HEAD O - MINISTRY OF HEALTH

Sitting resumed at 3.50 pm

[Mr Speaker in the Chair]:

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

[Mr Speaker in the Chair]

**** Head O - Ministry of Health

The Chairman: Head O, Ministry of Health. Mdm Halimah.

Mdm Halimah Yacob: Sir, I beg to move,

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

Sir, much has been done to improve our healthcare system but affordability remains a concern. The recent DOS statistics show that people are spending more on healthcare, which had gone up by 8% in 2005. Out of a total healthcare expenditure of $5.9 billion last year, the Government's portion is only $1.7 billion, which means that people are bearing the bulk of the cost. This has been the trend in the past and is likely to continue. In this year's Budget, only $1.4 billion has been allocated as operating subvention to the restructured hospitals and institutions, polyclinics and VWOs to enable them to provide subsidised medical care. Yet, the MOH estimated in the Budget this year that the average bill size for subsidised patients will increase further at a rate not exceeding the health CPI, which is usually higher than the general inflation rate. So healthcare cost is going up faster than wages, particularly for those at the bottom 30th percentile whose wages have stagnated or declined.

Sir, I would like to ask the Minister what more can be done to contain healthcare cost and ensure that healthcare remains affordable. Is the amount of Government subvention given to hospitals and other institutions for subsidised patients sufficient, considering that our population is ageing very rapidly and the significant increase in the number of those suffering from chronic illnesses?

Sir, it is true that we have high levels of subsidy for the B2 and C classes, but using the subsidy level alone as a reference point to determine affordability is not sufficient.

MOH should also look at two other factors. First, the subsidy should be based on the total bill and not only part of the bill. In other words, when the hospital says that it is subsidising 80% of the bill for the C class, then this should cover all the items in the bill and not only some of them. If the subsidy is not on the total bill and the patient has to pay the full cost of some items, then it actually means that the subsidy for the C class patient is less than 80%. This is very hard on low-income patients especially if the items excluded from the subsidy are expensive, and most who are on long-term care would have exhausted all their savings.

Sir, I would also like to ask the Minister to consider publicising the exclusion list of drugs and medical implants or accessories that are not covered by the subsidy or MediShield, so that people know upfront what is the total cost of treatment to them, as many believe that everything on the bill will be subsidised and they do get a shock when they receive their bill. This exclusion list could be displayed on the Internet or other forms of communication.

The Ministry could also track the total amount that the patient has to pay by treatment or procedures to determine affordability and if this keeps on increasing, then the hospitals should be asked to explain the reasons for the increase. The subsidy levels can be high but if the hospital charges keep going up, then it would still be expensive for the subsidised patient as the portion that he has to pay will be higher too.

Sir, we must also ensure that public hospitals continuously look at ways to reduce wastage and unnecessary cost to the patient, and provide greater transparency. The total project cost for the Computerised Physician Order Entry (CPOE) system and Inpatient Medication Records (IMR)Applications, for instance, for the two clusters alone is $41,905,000, which is a huge investment. But the question is: how has this helped to reduce wastage arising from duplication or multiple tests done on the same patient, and how has this helped in seamless care?

Sir, what cost savings or greater productivity can the public expect from the $11.5 million investment in teleradiology - again not a small amount? Or what is being done by the two hospital clusters to synergise and leverage on economies of scale in purchasing or other areas so that the cost savings can then be passed on to patients? Why is there a need for each cluster to maintain duplicating areas of specialties, such as heart, cancer or eye, for instance? Or now that we are trying to right site the management of chronic illnesses to primary care physicians, is there a need for a hospital to maintain a Diabetes Centre, which contradicts this effort?

Sir, what the public wants to see is greater accountability and transparency and concrete measures to address their concerns. I urge the Ministry to keep a close watch on affordability, as this is still a concern for Singaporeans. And I hope that the Minister can enlighten us on the issues that I have raised.

Sir, I think the problem is also that the two healthcare clusters see themselves as competitors with their own priorities, rather than collaborators in delivering a very important public good, and that is in delivering an affordable and quality healthcare system.

Next, SingaporeMedicine and Public Private Partnership. The decision to attract one million foreign patients by 2012 is a very bold plan, and the economic arguments are clear. However, there are concerns over how this will impact on subsidised patients when public hospitals too start chasing after foreign patients and treating them in the same hospitals as the subsidised patients.

There are a number of issues here. Compared to other developed countries, the general sense is that there is no firewall when the doctors in public hospitals treat the private patients leading to concerns of conflict of interest. So such concerns already exist now, hence, the question is whether it will be exacerbated when public hospitals start marketing and intensifying efforts to woo foreign patients.

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The question being asked is whether this will dilute the public hospitals’ core mission of providing affordable healthcare to Singaporeans. There are concerns that this will happen because, in the first place, foreign patients who come here do so because they want better and faster treatment and will have to be given priority in the use of scarce hospital resources, such as access to specialists or the use of medical technology, if we want to establish a reputation and continue attracting them. As it is, we are already suffering from a shortage of doctors, nurses and other allied professionals. The moral hazard becomes even more evident when the remuneration package of doctors is structured in a way which will incentivise them to treat more foreign or fee-paying patients. We need to address these concerns as it would appear that there is a policy shift in our public hospitals from one where its social mission is to provide good quality affordable healthcare to Singaporeans to one, which includes a commercial mission also, of providing excellent medical care to foreign patients.

Sir, I would like to ask what steps will be taken to ensure that subsidised patients will not be affected by the push to attract more fee-paying and foreign patients into the public hospitals. What checks and balances are in place? Is there a need to adopt a more arms-length approach when public hospitals deal with private/foreign patients? Would it not be better for public hospitals that want to attract foreign patients to do so under a separate company, so that there is separate funding, accounting and full accountability to prevent concerns about conflict of interest from arising, as one of the complaints is that doctors in the public hospitals have the advantage of using the facilities funded by Government but yet do not face the risks undertaken by private hospitals. I think a more arms-length approach in wooing and treating foreign patients in the public hospitals is important. This will lead to better accountability in the use of public funds. It will also ensure that our public hospitals do not suffer from schizophrenia - a serious branding problem - unsure of how to project themselves and who they should serve, subsidised or richer foreign patients.

Sir, I hope that the Minister would address some of the concerns and issues which I have raised. I must emphasise again that our public healthcare system is one of the better ones in the world and a lot of good changes have been made over the past few years, which I must credit the Ministry. But these two issues of affordability and the need to maintain and relook at structures and systems pertaining to the SingaporeMedicine and public/private hospitals are important issues of concern to Singaporeans.

Dr Lily Neo: Mr Chairman, may I ask MOH what are its proactive plans in meeting the new challenges of our ageing population? Is MOH expecting a ballooning demand for its services due to increasing life expectancy of people? How is MOH strategising to meet this demand in terms of both the infrastructure and the medical expertise? Is MOH prioritising preventive healthcare to keep the ageing population as healthy and fit for as long as possible? Is there a need to manage and alleviate increasing demand for the dependence on acute hospital beds? How does MOH plan to do this? Should there be further improvements and enhancements in step-down care and community care? Are there other viable solutions such as homecare system? Has there been study done to better postulate on the future healthcare demand of our ageing population to help us plan better for this need? How does MOH plan for the possible 6.5 million population growth in terms of healthcare? Does MOH have funding for this? Finally, is there an urgent need to look at ways to improve the capabilities and capacities of geriatric medicine to meet the needs of our changing demography?

Health Insurance

Mr Yeo Guat Kwang (Aljunied): Sir, the 3M (Medisave, Medishield and Medifund) system is one of the key pillars of our social safety net. Through this financial framework, Singaporeans can better cope with the medical costs and able to enjoy favourable standards of medical care. However, this framework provides just the basic. We hope that more could be done to help Singaporeans understand better the healthcare challenges that they face and options available, eg, more comprehensive coverage for everyone and family.

To kick off, MOH could consider actually working hand in hand with the labour movement and the grassroots organisations to promote public awareness of medical insurance. We need to help all to first understand the whole 3M framework fully and the need to get adequate personal and family medical insurance coverage to ensure that they can cope with hefty medical bills through better risk-pooling. Singaporeans should also be encouraged to ensure that their spouse and children also have adequate medical insurance coverage, with at least Medishield coverage.

I welcome the announcement by the Minister to make Medishield an opt-out scheme for the young. In fact, we should also consider actually making it an opt-out scheme at the point of marriage for all the housewives, so that all the men can easily include their wife who might not have been able to make contribution to CPF.

Sir, to strengthen our healthcare financing framework, we should also encourage Singaporeans to take up private enhanced Shield plan and, if need be, additional rider insurance scheme. This will ensure that working Singaporeans will not be dependent on or shortchanged by the loss of group hospitalisation and surgical insurance schemes that are in force, only if the individual remains in the company's employment. As lifelong employment is no longer prevalent in view of changing employment trends, working Singaporeans need a more comprehensive and integrated portable medical insurance scheme that is built upon the basic Medishield plan.

Sir, through greater awareness concerning the variety of the medical insurance policies available, individual Singaporeans then can better tailor their medical coverage to suit their needs.

Portable Medical Benefits Scheme

Ms Cham Hui Fong (Nominated Member): Singapore's healthcare financing framework aims to ensure fiscal sustainability and affordability for all Singaporeans. The 3M framework has worked well over the years and the linking of the Workfare to the CPF or Medisave should encourage more Singaporeans to join the social safety net.

