Human values are not constant. Our value system changes according to the times. Therefore, in today's context, it is

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necessary to review our traditional values. The ancients said: "人死留名，豹死留皮". It means that when a man dies, he leaves behind a good name, the leopard leaves behind its skin. So, in today's context, maybe we should consider changing this idiom to "豹死留名，人死留皮" – when a leopard dies, it leaves behind a good name, a man leaves behind his skin. We say, "救人一命，胜造七级浮屠" – to save a life, it is better than building a seven-storey Buddhist pagoda." If we can leave behind our skin when we die, it is also a blessing to be able to give and this shows self-reliance and, at the same time, rendering help to others. It is something worthwhile for us to promote in the society.

*Cols. 1807-1808.

Medical Tourism

Dr Lam Pin Min: Sir, more and more people the world over are seeing the attraction and benefit of seeking medical treatment overseas. The figures are staggering and, to illustrate this clearly, it has been estimated that the amount generated by medical tourism worldwide will amount to about US$92 billion by 2012. Every practitioner in the private medical industry wants a slice of this growing pie.

Singapore is no exception. Singapore Medicine was launched five years ago with the goal to attract one million medical tourists by 2012. Our share of the medical tourism market has been steadily climbing too. Achieving our target by 2012 would generate about S$2.4 billion in healthcare expenditure as well as 13,000 jobs. This is good for Singapore in more ways than one. It is also a goal that we can achieve, given the good reputation of the Singapore medical profession, both in the public and private sectors.

However, as it is, the world is facing a shortage of medical professionals. This

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has resulted in a brain drain not only between countries but also between the public and private healthcare sectors. Singapore is not spared of this phenomenon as well. It is common knowledge that our professional healthcare givers in the restructured hospitals and polyclinics are usually overworked and some may even conclude that they are under-remunerated. It is thus not surprising to see an exodus of healthcare professionals from the public to private healthcare sector.

For the average Singaporean, with the increased arrival of tourists competing for medical services, they fear that they may be sidelined. As it is, the current long waiting time in restructured hospitals would be worsened if the infrastructure is unable to cope with this increased demand.

I would like to ask the Minister:

(1) What are the plans and strategies to cope with this increased demand?

(2) What assurance can MOH give to the average Singaporeans that they would not be unduly disadvantaged or sidelined as a consequence of medical tourism?

The Minister of State for Health (Mr Heng Chee How): Sir, we agree with Mdm Halimah that helping persons with mental illness should be done holistically. Institutionalised care may be appropriate for some and in some circumstances, but not always. It also comes with big social stigma. Medication can help manage symptoms, but it is also not the full answer.

The Minister of State for Health (Mr Heng Chee How): To improve the outcomes for persons with mental illness, we must first recognise that it is not only a medical

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issue. Many factors, such as an individual's home, educational and work environment, his socio-economic status, and the quality of family and community support all influence the likelihood of improvement. Thus, holistic care for mental illness should, besides institutional care facilities and medication, also include access to behavioural therapy, community facilities and social support services. We believe that this will help patients recover and reintegrate into society faster and better.

We are, therefore, expanding our efforts to inject new capabilities into the community over the next five years. The inter-Ministry working group on Mental Health, chaired by the Permanent Secretary, Ministry of Health, is overseeing this. Its efforts include wellness promotion, public education, early detection and treatment, and reintegration into society. Employment and social needs are also examined. In strengthening the links between social care and medical support, we hope to reduce the need for hospitalisation and improve the chances for patients to regain their mental health, and to work and live well within the community and enjoy peace of mind. Let me update the House on four specific areas of improvement.

First, we will strengthen mental health care in the community, with customised approaches for children, youths, adults and the elderly.

We are doing this with our partners – VWOs, and community partners in the workplace and schools. For example, the Adult Community Programme will monitor patients with mental illnesses to ensure compliance with medication and provide psychosocial support to the patient and the family. A network of interested GPs is also being identified and trained to care for patients in the community, and to complement the existing Community Wellness Clinics in polyclinics.