For regular employees, most are already provided hospitalisation benefits by their companies while they are in employment, while most of the contract and the casual workers do not have such benefits.

Currently, Medisave can be used to purchase Shield plans or other Medisave-approved insurance scheme with co-payment and deductibles. We agree that this is a sound principle as it helps to eliminate the buffet syndrome. However, the employment landscape has changed over the years. There is now high turnover in the job market due to attrition, restructuring and many other reasons. So, while one is out of employment, especially for the lower-income workers, the only insurance he will have is probably the Medishield, that is provided he has not opted out.

Some insurance companies have introduced rider plans which help to cover for medical expenditure not covered by the Shield plans. Such scheme can be individual based and is portable. So, the tripartite partners, together with MOH, have discussed about the portable medical benefits scheme and the transferable medical insurance scheme (TMIS) for many years. The Economic Review Committee has also suggested that we promote both the PMBS and TMIS, but over the years, we have made very little success with both schemes to date.

As at end November 2005, only 109 companies have made additional contributions to the employees' Medisave. There is mention of insurance playing an even larger role in Singapore's healthcare financing in the MOH's Budget report. May I ask what kind of enhancement in the insurance design is the Ministry looking at? In the meantime, with more workers on Medisave, will the Ministry also review the use of Medisave for purchase of at least a basic Medishield rider, subject to a cap, just as what the Ministry has mentioned recently about using Medisave to purchase the Eldershield rider, subject to a cap?

With the withdrawal of medical subsidies for the foreign workers, employers are now obliged to purchase compulsory medical insurance for their foreign workers. From what I know, most of our Singaporean contract or casual workers do not have any hospitalisation medical insurance for themselves. While we are not asking for the Government to pay for them, can we at least allow them to use their own Medisave money to purchase for this rider? This will at least give them some certainties about their in-patient expenses. With the Government topping up Medisave contribution to the casual and the informal workers, allowing the use of part Medisave for rider scheme will certainly benefit those casual workers with no medical coverage by their employers. It will also help us to encourage more to join the CPF scheme.

Medisave

Mr Low Thia Khiang (Hougang): Mr Chairman, Sir, the Government has allowed Medisave to be used in the Chronic Disease Management Programme with the following conditions: A deductible of $30 is set on each outpatient bill; bills below $30 will continue to be paid in cash; a cash co-payment of 15% on each outpatient bill in excess of the deductible will be set; and an annual withdrawal limit of $300 per Medisave account.

Sir, I would like to know what is the average bill size incurred by such patients at polyclinics. The feedback I had was that the majority of patients seeking treatment for chronic diseases at polyclinics would cost around $40 to $50 for a two-monthly review.

Due to the $30 deductible, the amount of benefit to patients from using Medisave to defray the cash payment under the Chronic Disease Management Programme is minimal, since based on the average bill size of $40 to $50, only about $10 to $20 is payable using Medisave. On top of this, an administrative fee of $4 is also levied. It seems that the effect of the $30 deductible and co-payment requirement runs contrary to the intention to ease the financial burden of the patients who have chronic disease.

Many of such patients are senior citizens with no active income and are relying on their cash savings and children's contribution to pay their medical bills. The deductible and co-payment requirement pose the same heavy burden as before. So, I would urge the MOH to consider reducing or waiving the deductible of $30 and cash co-payment for senior citizens who have reached retirement age, but maintain the annual withdrawal limit of $300. I am also of the view that MOH should also consider waiving the $4 administrative charge, since this charge will be significant compared to the actual bill which will be incurred by this group of patients.

Awareness of Medisave, MediShield and Medifund

Dr Muhammad Faishal Ibrahim: Sir, in recent years, we have seen various efforts by the Ministry of Health to make changes to the health system, particularly in the use of the Medisave to enhance its relevance to the changing needs of the society. These changes have been well received, in particular to those who have been following the news and are affected by health issues. I believe this has certainly enhanced the level of confidence in our health system.

As one grows older and with an ageing population in the horizon, I think it is natural for an individual, as well as a society, to be concerned about health issues. As Singaporeans, we often hear about the 3M being one of our safety nets. However, during my block visits, I often meet elderly and low-income residents relating their concern about health matters. When I asked them about the concept of 3M and if they understood what Medisave, MediShield and Medifund meant to them, the majority of them did not have a full understanding about this.

To go on further, I did ask more than 100 students the same question. I received similar answer and they told me they have not come to that stage yet. While many understand about Medisave, the majority of those I spoke to did not have a full understanding about Medishield and Medifund. Wherever possible, I try to explain to them as well as work with my grassroots leaders to disseminate the information to my residents.

I would like to ask the Minister on the measures to enhance the awareness and understanding of the concept of the 3M, as well as individually, namely, Medishield, Medisave and Medifund. Are there any specific measures to reach out to the elderly and low-income Singaporeans? In addition, are our students well informed about such concepts as part of their school syllabus? What are the plans of the Ministry to increase the participation rate in this scheme?

Manpower Development

Mdm Halimah Yacob: There is a shortage of doctors, nurses and allied professionals in the healthcare sector. The situation will get worse as demand goes up due to an ageing population and the decision to attract one million foreign patients. Could the Minister give an update on the manpower situation and what plans the Ministry has to address this problem, so as not to affect the standard of medical care in Singapore? What more can be done to increase the supply without compromising standards, as there are also some concerns over the recent liberalisation of the registration process for foreign doctors and the addition of new foreign medical schools on the list.

Sir, while we are training more nurses in the polytechnics, retention is an issue as the attrition rate is high. After SARS, many were attracted to the nursing profession, which suddenly became glamorous, but reality sets in when they are posted to hospitals and find that the work is not suitable for them. So, there is a need to find a better fit. Recently, nurses' pay were raised and they also now have better career progression leading to the APNs, but for allied professionals, the situation does not seem to have improved as they feel that there is better recognition for them in the US and other developed countries

where they are treated as professionals compared to Singapore.

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Sir, as most of the nurses are women, could the hospitals consider providing more flexible work options so that they do not have to leave the service after having babies? The other option which the hospitals could also consider is re-employing people beyond the age of 62, ie, extending the re-employment. And I would like to commend SGH for their Silver Connect programme which is an excellent programme. I hope all the other hospitals would also emulate that programme.

Finally, Sir, there is also a concern among the APNs that, while they are required to take over some of the tasks of doctors, they feel that they are not sufficiently protected, in terms of litigation or other actions taken against them. Apparently, doctors have better protection compared to them. So the APNs are concerned about that. They also would like to be given the chance to have more challenging tasks assigned to them in the hospitals. Could the Minister please look at these issues?

Dr Fatimah Lateef (Marine Parade): Sir, with the current doctor to patient ratios, many studies have shown that it is going to be a big challenge for the elderly in many ageing nations to receive the optimal holistic care they require. Unless we can make managing healthcare issues of the elderly top priority, the supply of trained healthcare personnel will be insufficient to meet our elderly explosion. Currently, there are only a handful of geriatricians in Singapore. The British Geriatrics Society recommends one consultant geriatrician for 4,000 population over 75 years, or one consultant per 50,000 general population, and this refers to a full-time consultant. A significant proportion of the healthcare budget is allocated towards manpower training and upgrading. Can the Minister please share with us the numbers of doctors and nurses who have received specialised training in disciplines, such as geriatrics, psychological medicine and psycho-geriatrics? And also, will the Ministry of Health be opening up the number of slots available for basic and advanced training in these disciplines over the next five to 10 years? We need to attract more young and interested doctors and nurses into these areas and we are still short of role models and mentors for them locally.

Finally, Sir, I also have a suggestion to add. Geriatricians must be utilised more efficiently. They should not become adjunct primary healthcare providers, but instead be allowed to focus on age-related syndromes that fall through the cracks. We cannot overload the limited number of geriatricians we are going to have. Rather than being a vertical discipline which focuses on one area or one organ system, geriatricians will manage diseases in a horizontal fashion, cutting across organs and systems. We should also, on the other hand, train every medical student, every medical officer and every trainee with some basic knowledge of geriatrics. This is because not every old person needs a geriatrician, but every physician needs to have some training in geriatrics.

Mr Zainudin Nordin (Bishan-Toa Payoh): Sir, with the development of the new hospital in the north of Singapore, I would like to know whether we have enough medical officers to cope with the Health Ministry that is growing at the moment. Specifically, Sir, I would like to know how is the progress of our training for nurses and what is the quality of our nurses compared to the other developing and developed countries. I would also like to know whether the number of nurses that we are training is enough and are we producing enough Advanced Practice Nurses (APNs) that are equipped with up-to-date and advanced skills to reduce the over-dependency on doctors to perform basic operations, like what is being practised in the developed countries.

I would like to echo the same comments made by the GPC Chair about the need for us to protect our APNs more. Because if we want to treat the professional nurses as equal partners in the treating of our patients, we also need to give them proper protection so that they can do their job better and perform their task better. May I also ask the Minister what is the progress of our hospital in the north? Is the progress up-to-date and when can we expect the hospital to be ready?

The Minister for Health (Mr Khaw Boon Wan): Sir, this is my 4th Health Budget. Having dealt with the more immediate issues for three years, I will from now on focus on gearing up Singapore for its 2020 healthcare needs.

Sir, I will be 68 by then. My wife and I will be silver haired. What about you, Sir? Actually, I am already silver haired, except for the wonders of hair dye. My daughters should be married by then and, hopefully, we will have a hall full of grandchildren. My family and I would need much more healthcare than we do now. That is why I am most mindful that 2020 is only 13 years to go. We must not let it slip by casually. The questions posed by Mdm Halimah, Dr Lily Neo and Members are all pertinent ones. We must find answers to those questions over the next few months and continue to refine them over the next few years.

The socio-demographic changes to come are well known. Still, it is worth highlighting what are the key factors that would significantly impact our future healthcare demands. Most Singaporeans would be better educated, have higher expectations and they want high-quality care and, I hope, they are able and also willing to pay for it. But for the bottom 20% or 30% striving to cope with global competition, money will always be tight and healthcare cost will be their key concern.

The number of people above 65 will increase; fortunately, most will be healthy and well. Many will however be health conscious and will seek medical attention without hesitation to address any discomfort or just to get a reassurance. The number of "old-old", exceeding 80 years, will increase many-fold. By the time they hit this age, many will have some medical problems. Just now, over tea break, I remember discussing this particular problem of elderly patients with Mdm Cynthia Phua and Ms Denise Phua. Many will be financially comfortable, but there will be a sizeable number who will be very tight financially.

Scientific discoveries and medical technologies will accelerate and make available diagnostic and treatment modalities that we can only dream of today. But many of these will be costly and the companies are not going to give it away for free.

Clearly, one size cannot fit all. As Health Minister, my duty is to put the big pieces in place so that, by 2020, we will have a healthcare system that offers a whole spectrum of care that meets the needs of the young and the old, the rich and the poor and the large numbers in between, and we have the financial resources to pay for them. So, let me start with funding.

In the musical cabaret, Liza Minnelli had that popular line, "Money makes the world go round" and our Jack Neo made "Money no enough" part of our psyche. Money does not make the world go round, people do. And we will have money for healthcare if we save for it, have the right expectations and do not waste it.

What are the realities of healthcare? Everyone will need it, most of them towards the latter part of life when they are not at their peak in earnings. Social welfare and comprehensive insurance are seductive ideas - no need for co-payment, make it free at the time of consumption, so that nobody needs to worry about healthcare cost. But we all know that both lead to the "buffet syndrome" of abuses, over-servicing and financial disaster. And when the healthcare system is overwhelmed, it is the poor who suffer because unlike the rich, they cannot afford the other alternatives. The truth is that healthcare demand is unlimited but supply is, because not many people are willing to pay more taxes or insurance premiums, which are needed to expand supply.

The rational approach is therefore to require some co-payment by patients. Co-payment makes a dramatic difference to patient behaviour and even doctors' behaviour. For everyone to afford the co-payment, we have to get everyone to save through Medisave for a rainy day. And, on top of that, we pool the risks through a basic insurance plan, MediShield, as a backup. Finally, we provide sensible social welfare through Medifund as the ultimate safety net. This is how we tackle our financing challenge, with 3Ms providing multiple layers of safety nets. Each layer does not cover everybody, but together the multiple layers of safety net cover everyone. Dr Faishal asked that we explain our healthcare financing schemes more thoroughly and frequently to Singaporeans. I fully agree, and we will. We must keep the schemes easy to understand, because healthcare can sometimes be very complex. And we will improve our public communication efforts. Let me use this opportunity to reiterate our model.

For minor treatment and healthcare needs at GPs and polyclinics, $20, $30, $40, or even $50, I think, preferably use cash. Our GP services are very competitive, inexpensive and affordable for most people. But for larger medical expenses that require hospitalisation, our Medisave scheme is working as designed, especially after we have fine-tuned it in recent years. Every year, some half a million transactions are funded through Medisave. I have now extended Medisave to cover outpatient treatment of four common chronic diseases. And the full impact will be felt over the years when the scheme matures. I am optimistic that, if participating chronic patients cooperate with their family physicians and actively change their lifestyle, comply with medication, their health would improve. This will avoid future complications and save patients money and suffering.

Mr Low Thia Khiang asked that we remove or reduce the cash co-payment; I think that will be unwise. Remember that Medisave was not designed for outpatient care. I make an exception here, and we must not unwittingly deplete it for purposes not originally planned. Because if you do, then the contribution rate will not be enough. You have to raise the contribution rate.

Collectively, there are now $36 billion in our Medisave Accounts today, and this is still growing at more than $1 billion a year. This is healthy but only because we are still a very young society. Medisave is our savings for the future when we will all grow old. The only structural problem now is that some Singaporeans, a minority, are not saving. They are naturally worried about healthcare cost. The solution is not to make healthcare free but to get them to save. Workfare and Government top-ups will help them build up their Medisave for the future rainy day. But they must themselves make some effort.

For larger medical expenses requiring intensive and prolonged hospitalisation, we have MediShield. After the reform in 2005, it is now working better. We will continue to refine it to reduce the co-payment by patients, but we must not make it a comprehensive medical insurance scheme without any need for co-payment. Some insurers sell MediShield riders to eliminate co-payment. This is not wise and we do not encourage this. That is why we do not allow Medisave to pay for the premiums of such riders, as proposed by NMP Cham Hui Fong. But if Singaporeans want to buy such riders out of their cash savings, I cannot stop them.

I have a couple of ideas to enhance MediShield further. MediShield coverage among active workers is not bad, 90%, nine in 10 workers. But 390,000 Singaporeans below 20 years of age are still not insured. The premium at their age is inexpensive. It is only $30 a year. And young parents can use their Baby Bonus to pay for the premium in full. So cost is not an issue. Many parents already do so, in fact, about half of our youths are covered by the enhanced MediShield promoted by private insurers. Some parents who did not do so told me that they know MediShield is a good product, but inertia is the reason for their lack of participation.

I will make it easier for these parents to sign on their children for basic MediShield coverage. We will introduce an opt-out scheme for infants to be automatically covered under MediShield from the time their births are registered. Premiums can be deducted from their fathers' Medisave Accounts or, alternatively, their mothers'. Parents who do not want such coverage can opt out any time by informing the CPF Board. We would get this done soon so that all babies born on Christmas can have MediShield. I would try to get it done hopefully in less than nine months so that some babies who are already conceived can also benefit from it.

For those who are already born but below seven, we will work with the Ministry of Education to provide this opt-out service at the time of Primary 1 registration. For older students, we will work with MOE to see how we can get them in as a one-off exercise. I think this can happen next year.

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I thank Mr Yeo Guat Kwang for his support of the measure, and I hope all parents will support it too. It will be good for their children. To keep basic premiums affordable for the majority, MediShield will continue to exclude coverage of congenital illnesses. But for the vast majority, MediShield coverage from young will give parents peace of mind that, should their children develop any illnesses as they grow up, they will have insurance coverage for such illnesses and the subsequent treatment. After I have brought the children into MediShield, I will see how best to bring in the 100,000 or so housewives who are still outside MediShield. I will study Mr Yeo Guat Kwang's suggestion for an opt-out scheme for husbands to sign on their wives. Actually this is already the case. At the time of marriage, there is this opt-out scheme in place. But for some couples, after marriage, somehow, some husbands decided to opt out their wives. We have to find some way to get them in.

Medifund provides the ultimate safety net to catch anyone who drops through the Medisave and MediShield nets. We aim to build up Medifund to a capital sum of $2 billion. So this year, the Government has topped up with $200 million, making it now $1.5 billion. Every year, we make use of the interest income to help those who fall through the net. Our hospital Medifund committees work very hard to prevent any Singaporeans from falling through the cracks. These are good-hearted, busy and successful people who volunteer their time, expertise and wisdom to help us manage this piece of social welfare in a wise and compassionate manner.

The Minister for Health (Mr Khaw Boon Wan): 4.31 pm

Last year, Medifund handed out $40 million to 290,000 applications for financial assistance. About one-third of these beneficiaries are over the age of 65. With ageing, we know that such demand will only grow. We need to build up Medifund when our economy is doing well and whenever there are budget surpluses. Some elderly patients are worried if their Medifund needs will be squeezed out by the needs of their younger applicants, and I get such feedback occasionally. We have reassured them that all cases will be assessed based on needs, and that we do not bias our decisions towards the young or the old. However, we will give our senior citizens added peace of mind. I am thinking about carving out a portion of Medifund, ringfence it as the Medifund for the elderly. We can call it Medifund-Silver, protected for the use of needy senior citizens above 65. It can have a capital sum of $500 million, about a third of the entire Medifund today. This way, we can address the needs of the elderly patients in a more targeted manner.

With the financial resources through the 3M system, we can then work to match supply of physical resources with demand. Just to maintain this year's standard of care, in the year 2020, we will need more hospital beds, clinics, doctors and nurses than what we have today. That is why we are building a new general hospital of 550 beds in Yishun. When it fully opens in 2010, our acute hospital beds in the public sector will total 6,500. But between now and then, we will add beds, where there are opportunities to do so. This year, for instance, we will add 120 beds in Tan Tock Seng Hospital, Changi General Hospital and National University Hospital.

In parallel, we will continue to expand day surgeries to reduce unnecessary hospitalisation. Last year, I remember discussing the Jurong Medical Centre idea. It has now materialised. I visited it not long ago and am very pleased with the development there. Alexandra Hospital, which runs it, has started to systematically transfer their day surgeries and outpatient follow-ups for their patients who live in Jurong. This brings good specialist services closer to their homes. The patients I spoke to were very happy with the change.