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5.00 pm

Second, we will press on with public education on mental health, and encourage people to seek treatment earlier. This will help deal with the onset of conditions better. The Mind Your Mind programme, a mental wellness programme for school children, will be expanded to cover tertiary institutions. HPB launched the Workplace Mental Health Programme, “Treasure Your Mind” (TYM) in October last year, and 95 organisations have registered under the programme. Last year’s National Healthy Lifestyle Campaign was centred on having a “Healthy Mind, Happy Life.” This year, a media campaign will be conducted, focusing on building positive relationships.

Third, we will invest more in manpower development for mental health. We will train more psychiatrists, psychiatric nurses and allied health professionals such as psychologists, medical social workers, and occupational therapists by increasing specialist training places and scholarships. This will translate into better care for the patients.

Fourth, we will facilitate more research into mental health so that we are able to plan and care for our patients better. The National Mental Health Evaluation Programme, led by researchers from the Institute of Mental Health, seeks to better define the extent of mental disorders in our population, to identify barriers to mental health care in Singapore, and to study social, cultural and economic factors associated with major mental disorders, and then from there to transfer those research findings into treatment and health options.

Now on preventive healthcare. Various Members suggested that we increase the focus on health promotion and preventive healthcare. Mr Zainudin Nordin asked about how we have done in

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our level of health in the population. Dr Lily Neo is concerned about how we can reduce the time spent in poor health as we live longer.

Singaporeans are living longer, and we all want to live long and to live well. Thus, it is right that we pay attention to prolonging our healthy years, and shortening the unhealthy ones. Dr Neo noted from the recent article in the Straits Times that Singaporeans on average suffer eight years of poor health. I do wish to clarify that this does not necessarily mean that we spend eight years of our life hospitalised or severely disabled. The figure of eight years refers to the gap between life expectancy and healthy life expectancy or HALE. HALE is the average number of years of “healthy life” a person can expect to live. But living in less than full health might be due to illness of varying severity and duration. So it is a broad definition.

Still, the point remains that we must continue to work at increasing our HALE years, so that we may indeed be hale and hearty for as long and as much as possible.

Mr Zainudin Nordin asked about nutrition of Singaporeans. The diet of adult Singaporeans is generally adequate. The mean intakes of energy, protein, carbohydrate, vitamins and minerals of Singaporeans met at least 70% of the Recommended Dietary Allowances levels. Between 1998 and 2004, the proportion of Singaporeans who eat more fruits and vegetables has also increased – in the case of food consumption – from 20% to 28%, and in the case of vegetables, from 15% to 43%.

The recent MOH study showed that the main causes of ill-health in Singapore, and as pointed out by Dr Lily Neo, are cancers, heart disease, stroke, diabetes

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and mental disorders. We believe that prevention is the key to reducing ill-health and disability arising from diseases, and we can do it in three ways:

First, by preventing and delaying the onset of illness and disability through a healthy lifestyle like eating well, exercising regularly, not smoking and practising mental wellness and having a good sleep;

Second, by detecting illness, especially chronic diseases and cancers early, through regular screening; and

Third, by minimising disease complications, through taking medication as prescribed and following up with the doctor promptly.

To help get the message across to the people, MOH and HPB have done many media campaigns. Examples include the National Healthy Lifestyle Programme, the National Anti-Smoking Programme. Screening programmes such as Breastscreen and Cervicalscreen (for breast cancer and cervical cancer respectively) have also been introduced to facilitate early detection of these cancers.

On the whole, Singaporeans have become healthier. The prevalence of hypertension, diabetes and smoking has fallen. Between 1998 and 2004, the prevalence of hypertension had dropped from 27.3% to 24.9% and that for diabetes came down from 9% to 8.2%. The smoking prevalence rate had also decreased from 15.2% in 1998 to 12.6% in 2004. So, if you look at these figures, more Singaporeans are adopting healthier lifestyles. The proportion of Singaporeans who exercise regularly, for example, had increased from 17% in 1998 to 25% in 2004. The proportion of women aged 40-69 years who had gone for mammography at least once before had increased from 27% in 1998 to 51% in 2004.