The private hospitals will also need to expand to cope with rising demand. They are important partners, serving the middle and higher-income groups, or about 20% of the national patient load. They provide Singaporeans with more choices. As our medical standard is high and our fees internationally competitive, naturally we attract many foreign patients in the last few years, increasing by more than 20% a year. It could actually have been higher, but the private hospitals had under-invested in the past and they are now missing out on opportunities.

EDB’s feedback is that private hospitals are now ready to invest and expand their capacity. There are also international investors who are interested in setting up in Singapore. The Government intends to launch two land sites for private hospital use in the second half of this year, so this will be quite soon: one near the Novena MRT Station by URA, another within One-North by JTC. Both sites can add about 400 beds to the private hospital bed capacity, which is quite significant. Meanwhile, we are also preparing other sites for possible release in the next few years.

The beds described above are acute hospital beds. But healthcare is more than that. As emphasised by Mdm Halimah and Dr Lily Neo, with ageing, there will be increasing demand for longer-stay, lower-cost, lower-tech facilities in the step-down care sector. We will need more community hospitals, nursing homes, hospices and day-care facilities for rehabilitation and home-nursing services.

We have not had to pay much attention to this sector as our population is still young. But by 2020, the needs for step-down care will be significant. To gear up for 2020, we have to ramp up supply and systems from now on. Briefly, we need to do four things for step-down care.

First, we need to expand capacity. We are reviewing the requirements for community hospitals and nursing homes, and will facilitate investments at the appropriate time.

Second, we need to widen participation by all providers in this sector because the needs of the elderly are diverse, from the higher-income to the indigent. Today, our step-down care facilities are largely run by charities and they do a reasonable job. But higher-quality nursing homes to serve the needs of the middle-class elderly are still in the early developmental stage. We must widen the range of choices, at different pricing levels and at different service standards. It costs much more to run Ritz-Carlton than Hotel 81. If Ritz-Carlton were to charge less than Hotel 81 or the same, there would be a long queue outside Ritz-Carlton and Hotel 81 will be empty. But because hotel pricing is sensible and undistorted by Government subsidies, both businesses are full with their respective clientele. I know some might not agree that the economics of healthcare should be the same as the economics of hotel services. But the reality is that healthcare services need to be financially viable in the long run, and there is no other way. Even if the Government pays for it, it is still taxpayers’ money.

Third, we need to attract more allied health staff to this sector - and several Members talked about this - with better skills and higher education level, to service the rising demand for a higher level of care. We will need more physiotherapists, speech therapists, occupational therapists, podiatrists, counsellors, psychologists and also doctors and nurses with skills in geriatric medicine, as highlighted by both Dr Lily Neo and Dr Fatimah Lateef. We will also push up the skills of our nurses so that they can take over those routine tasks from doctors, as advocated by Mr Zainudin Nordin. We call them Advanced Practice Nurses (APNs). I remember we discussed this in this House when I moved the Nurses and Midwives (Amendment) Bill two years ago. I have noted the point about liability issues and I will take a look. I am sure our cluster would have adequate coverage for them but I will take a look.

Fourth, we need to address the financing of this sector. The needy will need some subsidy by Government or charities. But with healthy competition among providers, the majority of patients should be able to self-fund either through savings and/or long-term disability insurance, like ElderShield. ElderShield, as a product, is rather new to Singaporeans. I agree with Mr Yeo Guat Kwang that we should educate the public more on the different types of insurance products and their users. For example, there is still confusion between MediShield and ElderShield. MediShield is for acute hospitalisation, with payouts based on reimbursements. But ElderShield is a cash supplement for step-down care in the community, often at home or in a nursing home.

I am reforming ElderShield to make it work better for Singaporeans with their needs in 2020 in mind. I shared my thoughts on this during my recent Ministerial walkabout. I will continue the public consultation and welcome feedback and suggestions. We will get the reform implemented this year.

Beyond financial and physical resources, human resources are the key to a good healthcare system, as highlighted by Mdm Halimah and Mr Zainudin Nordin. Our doctors, nurses, allied health professionals and other support staff work very hard in public hospitals and polyclinics. To keep healthcare cost low, we run our facilities at very high occupancy rates. Our doctors and nurses see many more patients than their counterparts elsewhere. If not for their sense of public duty, many would have quit for an easier time.

Yes, we may have service lapses at times. But most of the time, our healthcare workers do a competent job, and often go beyond the call of duty. They do not expect gratitude, although we do receive many complimentary letters that cheer them up and keep their morale high. So, please, give them your moral support. They are the unsung heroes and heroines of our excellent healthcare system. They deserve our appreciation and understanding.

Medical specialists take a long time to train. It is especially difficult to get manpower planning right in Singapore because we have a significant foreign patient load which fluctuates from year to year. I have noted Mdm Halimah’s comment on SingaporeMedicine and foreign patients and their possible impact on local patients. I will address them in my next speech. Meanwhile, we are recognising more good medical degrees and we are recruiting more foreign-trained doctors. From about 85 a year in 2003, last year, we took in 180 foreign-trained doctors from very good medical schools, bearing in mind we ourselves produce only 230 last year. So it is almost one to one. This is good, but we remain particularly short of certain specialists who are also in huge global demand, like renal physicians, neurologists and cancer specialists. We have to devise more effective schemes to attract such specialists from abroad to augment our team.

As I said earlier, we will also pay attention to the allied health professionals. The good news is that many more excellent students have been entering nursing, pharmacy, radiography, therapy and other courses in recent years. They are bringing up and changing the profile of our allied health workers. Many existing staff are also upgrading themselves. We encourage and facilitate this through many scholarships and overseas attachments. Our healthcare team is getting stronger.

Students and mid-career Singaporeans are discovering the job satisfaction of a healthcare career. We must be doing something right in our hospitals. We will press on. Recently, I suggested to my parliamentary neighbour, NTUC Secretary-General Mr Lim Swee Say and also WDA’s CEO, that let us work together to get more mid-career workers to work in hospitals. We have a successful scheme for nurses. Let us now promote other professions like physiotherapists, speech therapists, podiatrists, and so on. At the same time, we will work hard to retain staff. This requires us to keep our wages competitive. This is also the reason why medical fees need to be raised periodically because manpower cost is a major component, more than half, of our medical cost.

Sir, let me conclude. Gearing up for 2020 does not mean that we can simply do more of the same, because patients’ expectations are changing. Patients Google the latest information on their illnesses and treatment options, and want to engage the doctors in our treatment choices. This is good, but it means a longer consultation time. Such patients will not be satisfied with a 10-minute consultation. But if everyone demands a 20-minute consultation, we will have to double our doctor-patient ratio, double the number of doctors and, of course, double the unit cost of treatment.

We will maintain our current subsidy policy of Class C patients paying 20% of cost, polyclinics, 50% of cost, and so on. But when unit cost goes up in line with a higher standard of care, the dollar co-payment by patients will have to go up accordingly. These are the types of adjustments that Singapore

will need to make over the next 13 years, if we want the medical standard of Singapore at 2020 to match the expectations of Singaporeans and to stay ahead of our neighbours. In practice - let me assure Mdm Halimah and other Members - we will weave in such adjustments gradually, compassionately and pragmatically.

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We will pace the adjustments according to what Singaporeans can afford. Maybe, a couple of hospitals can move ahead slightly faster than others. All hospitals will receive the same unit subvention from my Ministry for the same illnesses, and all patients will receive competent medical care. But the hospitals, which can offer shorter waiting time because they have a higher doctor-patient ratio, will need to cover their higher operating costs with slightly higher fees.

My mission is to ensure that our healthcare services remain affordable to Singaporeans in general, particularly the lower half of the population. It requires careful planning and cooperation from all the stakeholders. It requires all of us to have realistic expectations. My Ministry will do its best to expand our capacity and our service levels to meet up with the rising demand and rising expectations. That is why the Finance Minister, in his Budget Speech, talked about healthcare budget, rising from about $2 billion to $3 billion within five years. This is a very substantial expansion in the Government's commitment to healthcare. My job is to make sure that the funds are wisely spent.

Management of Chronic Illnesses

Mdm Halimah Yacob: Mdm Deputy Speaker, for chronic illnesses to be managed effectively, we require a well-functioning and effective primary care system. This is one weakness in our healthcare system, as a result of which there is a high dependence on specialists pushing healthcare costs up. So there is a need to expedite the training of GPs as family physicians to take care of the chronically ill. Could I ask the Minister to give us an update on this and other measures to better manage chronic illnesses in Singapore?

One major complaint of the elderly suffering from chronic illnesses is the poor integration of services from the hospital to step-down care, such as community hospital or nursing home, which are subject to means-testing and are under-funded as they enjoy lower subsidies. There are also insufficient homecare services for those suffering from chronic illnesses and there is no subsidy for such services which act as a deterrent for families to take care of the elderly sick at home. So, what more can be done to ensure better integration of services for the elderly sick suffering from chronic illnesses?

Could the Minister consider extending the same level of subsidy to the step-down care services as the ones that are found in the hospital and do away with the requirement for means-testing for those moving from the hospitals to step-down care? Because once they are out of the hospitals, they go through any means-testing for step-down care and sometimes, they do not get subsidies as a result of that. As a result, patients do not want to move from the hospitals to the step-down care. Also, the level of subsidies are different compared to the hospitals and the step-down care.

Could the Minister consider extending subsidies to the elderly sick who are taken care of at home to lessen the burden of families and reduce the overload on hospitals? Because there are some families who want to take out the elderly sick, but they do not have any subsidies for providing homecare services to their parents or elderly sick. Could the Minister also look into that?

One final point is that I support the ElderShield changes. Could the Minister review the qualifying criteria, which I think are too stringent and many do not qualify?

Focus on Patients

Mr Sam Tan Chin Siong: Madam, the Ministry of Health has been given an extra $300 million in this Budget. So, the Ministry has more money to spend in this financial year. My concern, and I am sure the Minister's as well, is that the fund should go to the right places.

To begin with, I must say that our restructured hospitals are already one of the best, if not the best, in the region. However, like many other things, there is always room for improvement. In my opinion, building a large water feature, three-man high and about the length of a small swimming pool, in a place mostly meant for hospital staff, is not the best way to spend the money. Hiring high profile consultants at millions of dollars is not the best way either. Having more non-professional than professional directors is also not the best way too. Yet, all these are being done in a large restructured hospital.

I believe we can afford to be more restrained in our landscaping and renovations in our restructured hospitals, especially those at the staff block where few patients go to.

Madam, my second point is more paradoxical. I believe that our restructured hospitals should be more concerned with taking care of patients than the bottom line. It is good to be able to say that our private patients subsidise our public patients, and hence, each hospital is able to cut its spending, require less funding support from the Government, and lower the tax burden on Singaporeans.

To me, this is an attractive argument but not a convincing one. I feel that our restructured hospitals should not be in the business of competing with private hospitals to improve their bottom line. My GPC Chairperson had elaborated on this point in her speech just now. I fully agree with her that our restructured hospitals should focus on taking care of the public patients and improving their services.

I would like to share a personal experience at a large restructured hospital recently to illustrate the importance of patient care. A few weeks ago, I visited a relative and found him to be quite ill. So I accompanied him to a restructured hospital. He was sent to the A&E Department around 2.30 pm. Within an hour, the A&E doctor had examined him, and informed us that he needed to be hospitalised for treatment. This was an excellent and speedy action taken by the doctor, and I think the doctor deserved a commendation. We were told to wait for a ward and a bed. At 5.00 pm, the ward admission procedure was done as a bed had been made available. However, from 5.00 pm to 7.00 pm, the patient and family members were made to wait outside the A&E Department. Despite making four enquires on the status, the patient was still left at the A&E Department. At 7.00 pm, I finally went up to the A&E counter to enquire about the long wait. The nurse on duty checked and explained that due to manpower shortage, they could not send the patient to the ward early.

I am not sure whether it is manpower shortage or communication gap, or both, that had resulted in two hours of unnecessary waiting time. This is not a unique experience to us. I asked some people waiting around at the A&E Department, and they told me they had been waiting for between four and six hours, and they were still waiting.

Long waiting time is just one of the many complaints we often hear from people, or read about in the newspapers' Forum articles. Indeed, Lianhe Zaobao carried two more complaints on 12th February 2007 and yesterday. While acknowledging the hardwork and good work of our healthcare professionals, I think the service gaps need to be plugged. While focusing on improving the facilities and amenities, I feel that the restructured hospitals should adopt a patient-centric approach in providing medical care and services.

While we strive to become a medical hub, we need to ensure that our focus remains on patient care, not just making sure that our hospitals can attract more foreign and well-paying private patients, not just making sure that doctors and nurses are well trained, not just making sure that we have the state-of-the-art equipment, but also making sure that we turn our attention to things that matter to the patients and their families.

With so many medical advances today and even more rapid advances tomorrow, I am sure that the care for the patient can only become more complicated and sophisticated with an ageing population, and all the more reason then to focus on getting our basics right.

The Chairman: Mr Low Thia Khiang, you might like to take both your cuts together.

Healthcare Cluster

Mr Low Thia Khiang: The healthcare clusters, mainly SingHealth Group and the National Healthcare Group, were set up when public hospitals were restructured in the 1990s. In my view, it seems that the intended objective of promoting competition with the presence of two healthcare clusters has led to some unnecessary shortcomings and wastage as a result of this artificial market competition created.

Firstly, there is duplication of services. All public hospitals have cardiology, respiratory unit, ENT, Eye Department, etc. These disciplines require costly specialised equipment.

Secondly, having two clusters incur double the overhead costs, such as manpower and resources in administration, corporate support functions, as well as management staff needed to manage these two clusters.

Thirdly, there are different IT set-ups and technical requirements for the two clusters, for example, the software used by SingHealth and NHG Polyclinic is different and not integrated. When a patient changes his healthcare provider from one cluster to another, the patient's record cannot be transferred seamlessly between the two clusters because they are not integrated. This lack of integration increases the administrative hassle and potentially impacts the efficiency and effectiveness of delivering healthcare, particularly for patients who have chronic diseases, such as hypertension and diabetes. This is because the patient's history is critical for proper referral to ensure a complete handling over of care between the previous and the current doctor managing the patient. The two clusters may also have different policies and treatment protocols. This may also result in confusion for the patient.

Madam, the long waiting time, especially at outpatient clinics, which according to MOH's survey, was due to the uneven workload. Would the MOH study the possibility of centralising the scarce medical resources and set up specialist-based HQs, and let these HQs handle the workload and distribute manpower according to the patients' workload of individual hospital? This would reduce the resources, wastage of specialist manpower in specialist outpatients clinics, with lower patient load. For example, the ENT and Eye Clinic of Alexandra Hospital and Changi General Hospital have a lower utilisation rate than those at SGH, TTSH and NUH.

I believe that it is time for MOH to examine the cluster model of healthcare, particularly to assess how a better integration of medical services and administrative systems can be achieved and an efficient delivery of healthcare services. The clusters could be restructured into centres based on services, such as polyclinic service, hospital in-patient services, etc.

Human Organ Transplant Act

The recent scuffle between the relatives of a brain-dead man and the SGH team over the harvesting of the deceased's organs has raised a few disturbing questions about how the SGH implements the HOTA. Could MOH release more details of the case as the public has so far been relying on media reports and blogs for information about the incident?

The public understandably is concerned about the case because it raises the question of how HOTA is implemented and how organs are removed from brain-dead patients. I would like to know: does the hospital has the discretion to unilaterally determine when should life support be turned off when the patient is declared brain-dead? What are the considerations in deciding when to switch off life support? Would the relatives of the brain-dead patients have any say in the decision? What processes are there in place to handle such requests from relatives to delay the turning off of life support? Would the hospital have respected the relatives' decision in this case if the patient was over 60 years old and whose organs were not suitable for transplant?

Madam, in light of the strong public concern over the incident, I would like to know whether the Ministry have any plans to educate the public and to build up public confidence on the issue of brain-dead and the implementation of HOTA I would also like to know whether the Minister would consider amending the Act to respect the wishes of the family members should they have strong objections towards the organ donation, notwithstanding the fact that the deceased has not opted out.

Dementia in an Ageing Population

Dr Fatimah Lateef: Madam, we are on the brink of a dementia epidemic in the Asia Pacific region. The disease burden will increase significantly in the coming years with tremendous economic and social impact. How this translates into cost in public health will vary according to the country and the mix of care provided.

Currently, there are 22,000 elderly diagnosed with dementia in Singapore - this is about 6.8% of our population. By 2020 and 2050, the numbers will be 54,000 or 15.7% and 188,000, that is about 56.7% patients with dementia and related illnesses respectively.

Direct cost will include quantifiable cost from hospitalisation, treatment, drug, nursing care, etc. There will also be indirect cost incurred to the family, the healthcare system and society as a whole. Will MOH be conducting some analysis on this projected cost to Singapore to fine-tune our public healthcare system, our 3Ms, ElderShield, and so on? The Kyoto Declaration which provides a framework for determining the actions required may be used as a reference document. Indeed, we just heard earlier that the Minister has mentioned some reform to the ElderShield as well as the Medifund Silver. Certainly, these are steps in the right direction.

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We may also have to consider some different imputation

algorithms based on international statistical data to reach an appropriate estimate for Singapore in Singapore dollars, as we may not have local current statistics.

Electronic Medical Records Exchange and Telemedicine

Dr Lam Pin Min: Madam, an electronic medical record is a medical record in digital format. Its use facilitates access of patient data by clinical staff at any given location - sharing of patient information and clinical notes with other healthcare providers, enhancing safety by building automated checks for drug interactions and allergy, scheduling and easier archiving and storage of records. Electronic medical records exchange (EMRX) established in 2004 is an initiative by the MOH and the two public healthcare clusters to share electronic medical records across all public hospitals and polyclinics in Singapore.

The initiative also helps reduce cost as doctors from different institutions can now view the results of any recent blood test, X-rays and investigations online, thereby reducing the need to repeat the tests. In addition, teleradiology was also implemented in December 2005 at certain polyclinics where digitised X-ray images were diagnosed by a foreign country outsourcing partner.

With the Ministry's mission to ensure healthcare remains affordable, I would like to ask the Minister the following questions:

(i) to provide an update on the usage rate and the benefits of EMRX and teleradiology in Singapore since their implementation;

(ii) to consider extending the EMRX to all private healthcare institutions and practitioners, as the sharing of the medical information would minimise unnecessary and duplicate medical investigations being performed when patients cross between public and private sectors; and

(iii) to consider broadening the scope of tele-medicine to achieve cost and time savings for patients without compromising on quality and safety of healthcare delivery in Singapore.