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Much work lies ahead. For example, the percentage of our people who exercise regularly at 25%, I think, is still too low. More people should be exercising. And if you think that one in eight of the population still smoke, then, again, there is more to be done. In 2004, about half of our diabetic population did not know that they had diabetes, and about 40% of hypertensive people did not know they had hypertension. About one in four diabetics had poor blood sugar control and one in two hypertensives had sub-optimal control of blood pressure. So we must press on.

In the past, we used mass media messaging and in recent years, we moved to more segmented messaging focus. For example, we partnered community stakeholders to bring across messages about anti-smoking. We also customised programmes for specific target groups. As an example, we targeted young women in our anti-smoking campaign through messages about how smoking causes accelerated ageing. As a further example, “kebayarobics” was an exercise programme developed for Malay women. So moving forward, we hope to individualise these messages. With these examples and the experiences, and the more we can focus and individualise, we believe that we can reach out better and be able to get the message across and affect behaviour more. The earlier example of the nurse health educator programme which the Minister mentioned provides individualised health messages on diet and physical activity. In addition, HPB is developing an online health portal that sends specific advice to individuals based on their submitted health details.

Now on obesity. We share Dr Lam and Mr Zainudin’s concerns about obesity. The prevalence of obesity among adult Singaporeans is rising. It increased from 5.1% in 1992 to 6.9% in the year 2004. Obese people are more at risk to diseases such as diabetes and heart attacks.

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Although our rates are still lower than those in many developed countries (and they have reached double digit figures), their experience has shown that obesity rates can increase very quickly, as could be seen from the chart just now. Therefore, we must act early to contain the deterioration.

We have been promoting healthy eating and physical activity for many years. Together with MOE, HPB implemented school-based programmes to control obesity, such as the model school tuck-shop programme which provides healthier food choices in school tuck-shops. The other measures were targeted physical activity programmes and also referring children who are severely overweight for medical assessment and management. The total proportion of overweight and obese students (ie, overweight plus obese together) in the primary and secondary schools and junior colleges fell from 11.1% in 1994 to 9.5% in 2007. So, that broad category of overweight plus obese fell. Unfortunately, within that encouraging drop, the percentage of obese students increased from 2.8% in 1994 to 3.6% in 2007. HPB will continue to work closely with MOE to address this issue through various initiatives such as the counselling and medical referral programme.

For adults, we will strengthen current efforts to prevent obesity through promoting regular exercise and healthy diets. We will also create a supportive environment by increasing the availability of reduced-energy and healthier foods in supermarkets and food outlets and making exercise and fitness facilities more easily accessible for all Singaporeans.

This year, we will mount a campaign to increase awareness that obesity is a major health risk factor for diabetes, and to encourage Singaporeans to maintain a healthy weight in order to reduce their risk of diabetes. Next year, we will campaign

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against obesity directly. MOH will be forming an obesity prevention taskforce to explore strategies to address this issue among the young and the adults. We will study how other countries are approaching the problem, learn from them, and adapt to our local setting.

Controlling obesity in the population is tough. Campaigns can only do so much, and we need to move beyond healthy eating and regular exercise messages. As with other chronic medical conditions, improvements at the population level will generally be seen only in the medium term. It clearly calls for collaboration amongst various agencies and stakeholders, and the individual must take responsibility for his own health. We will study the scientific evidence to see what more can be done, and also learn from the promising initiatives elsewhere.

But the message is quite clear, at the end of it, there is no short cut to keeping slim and the only sustainable way is to control our diet and to exercise regularly. Unfortunately, there are some people who choose quick-fix procedures such as liposuction to improve their appearance by removing the excess fat. We do not recommend such an approach. Liposuction carries risks and, if improperly done, can result in life-threatening complications such as bleeding and infection, and, in some cases, even death. Major complications and deaths arising from liposuction have been reported in the US and in Europe. Nearer home, in a neighbouring country, there has been a report of a patient who underwent an eye-bag surgery, a tummy tuck and liposuction. She developed complications, went into coma and remains in coma. Singaporeans should be aware of this. Unfortunately, my Ministry has also begun to receive unconfirmed feedback of liposuction being done in some outpatient clinics that have led to problems.

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Let me stress that liposuction should be done by properly-trained doctors and in properly-equipped and staffed operating theatre facilities. Doctors have a duty of care to their patients, and they should practise only within their competence. For those customers who insist on undergoing liposuction, they should seek qualified and experienced doctors to do this for them in accredited surgical facilities. Otherwise, they risk their lives.

Now on HIV. Mayor Zainudin cited some statistics from a survey to express his concern about the public awareness on HIV/AIDS. The statistics remind us that we need to continue working hard with new strategies to address these misconceptions, improve knowledge and, more importantly, change behaviours so that HIV can be better prevented and diagnosed earlier. Another area that needs to be addressed is the stigma against people living with HIV and AIDS. HPB has specially targeted education programmes for youths, parents, high-risk heterosexual men, men-who-have-sex-with-men and single women. The programmes are carried out in schools, in higher educational institutions, workplaces, entertainment spots as well as within the community. To support the expanded efforts, we have secured an additional $10 million for HIV education over the next two years.

5.15 pm

On teenage abortions, our data showed that teenage abortions have not been on the rise. In fact, the number of abortions has declined from a peak of about 1,700 annually in the year 2000/2001 to about 1,300 in the year 2005/2006. But still it is a significant number, and therefore, we agree with Dr Lam that it is important to educate our youth on safe sex to prevent unwanted pregnancies and sexually transmitted infections, and we will continue to monitor closely the abortion rates among

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teenagers. HPB works closely with the MOE and MCYS in this effort. Today, all our secondary schools offer sexuality education that teaches the consequences of sex and how to say "no" to sex. Contraception and STI are included in the curriculum. HPB complements this with an STI/AIDS prevention programme called "Breaking Down Barriers". This programme has an interactive, multi-media mass education session that covers topics like abstinence and condom use, and a class-based component that teaches skills like responsible decision-making, assertiveness and negotiation skills on saying no to sex.

HPB is also taking the fight beyond the schools. It recently developed the "Love Them. Talk about Sex" Programme, in collaboration with MCYS. This is conducted in workplaces, schools and community venues and provides information and tips on how to broach and discuss sexuality issues with their children. The programme is supported by a toolkit, a helpline and a website. HPB is also working with Family Service Centres and other youth organisations to reach out to youth-at-risk and equip them with the life-skills.

As Dr Fatimah has pointed out, in our society, people are generally reluctant to think about or talk about death or issues related to death. My Ministry has thus far adopted a cautious approach in promoting Advanced Medical Directive (AMD). We acknowledge that it is a very personal decision.

Sir, although medical technology can sometimes struggle to delay death in the final stages of a terminal illness by very invasive and intrusive methods of treatment, it remains true that death cannot ultimately be avoided. The aggressive methods may also cause the terminal patients to suffer more rather than less. The living will or Advanced Medical Directive gives terminal patients

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with no prospect of recovery the ability to pass on in peace and dignity.

Although my Ministry has undertaken public education about the AMD since its introduction in 1997 to explain its value for both individuals and families, to reassure about the treatment safeguards and to allay fears about the process, to date fewer than 9,000 people have made an AMD. We will increase our education efforts to improve social awareness and understanding of AMD and end-of-life issues, especially when our population is rapidly aging. We will also review and simplify the administrative processes to reduce difficulties for those who choose to make an AMD.

I would like to thank Mr Sam Tan for bringing up this subject to help increase public awareness about skin and organ donations.

Currently, the Human Organ Transplant Act (HOTA) only allows for kidney, heart, liver and cornea donations. When the HOTA was enacted in 1987, it only included kidney donation and in 2004, the Act was amended to include liver, heart and cornea donations and was done after extensive public consultations showed that the majority of Singaporeans supported such inclusion. Because organ donation under the HOTA runs on an opt-out system, we have ensured that the inclusion of organs in the Act has public support and address the more urgent transplant needs of Singaporeans.