Managed Healthcare

Mr Sam Tan Chin Siong: Madam, I would like to dive into a relatively murky water, which is the managed healthcare scheme. I say it is murky because much of it is unknown to most people and yet it affects many Singaporeans' healthcare.

In Singapore, there are many healthcare schemes. The one that I would like to talk about is the kind that requires doctors to provide medical services and care to workers at a group rate that is fixed for the year. Many large companies here are on some kind of managed healthcare system. Under this kind of scheme, doctors are contracted by managed healthcare companies to see patients at a fixed rate for consultation and medicine. They have a set of parameters to abide by. All these, including the price of consultation, are not transparent to patients or their companies. These managed healthcare companies are generally called health maintenance organisations, or HMOs in short.

As an illustration, let us say a company engages an HMO to provide medical services to its employees, and the company pays the HMO $20 per patient per visit. How much of this goes to the doctor? We do not know. The doctor and the HMO staff, of course, know, but under the terms of the agreement, they are not allowed to disclose the amount. One doctor, writing in the Singapore Medical Association's newsletter, recently said that he gets no more than the price of a meal at the McDonald's per patient.

In 2003, a survey of 220 doctors by the Singapore Medical Association showed that doctors are generally unhappy with the way that they have to treat patients under their contract with a HMO. Their grievances include low consultation fees, slow payment by the HMOs and, at times, even restrictions on the type of medicine they can prescribe and the specialists they are allowed to refer the patients to.

I am not fighting for doctors to make more money, but I think all these conditions and restrictions do affect the quality of care provided by doctors. We know that there is always a trade-off between cost and quality of care. I am not advocating a Rolls Royce standard in a company healthcare scheme. But what I am concerned with is an adequate level of care for patients, particularly those whose employers contract out their healthcare service to HMOs.

In Singapore, doctors are subject to a strict code of ethics for their conduct. As far as I know, HMOs are not subject to any regulatory framework. In fact, anyone can register an HMO and start soliciting business from employers to provide healthcare services to their employees. So, how then can we ensure that the HMOs' business and coffee-making agenda do not compromise the healthcare services quality?

In Hong Kong, there has been a legislation put in place to regulate the HMOs compelling them to observe a certain set of code of conduct to ensure that a certain quality of healthcare is delivered to patients under their programme. As the situation and conditions between Singapore and Hong Kong are quite different, it may not be necessary for Singapore to also provide similar regulatory framework on the HMOs. Notwithstanding this, I think we can still start cautiously and prudently on the monitoring of the HMOs at the current stage.

For a start, I would like to suggest that the Ministry conducts a review, if this is not done yet, on the HMOs to see if the delivery of the healthcare service is up to the industry's benchmark. The review should be able to provide useful findings for the Ministry to consider the next course of action.

Many employees in Singapore rely on the healthcare given by their company's doctor, as a major part of their healthcare planning. It is estimated that spending by companies account for about 30% of the national health expenditure in Singapore. This is quite significant. It is therefore in the interest of our healthcare system to make sure that there is some oversight on this matter.

Singapore Medicine

Dr Fatimah Lateef: Madam, as we formalise SingaporeMedicine, the numbers of health-related visits will certainly increase. It is projected that by 2012, the number is going to hit a million. With regard to this, what are the plans and programmes by our healthcare institutions to cope with the increasing numbers and complexity of medical problems?

It is anticipated that we will require more inpatient beds, outpatient clinic slots, high-tech and state-of-the-art equipment and an increase in certain types of manpower, such as allied health personnel, nurses, pharmacists and specialists. There will certainly be competition from our rapidly ageing populace and also the increment from a larger population of foreigners and foreign talents that we are trying to attract to Singapore. We would also have to improve our service standards significantly, enhance communication skills, and this includes perhaps also some officers who are trained in foreign languages and also to strategise our plans to face the increasing medical tourism competition from countries in the region, such as Malaysia, India and Thailand.

Mr Khaw Boon Wan: Madam, just now, we discussed how we must gear up Singapore for our healthcare needs of 2020. We discussed the three key resources that we will need - financial, physical and human resources. But having more resources alone will not necessarily lead to a better healthcare system. Witness the huge amount of resources some countries are pouring into their healthcare today and yet they deliver much poorer outcomes than other countries which spend much less. More of the same will not do. We need to have the courage and the wisdom to transform healthcare.

Some analysts in the automobile industry compared General Motors with Toyota, and they criticised General Motors for being too product-focused. They praised Toyota for focusing on the changing needs of customers over their lifetime. Parents buy a small car for their child when he graduates from high school. A young adult buys a Corolla, then an MPV when his family grows, and when he gets a promotion, he buys a Camry, and later on, he upgrades to a Crown and perhaps a Lexus. Toyota made over a hundred models to meet the different needs of the different market segments.

Healthcare, unfortunately, is more like General Motors than Toyota. We focus on buildings, equipment and skills. This is not wrong, but I think we are not paying enough attention on the varied needs of our patients.

Let me give some examples. An infant with a hole in the heart needs a one-off highly specialised care involving a large team of specialists and other staff to fix the problem using highly sophisticated equipment. But once fixed, the infant will be, more or less, normal and well.

Another infant born with severe brain damage will also require sophisticated care but the best outcome may still be a lifetime of pain, discomfort and total dependency.

An 80-year-old with advanced cancer may also need highly specialised care involving experts and sophisticated equipment. But the outcome may be a prolongation of life or postponement of death by a few weeks with pain and discomfort.

Another patient in a similar condition may well choose a less aggressive treatment regime focusing mainly on palliative care and pain management.

A young person with a broken bone needs a surgery and after a few weeks will be back to normal. The surgeon plays a key role and the patient plays only a very minor role in that treatment episode.

On the other hand, an obese patient with diabetes will need life-long medical attention. The patient’s well-being is almost entirely dependent on his personal willingness to change his lifestyle and follow the treatment regime strictly. The healthcare team can, at best, play a supportive role, a coaching role.

As Members can see, a patient’s treatment choice is often determined by a complex interplay of his understanding of likely outcomes, the advice he gets from his doctors and friends, his personal expectations, values and philosophy, and his ability and willingness to pay for treatment. Clearly, one size cannot fit all. Even a dozen sizes will still not fit many. There is a need for us in healthcare to segment patients more, clearly understand their needs by observing them closely and consulting them. We have to develop practical treatment strategies, innovate and continuously fine-tune approaches to improve outcome and to reduce cost.

To transform healthcare to better meet the different needs of our patients, we must innovate. To innovate to meet diverse needs, we must have diversity in organisations, structures, models of care and pricing. This requires a change in mindset on the part of the healthcare providers. In particular, hospital specialists will need to work more closely with family physicians and step-down care facilities as a team, with patients at the centre. Ideally, they will all share a common medical record for each patient, and they consult regularly and they function as one team whose sole purpose is to advance the health of the patient.

This is challenging even when all the healthcare providers are from one single employer and serve patients with the best of intentions. Complications multiply many-fold as such a team often comprises members coming from all the three sectors - public, private and charity sectors. Coordination and trust take time to build. That is why true care integration has not yet happened, whether here in Singapore or in other countries. It will take us years, not months, to achieve such an optimal outcome. Many pieces have to fall in place. Let me highlight some of them.

First, an important infrastructure is the Electronic Medical Record (EMR). I have coined the slogan, “One Singaporean, One EMR” to catalyse this initiative. Right now, it is one Singaporean, many medical records, stored away in different clinics and hospitals in different formats - some in papers, some in CDs - and not connected or consolidated. As a result, when patients visit different doctors, their tests have to be repeated, x-rays redone. This adds to unnecessary cost.

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We are moving towards this target of “One Singaporean, One EMR”. Because of legacy systems, we cannot achieve it in one step. But we have made progress. As pointed out by Dr Lam Pin Min, public hospitals now have the EMR eXchange (EMRX). We achieved a first but very important psychological step in 2004 when public hospitals began to electronically exchange their Hospital Inpatient Discharge Summaries. These are summaries that each time a patient is discharged, the

consultant-in-charge will summarise it up - what exactly is the problem with the patient, what were the treatments made or given to the patient and what is to be expected in the future. And sharing this is crucial because when the patient appears again in another hospital, access to this summary immediately updates the doctor about this particular patient. Since then, we have made the EMRX more comprehensive by adding other patient records such as laboratory tests, radiology reports and medication information. The electronic volume of laboratory results exchange has grown seven times in two years. Thousands of patients benefit from EMRX every month.

Our doctors' feedback is that EMRX has made their work easier. I am sure Dr Lam agrees with that. In particular, our Emergency Department doctors have said that the EMRX gives them greater reliability and confidence in treating patients, especially those with long and complicated medical histories. And I am glad to see Dr Fatimah nodding her head.

Extending EMRX to private doctors would be a natural step and it is the objective. As Dr Lam pointed out, a national EMRX will minimise unnecessary medical investigations. More importantly, I see EMRX playing a critical role in the integrated delivery of care to patients. However, this is a very complex national project. Very few countries, if any, have successfully implemented a system that links up public, private and the charity sectors. This is because there are many issues such as data protection, regulation and audit to be addressed. We need to take a measured approach to pilot and then put together a comprehensive framework that takes care of these issues. This will begin with common data standards. We will do this within the public sector first, test it out, and extend this to the step-down facilities. We have started to build the linkages to the private sector GP clinics by helping them to set up their IT systems under the Medisave for Chronic Disease Management Programme. I am confident that we will get there.