Although skin donation is not covered under the HOTA, Singaporeans can pledge to donate their other organs including the skin through the Medical (Therapy, Education and Research) Act. This does not affect their decisions under HOTA.

Skin donations are no less important than kidneys in saving lives. From 1998 to 2007, the National Skin Bank managed to receive over 100,000 square

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centimetres of skin grafts from 50 donors after their death. This has benefited more than 100 Singaporean patients, mostly suffering from extensive burn injuries.

Mr Sam Tan thought that each year, up to 20 burn victims die because there is not enough skin to cover their burns. From our data, for the past five years an average of eight deaths per year come from severe burn injuries. This figure includes both Singaporeans and foreigners. Most of these patients die not because there are not enough skin grafts available, but because of their other very severe injuries. Our Skin Bank maintains a good reserve of skin grafts. However, in exceptional situations, we have the ability to tap the assistance of overseas Skin Banks for additional grafts.

As we intensify our public awareness efforts on organ donation over the next few years, we hope that more members of the public will consider pledging their skin as well as other organs.

Dr Lam Pin Min was concerned about the impact of medical tourism on healthcare for Singaporeans. My Ministry will ensure that Singaporeans have access to good and affordable healthcare. My Minister has earlier explained how we will be investing to further improve the quality of our healthcare for our citizens. Indeed, it is the high quality of our healthcare that attracts foreign patients to our shores.

Although foreign patients can choose to go to our restructured hospitals as unsubsidised patients, they make up less than 2% of admissions in our restructured hospitals currently. That said, MOH understands the concern that Dr Lam has described, and will ensure that Singaporeans are never disadvantaged even as foreign demand for healthcare services here grows.

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And to do so, we will build more restructured hospitals as well as add more beds, and this has been explained also by my Minister. Next, we are facilitating the private sector's building up of medical infrastructure to meet increased foreign demand. Third, we are strengthening our healthcare manpower pipeline – both local and foreign. Together, these measures will increase our capacity to meet the anticipated healthcare needs in Singapore.

Mdm Halimah Yacob: Mdm Chair, I have three questions to ask. Firstly, I would like to ask the Minister with regard to medical tourism and manpower development. Now that we are focused on attracting one million medical tourists by 2012, how will that impact on the Ministry's manpower situation, particularly since now we are already seeing quite a critical shortage in some areas like specialists, and so on? So is that in the Ministry's projection as well?

Secondly, I would like to ask, now that we have got means testing in place, and it will be implemented in January 2009, whether the Ministry will be allocating more resources to the B2 and C class wards, particularly in reviewing some of the areas where currently subsidies are not given or lesser subsidies are given, for example, the list of standard and non-standard medicines. Some medicines are non-standard and prescribed by doctors because they are more effective, but they are still considered non-standard in the B2 or C class treatment.

Thirdly, I would like to ask how much of the $88 million that has been given to help in developing mental resilience has gone into supporting community-based mental groups, that are helping to provide shelter and other forms of assistance to those suffering from mental illness.

Finally, I would say that I am very happy with the Minister's announcement

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on means testing. It is really most welcomed and I think it would allay a great deal of the fears of Singaporeans.

Mr Khaw Boon Wan: I thank Mdm Halimah for the three queries. For medical tourism, the projected million more tourists coming to Singapore, yes, surely as I explained in my earlier reply, all this must impact the supply on the manpower side, particularly at the specialist level. The key, I think, is not to stop them from coming, but to make sure that we ramp up supply at the same time. So part of the big increase in the health budget this year will go towards enlarging our manpower pool, as I elaborated earlier. On local training, we will always be short, and that is why it is crucially important that we continue to tap on external sources as well. In my earlier reply, and I think it is worth repeating, last year, while we graduated slightly more than 200 doctors here, we recruited more than 400 from overseas with recognised degrees. This is the approach that we will take on this particular subject.