Second, we need to strengthen the collaboration between acute hospitals and community hospitals to achieve seamless care for patients when they move between these two types of institutions. For patients who no longer need medical treatment in acute hospitals and who should move into community-based care, we must ensure the continuity of patient care and eliminate barriers and bureaucracy. The handover must be smooth, as though it is from one ward to another in the same hospital. For a start, we need to enhance medical collaboration between the doctors in our hospitals and either their counterparts in the community hospitals or the family physicians who look after the patients over the long term. Patients at the end of the day must feel confident that they are getting seamless care.

The same approach is needed for patients who require care and nursing homes. We are working with MCYS on this. We are also studying the longer term feasibility of integrating different residential and community-based healthcare and eldercare facilities so as to help the elderly to age in place and to continue using familiar facilities even as their care needs change with time.

Third, we need to have patients treated in the most appropriate locations by medically-competent teams at the lowest possible cost. This is commonly referred to as "right-siting" of healthcare services, and the logic is obvious. But the outcome is seldom the case. Today, many patients who choose to be treated at SGH or NUH, in fact, should not be there. They can be and should have been treated by their family physicians, less hassle and at a lower cost. For various reasons, they get wrongly-sited there.

Wrong pricing, as observed by Mdm Halimah, is one factor. Mdm Halimah's proposal is for us to reduce prices at step-down care so that patients will have an incentive to leave the hospital. To achieve this, Mdm Halimah suggested that we exempt such patients to be transferred from hospitals from means testing at nursing homes. I am afraid I do not agree. The correct solution is to extend means testing at nursing homes to the hospitals so that we eliminate this policy anomaly. I have asked Ministry of Health to study how we can do so, at least for those patients who have exceeded the average length of hospital stay.

Meanwhile, we will continue our push, through the Medisave scheme for chronic disease management, to shift chronic disease management to the primary care level by family physicians and in the community. If patients can be right-sited to family physicians and they feel confident that they will be well looked after, we can reduce overcrowding at hospital specialist clinics.

Fourth, we must exploit technology to improve care and lower cost. Telemedicine is a good example and can potentially bring benefits to many areas of healthcare. As Dr Lam pointed out, we have started with tele-radiology in our polyclinics with very good results. Patients save time as they no longer need to make a return trip just to get their results. Increased competition has resulted in cheaper x-rays and improved turnaround times from local radiologists. Almost 60,000 patients can benefit from this per year.

We are moving beyond simple x-rays now to CT scans and MRIs. I have no doubt this will bring further benefits and those cost savings will be even more significant. We will continue to study other applications of telemedicine and get it to work for our patients here. I have also encouraged our radiologists, wherever there is spare capacity, to sell their services to buyers in developed countries. We can sell tele-radiology services as well as buy tele-radiology services.

Fifth, medical science here will continue to progress and we have reached a stage where Singapore should be part of the global search for faster diagnosis, better and more cost-sustainable care for patients. Our public sector doctors have always been bogged down with heavy patient loads. If we are able to recruit more doctors to improve our doctor-patient ratio, we can ease their burden somewhat.

Through this process, we hope some doctors with special interest in clinical research will find more opportunities to do so. Every generation of doctors has always yielded a few outstanding researchers, for example, Professors Wong Hock Boon, the late SS Ratnam and more recently, Ng Soon Chye, Yap Hui Kim, Donald Tan, and so many others.

With our latest emphasis on life sciences development, public hospitals will now be better supported with research funds to pursue this interest. Over the next five years, Ministry of Health, National Research Foundation and A*Star will jointly contribute $1.55 billion to support translational and clinical research. It is a major boost to our researchers, although in the scheme of things, it is not really a huge pool of funds. So we will have to prioritise and focus on specific areas where Singapore-based researchers already are strong or in diseases where strong capabilities can best benefit Singaporeans. Because the greatest potential impact will come from areas where we are strong along the value chain from basic sciences to clinical treatments, we will encourage our doctors in the hospitals and the scientists in the laboratories to work very closely together.

We will not be able to allocate research funds equally to each hospital. Hospitals and researchers will have to compete for them. Those who are able to better manage unnecessary overcrowding and free up manpower resources will have an advantage and that is why it is so important for hospital specialists to learn to work with the GPs, to co-manage or joint-manage the chronic patients and make right-siting of care a reality.

Sixth, we should not shy away from organisational changes that can help us achieve our mission more effectively. That is why we restructured our hospitals more than 20 years ago. We moved from central planning by Ministry of Health Headquarters to a decentralised competitive model. This allows individual hospitals greater room to innovate. How else can we nurture experimentation and bring about improvements?

Mr Sam Tan asked if our restructured hospitals are wasting resources on rich patients and foreign patients at the expense of subsidised patients. All patients, rich or poor, receive competent clinical care. Hence, all patients requiring urgent medical attention are promptly seen: three minutes for the critically ill, 30 minutes for other true emergency cases. For non-emergency cases, service standards vary and we publish such data so that patients can choose the less busy hospitals. All doctors who practise in the public sector will treat subsidised patients. This is part of the ethos of public service which our doctors feel very strongly about.

As for physical provisions, the Ministry decides on the distribution of beds among classes. The fact is that 80% of beds in Singapore are in public hospitals and over 70% of public hospital beds are the heavily subsidised B2 or C. In other words, more than half of the patients treated in Singapore are subsidised by the Government to more than 65% of the cost at least. We also have guidelines in place to ensure that public hospitals do not spend on lavish fittings and renovations. But some renovation is inevitable to enhance efficiency and to meet public expectations. Nobody want to be admitted to a run-down hospital.

Mr Low Thia Khiang asked if our hospital cluster system has led to wasteful duplication and if integration has led to better service level. One key objective of clustering is, in fact, to facilitate better integration of care between hospitals and polyclinics. This remains an important objective which I have discussed earlier. We have made some progress integrating public hospitals and polyclinics but full integration requires us to bring in the private GPs and the rest of step-down care providers. So our journey to restructure and bring about organisational change continues. Certainly, our hospital clusters will make a big push on this front this year but it will always be work-in-progress. We must never be fossilised into a concrete structure and become unresponsive to external changes and expectations.

Mr Low made an added point which is, for certain specialties, is it not better to centralise instead of mini-units spread out in the various hospitals? I think both solutions are relevant. It depends on the specialty. My preference is always to have at least two competing departments because competition will always push up standards and I have an added reason. Having run hospitals and dealt with doctors, I know they are highly individualistic and sometimes, for various reasons, you just cannot work for a particular Head of Department. So we must allow some space. There is a Chinese saying: " Yi shan bu neng cang er hu ". So sometimes, you need two mountains to hold the two tigers. But as far as possible, we try to decentralise it for the convenience of the patients. Of course, if decentralisation means one-man-team in a department, then it does not make sense. If you look at how we handle it, for example, neurosciences, neurology, it is centralised. But because accidents, like head injuries, can crop up anywhere, and if you centralise it, all ambulances will rush to SGH, we will have a mad-house there, and Dr Fatimah will have no time to attend Parliament. So the neurology services are decentralised, but the department running it is centralised. The department is the one who decides on staff deployment. That way, you can sub-specialise and you rotate staff accordingly. But once the specialty has reached a certain size where it is possible to have two very well-run departments, I encourage them to split up. I do not encourage families to break up though but for clinical departments, it is always better that way. Two, three, or four departments, so long as the volume can justify it. And this is one of the reasons why SingaporeMedicine has some benefits to Singaporeans because if more patients are coming in, then you can justify a higher level of care and you can allow this decentralisation to take place.

But at the end of the day, organisational structures are merely the means to an end. Our mission is to serve patients, particularly those in the lower half of the population. When a person falls sick, what does he want out of our healthcare system? Talking to patients, I reduce it to just two basic questions: what is wrong with me? What can you do for me so that I can recover fully, if possible? These are the two basic questions.

Our job is to provide accurate answers to these two questions and then to do so in a way which makes the total care experience for patients as smooth as possible and does not bankrupt him or society.

But as I stressed just now, patients too have a big part to play, particularly, while they are healthy. So while you are healthy, ask yourself a different question. How do I maintain my health so that I do not fall sick and have to go and visit Dr Loo Choon Yong or Dr Fatimah? And we know the answer, that is, please adopt healthy lifestyle. Many do, but many still do not.

Mr Sam Tan spoke about Health Maintenance Organisations (HMOs). They organise GPs and then they market their services to some company employees. It is an idea imported from the US a few years ago. I do not know how wide is their coverage today but while we do not regulate HMOs, we do regulate the doctors working for them. And I am sure any attempt by HMOs to cut corners will be resisted by our GPs as they have high ethical standards. Otherwise, the Singapore Medical Council will run after them. Companies and unions should also chip in to ensure that their employees do not get short-changed.

Seventh, we will release even more information to Singaporeans. We will measure and publish outcomes and performance indicators to increase market transparency and help patients make better choices - which doctors to consult, which clinics to go to. NUH, KKH and SGH have recently, just a few weeks ago, through their own initiative, begun to publish clinical outcome data selectively on their respective websites. This is the first for any hospital in Singapore. I applaud their public commitment to quality improvement and greater transparency. I will encourage all our hospitals - public or private - to publish outcomes and benchmark themselves with international outcomes. Maybe Raffles Hospital will do that too.