As for means testing and standard drugs list, we have a medical committee of experts to advise us and they regularly review the standard drugs list. Each year, they will add some but there is hardly any year when they withdraw some. They will top up the list as and when they have better evidence of the cost-effectiveness of the new drugs and I stand advised by the medical professionals.

But a key theme that ran through my earlier speech – which is also the point that Mdm Halimah shared with us just now – is moderating public expectation. The easiest thing in the world is to keep on expanding the standard drugs list. In fact, why have a list? All drugs should be allowed. Then you have Avastin, the example that I gave, but it is US$100,000 per drug, per patient. So while we keep on increasing our health budget, if the economy is doing well, there is always a

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limit to things, and that is why it is so important how we target our subsidy, so that those who genuinely need it will get it, and those who can afford to pay more, they should co-pay more. I am glad that Mdm Halimah finds the parameters that we have finalised on, which is in Annex A, an acceptable scheme.

As to the $88 million fund for mental health, how much of it will go into community groups, I do not carry those figures on top of my head. I do not know whether Mr Heng does.

Mr Heng Chee How: On the $88 million, I would just like to say that $55 million out of the $88 million is actually earmarked for developing community themes as well as manpower development for use in this area. I do not have the detailed breakdown in terms of whether or not it goes into those organisations that she has mentioned, but certainly this $55 million is targeted in that direction.

Mr Low Thia Khiang: Madam, first I would like to clarify that I did not say Singaporeans are denied the choice of class of wards in the hospitals, as what the Minister has said earlier. The point I made was that Singaporeans are now denied the right to decide for themselves what is affordable to them upon hospitalisation and the patients decide which class of ward they would like to get admitted to. The affordability is now decided by the Government by means testing, as the percentage of subsidy to C class ward is based on that. This is a fundamental change.

Madam, I would like to clarify with the Minister: does the Minister not agree that the outcome of means testing would be for the not-so-rich to pay more? The very rich will go to a private hospital. Is the Government unable to afford providing healthcare without implementing means testing? Madam, I am alarmed by the Minister's statement that if we do not

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implement means testing, our C class ward standard might degenerate to standard in the 70s. Are we that poor now as a nation, that we need to do that, poorer than in the 70s as a nation?

Madam, I refer now to the Annex distributed by the Minister. The percentage of subsidy for C class wards is stated in the Annex. I would like to know from the Minister how long will this percentage last. What is the commitment of the Government to the long-term subsidy percentage of C class wards based on the income level that is listed here? I note that the $3,200 income level which would qualify for the C class ward subsidy of 80% is higher than what was intended to, as reported in the press. I would like to know what is the basis on which he decides on what income level he will subsidise 80%. In the longer term, what level of subsidy can we expect after means testing is implemented?

5.30 pm

Mr Khaw Boon Wan: Madam, the first point on whether Singaporeans are being denied as to choice of wards, my point is that nobody is denied any freedom of choice. Anybody can put up his hand and if he wants to go to class C, provided he is sick and he requires medical treatment, then he will have a choice of classes,

and, in the hospitals, at the admission counter, we have been doing this for many years now, what we call financial counselling, because we also want to make sure that the patients choose the right class of wards. At the point of admission, once we know what are the patient's medical conditions, we can counsel the patients. We have a lot of statistics, average figures and percentiles, to tell us that for this particular condition, there is a likelihood that you will stay six days and if you go to class A, this is the bill size; if you go to class B2, this is the bill size;

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and C. The patient can then make an informed choice. So that freedom remains. Means testing allows us, once we know your salary level and which subsidy band, to churn out similar tables accordingly and customise it to the particular illness the patient is being admitted for, the patient then makes his or her choice. That is how it will work.

Mr Low's point is that means testing will hurt the middle class. Yes, potentially. The lower class, the low-income group, has no means testing and precisely because of this, that is why if you look and study carefully Annex A, we have purposely "erred on the side of generosity" – I used those words – and I think nobody can fault me for not doing so. That we have deliberately included a substantial number of the lower-middle and the middle-middle and perhaps even part of the upper middle-income group. So, at $3,200, it is almost 60% of the Singaporean working population. And so for those 60%, full subsidy remains and even then, if you cross that one, it is a graduated scale – which happens to be a suggestion that came in from the public which we then incorporated.

I think the key point is this – which was a question that I posed in my earlier speech – what are class C and B2 wards built for? That is a fundamental question. Is it built for every Singaporean? In other words, 100% all go to class C, which is really the British National Health System. One class – rich or poor, millionaire or pauper, you go into that one class, take it or leave it. In fact, then there is no choice. Here we provide full freedom of choice. You can go to a private hospital, or you can go to different classes in a public hospital. So that is the way we handle it. But things, as I have said, have now developed in such a way that today, the situation is quite different from 30 years ago. We cannot unwind the clock. When I started my career, class C ward was really for the very poor, and I spent

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time walking the ward floor, and I talked to patients who were clearly the poor. Thirty years later, today, it is very different. Yes, the poor, some of them, remain in class C, but many do not look poor to me at all.

This is the current situation which I think is not a bad development, in a sense, because over the years, the economy does well, so we share out the economic growth with all strata of the Singaporean population. So even the poor can see their service level improve over time and, over the next 10 to 15 years, I hope we can continue to do so, so that no matter how poor you are, your healthcare continues to rise up in accordance with the economic status of the whole country.

So, that is the approach we take. But if you do not put in this filter, which is the means testing, and if you keep on doing that, today, it is all right, only less than 10% of the top 20% stays in class C. But without means testing, do you think it will stay at 10%? Surely not, unless, as suggested by Ms Sylvia Lim, we freeze: no more development of class C wards. But I think that will be unfair to the poor in 10 to 15 years' time, and they may not agree that today's current standard of class C will be adequate by the year 2020.

That is the problem we are trying to resolve here, and I think it is a very practical way forward. So all patients, rich or poor, you are eligible to go into class C, and if you look at the subsidy for the rich, it will still be very heavy. At class C, you only pay one-third of the cost, and for those who are earning $8,000 to $9,000, you can well afford it. I have checked the Medisave balances of all those of the higher-income group – largely $28,000, $27,000, more than $25,000. So there is enough money in their Medisave, even if they are not insured.

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But my key message remains the same. Means testing is not to deliberately upset people or that we want to means test you and charge you more. Means testing is to remind Singaporeans that, going forward, please think about hospitalisation and, therefore, buy insurance. Everyone must buy basic MediShield, and if you are of the middle-income group, let us say you earn more than $4,000, please top it up with a rider. And if you do, you do not have to go to class B2 or C because if your insurance entitles you to class B1 stay, and, of course, you go to class B1. So why go there (B2/C) and compete with the poor? In fact, the more we tightly implement means testing, the more we can do for the really poor. Why is it that the standard drugs list which Mdm Halimah talked about expands so slowly? It is because many can afford to pay for the more expensive non-standard drugs and they should be paying out of their pocket or get their insurance to pay for them. Without means testing, they can easily go to class C and they know they will be entitled to these very heavily subsidised expensive drugs. But it is the same limited budget. Of course, every year, we grow that budget but when more people are putting their hands in for these drugs, surely, each will get less. This was similar to our family planning slogan many years ago – "more mouths to feed, so less to each". This is the situation. So, let us be practical. This is the reality: between demand and need, there is a wide gap. Therefore, let us take a realistic and practical approach to this. Face the fact and the way I am doing it is extremely gentle.

Mr Low asked how long will Annex A stay as it is. It depends because situation will evolve and income group adjusts. As the economy grows and income profiles change, we will adjust with time.

So whether it is PA's rates, or whatever means testing criteria for housing and education, they are adjusted

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periodically and, surely, whoever is the Health Minister prevailing at that time will do that kind of adjustments too. But the fundamental policy remains, that health subsidy is limited. So let us see how we can share it out as fairly as we can but, at the margin, be flexible, so that those we think are of the high income group, if they have genuine difficulty, if they are not able to buy an insurance because of some complicated congenital illnesses, I am sure whoever is the Health Minister, or the hospitals running it, will take a flexible approach to that.

Dr Lam Pin Min: Thank you, Madam, for giving me this opportunity to ask two clarifications. One is with regard to retaining medical health professionals in the public sector. We understand that there is always an efflux of top surgeons or specialists into the private sector because it is always more lucrative in terms of monetary factors. I remember the last time we had a pay revision in the public sector, it was probably umpteen years ago. I want to ask the Minister whether there is a feasibility of benchmarking the pay of public healthcare workers to those in the private sector.

The second question is with regard to incentives to stay trim. One of my suggestions is whether we could incentivise by lowering the medical premium for health insurance for people who keep trim and fit. We can actually use the BMI as a standard to measure health, maybe even a lucky draw for people who remain healthy or thin for that matter.

Mr Khaw Boon Wan: The resignation of public sector doctors to the private sector is a problem that we have to manage day by day, year by year, because so long as the private sector exists and they pay

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better, some of our staff will be tempted to go there. Therefore, we have to be competitive in our remuneration terms. Dr Lam mentioned about some adjustments "umpteen years ago" – those were the words he used – but that was not quite right. We have been adjusting and last year, for example, there were some adjustments, and I am quite sure this year we will look at it again. Maybe the KK Hospital did not make an adjustment, but I believe that we certainly provided budget for the hospitals to make such adjustments. But the key point remains that we must compete with the market and we have to retain them. I am always grateful that we have so many very good doctors. They could have easily crossed the road and make more money, but they stay because they know that the bottom half of Singaporeans have no choice, that if they do not stay, their expertise will be lost to this bottom half of Singaporeans. We are truly grateful to them. But being grateful is not enough, we should also pay them properly, which we will.

On staying trim and the incentives for doing so, I have been watching this development with interest. Many insurers talk about it. When I probe more deeply, it is fluff. The theory is easy – if you engage in healthy lifestyle and, therefore, your health should be better, I reward you. The difficulty is always this – how do you certify? Everybody will put up their hands and say, "Yes, I exercise three to four times." What am I going to do? Put a CCTV and watch their movement? Impossible. Check BMI but there will be many people who will say, "I am born, for some reason, fat. The fat cells are more and therefore I am fat. It is very unfair." So these are the problems that we will face, but I think we should try to keep it on our mind and see if they are practical to do, we will.

The Chairman: I will allow one last clarification because we have got 5 minutes left. Dr Ong Seh Hong.

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Dr Ong Seh Hong: Actually, I have three clarifications.

The Chairman: You have to do them very quickly.

Dr Ong Seh Hong: The Minister just now said that he does not want to use the same model of means testing for step-down care because he wants to be more generous with the bigger bill. But for step-down care, the bill may be small on the monthly basis but over time it can be very big. Will the Minister consider maybe a similar approach, a hybrid system? You still use this very simple approach but for the special case, you use a different method.

Mr Khaw Boon Wan: I will find it difficult to implement such an idea.

Mdm Halimah Yacob: Madam, we have had a very useful debate this afternoon and I am very glad that the Minister has agreed to consider some of the proposals made by Members of this House. In particular, I am very happy with the details on the means testing mentioned by the Minister on two counts, firstly, on the income cut-off point. Instead of the 50th percentile announced publicly, it is now the 60th percentile of salary level. And, secondly, between the 60th and the 80th percentiles, it is not going to be a steep incline but it is going to be incremental and gradual. These two amendments have been made as a result of extensive public consultation, which I am glad the Ministry has taken into account and also because of the feedback given by some of our MPs. I think this augurs well for our public consultation process and it is definitely a positive influence on public policy making.

On that note, I wish to thank the Minister and the Minister of State. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn .

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The sum of $2,415,776,200 for Head O ordered to stand part of the Main Estimates.

The sum of $216,818,500 for Head O ordered to stand part of the Development Estimates.