This will similarly apply to step-down care providers. My Ministry is working with them to develop indicators to measure their performance in service development, utilisation and clinical quality. We will ensure that minimum care standards and patient safety are met. For those who do not perform well, we will help them improve their standards.

Eighth, we need to further empower our patients by engaging them in their care and their care choices. Patient empowerment led me to introduce the Medisave scheme for chronic diseases last year. We know that chronic diseases account for the bulk of the workload in public hospitals and the polyclinics. And these diseases will not go away because today, there is still no cure, and if left unmanaged, they would only get worse, not suddenly, but gradually over time.

Fortunately, medical science is now clearer on how to manage these chronic diseases to minimise future complications. The correct approach comprises three elements: early detection, regular ongoing low-tech, low-intensity treatment by family physicians, and good compliance by patients in changing their lifestyle and habits.

I remember Dr Lily Neo reminding us about this frequently in this House. The wrong approach is to ignore the disease, persists with an unhealthy lifestyle and then when complications emerge, rush into hospitals for high-tech, high-intensity attention by multiple specialists, hoping for a cure and a quick return to the same lifestyle. But there is no such cure. When a chronic illness is still mild, that is the time to change your lifestyle and begin treatment. If you wait, the complications are a lot harder and much more costly to manage.

With the Medisave scheme for chronic disease management, I hope to bring about a mindset change among our chronically ill. Through Medisave, we have eased the financial burden. It is now up to the patients to come forward and help themselves, to work with their doctors to actively manage their chronic diseases. If they do so, their health will improve. It can be done. In small-scale pilots, we have seen such improvements among participating patients. Through Medisave, we are scaling this across the nation.

Mr Low asked about the cost of treatment for the chronic disease. I think he specifically asked about polyclinics. It depends on the state of the illness. If you neglect it, and it has become highly complicated, with all sorts of other problems, then of course, the treatment will be more complicated and the bill size is bigger. But the key point is, if you come in early, then the treatment is simpler, the cost is lower. So it really depends. It also depends on what type of chronic disease, say, diabetes or stroke. What we are also hoping to achieve out of all this is that patients do not hop from doctor to doctor. For chronic diseases, it does not help the situation. It is best to stay faithful. You can shop around initially if you do not like this doctor for various reasons. Once you find he or she is good, then stick to one. I have another slogan for that, "One Singaporean, one family physician". I think that works best for Singapore, and for other people too.

With the Medisave scheme for chronic disease management, now that we have gotten over the implementation phase, we will use this whole year to collect and analyse the outcomes. By next year, we should be better able to answer some of the questions, as posed by Mdm Halimah and Mr Low. How do the various clinics perform, in terms of managing their patients' chronic diseases? How much do they charge their patients and for what treatments? And very important, are their patients showing signs of improvement? Then I am going to publish them. Then you can see if you are diabetic, there are diabetes care at Ang Mo Kio, Sembawang or Hougang. Is there a difference? And then patients can make better informed decisions about which family physicians to be loyal to.

Every patient should be given a personal health information folder by his doctor on his chronic disease and what he should do to improve his health. His health status should be regularly tracked and charted and explained to him by his doctor. If your doctor does not do this for you, ask him why not? Suitably empowered, I hope many patients would take their health more seriously and work to improve on it. If we do it well, the long-term impact will be significant. If we cut down unnecessary hospital care, it means major savings in dollars and human suffering. Let us work to make it succeed.

Finally, let me touch on SingaporeMedicine, the strategy to attract foreign patients to Singapore. This is an economic objective, not a strictly healthcare mission. In fact, my advice to the public hospitals' CEOs is that SingaporeMedicine is not our primary objective, but a secondary and consequential outcome. Our primary objective is to serve Singaporean patients, rendering good medical care at competitive prices. That is our mission. But if our standard is high and our prices are reasonable, Singapore is bound to attract all sorts of foreign patients to come here.

Our regional neighbours have raised their medical standards over the years. But we remain ahead of them and should always strive to stay ahead. If we do our job well in serving Singaporean patients, we will always attract foreign patients. It is a validation of the quality of our healthcare. We should therefore factor in this reality when we make projections of beds, doctors, nurses, and so on. If we do not do so, and since we cannot prevent foreigners from coming here for treatment, public hospitals and subsidised patients will get crowded out. If nothing else, costs will go up because private hospitals will poach public sector doctors and nurses, pushing up wages. This is the reason why we are stepping up foreign recruitment of foreign doctors and nurses, even as we ramp up local training.

While we may see some foreign patients in public hospitals, the fact is that the majority of foreign patients go to private hospitals and clinics. 80% of foreign inpatients stay in the private hospitals. Foreign patients make up less than 2% of public hospital admissions. Ultimately, I agree fully with Mdm Halimah that SingaporeMedicine must benefit Singaporeans, and must not come at the expense of care for Singaporeans.

Mdm Chair, I believe I have addressed all the queries by Members. I know Mr Low Thia Khiang spoke on the Human Organ Transplant Act (HOTA). He was not in this House last week when we had a full discussion on this when Dr Lim Wee Kiak raised the same issue. In the interest of time, I do not wish to repeat the points already made here last week, except to say that we will learn from the SGH incident and try to do a better job. We will certainly step up public education on organ donation and brain death and help Singaporeans think about the plight of those fellow Singaporeans on the waiting list. As I said in this House last week, it is the luck of the draw. We cannot be sure whether we may end up on the waiting list. Before HOTA, we could only save five lives in one year. After HOTA, we now save one life every week. So from five a year to one every week. HOTA is good both for the dead and the living, from the religious point of view. But we respect the wishes of those who want to opt out of HOTA. We will facilitate it. Every year, about 2,500 opt out of HOTA. The number went up soon after the SGH incident but has since come down to about 80 a day, which is high. But I respect the wishes of those who opted out but I worry for the poor patients on the organ waiting list.

In conclusion, I acknowledge that our healthcare system is not perfect. But actually, it is not bad. My foreign counterparts told me so. And they would happily trade off their system for ours.

But it can be better. Over the next few years, we will get the pieces together and be better ready for the challenges ahead. And I thank Members for their continuing support and advice.

Health Promotion Programme

Dr Fatimah Lateef: Mdm Chairman, health promotion has been given a new prominence. The increasing focus on health outcomes reconfirms the priority placed on investment in the determinance of health through health promotion. Continually asking ourselves the question, where and how is health created will link us to two major reform debates, firstly, the formulation of new public health strategies and, secondly, the need to reorient and refine health services.

Health promotion is the science and art of helping people change their lifestyle to move forward to a state of optimal health. Optimal health is the balance between physical, emotional, spiritual and social health. Lifestyle changes are facilitated through efforts to enhance awareness, change of behaviour and promotion of environment that supports good health. The Ottawa Charter of Health Promotion from WHO Geneva 1986 emphasises the prerequisite for health promotion. It touches on advocacy for health, enabling all people to achieve their full health potential and mediating between the different interests in society in the pursuit of health. The Jakarta Declaration on Leading Health Promotion into the 21st century is also relevant as well in this context and stresses on the importance of participation through sustained efforts.

For the sum of $86 million expenditure on health promotion programmes every year, like the healthy lifestyle programme and the school health services programme, are we seeing the results that we expect? Is Health Promotion Board tracking some of the KPIs on these? And are we meeting the targets that we have set, for example, the identification of early psychosis results from the Trim and Fit programme in our schools or even the numbers coming forward for cancer screening?

Preventive Healthcare

Mr Yeo Guat Kwang: Madam, one of my key concerns is how we are going to help Singaporeans monitor and reduce health risks. What are these risks? These are risks arising from not eating right, not exercising enough and smoking. Based on the statistics, we know that more than half of the deaths and disability from heart diseases and stroke can be cut down. All it takes is a national effort and individual action to reduce health risk factors, such as smoking, high blood pressure, high cholesterol and obesity.

Let us now make a more structured approach and effort to make all Singaporeans, particularly those above 40 years old, first, to be aware of and, then, take efforts to manage their health risks. We should make basic health screening more accessible, followed by way of facilitating Singaporeans, particularly those who are working, to take personal responsibility to improve their health risk profile. In short, raise their awareness and help them create the drive to take action.

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What are the actions that we can take? I think we can simply round it up to say, "CHEERs", ie, "C" for "Cease smoking"; "HE" for "Healthy Eating"; "ER" for "Exercise Regularly"; and make the "s" small for manage "stress".

Madam, I wish to highlight that while many companies readily agree and say openly that they would like to re-employ older workers and even employ them beyond retirement age, more often than not, the health of the older workers is an important criteria in determining whether the company is going to grant him employment or not. Many companies, in fact, specify very clearly in their documents for re-employment to make it a point that the workers must, first, have to be assessed to be medically fit to work. So, no matter how successful our efforts are in getting our older workers to be re-employed, up their skills, change their mindset, these would count for nothing if, at the end of the day, the worker is not healthy enough. I would like to urge the Ministry to allocate more resources and work more closely with the labour movement and any organisation involved to help workers regularly assess and monitor their basic health profile and better manage their health risks before it is too late. This will, in fact, help strengthen the employability of all our mature workers. I hope MOH could spend more on preventive healthcare.

Mental Health Programme

Mdm Halimah Yacob: Madam, could the Minister give an update on the Ministry's plans to upgrade Singapore’s mental health programme to make Singapore an emotionally resilient community?

Recently, I met a man who was suffering from severe bipolar disorder. He has two young children and his wife is the main breadwinner as he is not able to hold down a job. He pointed out the many gaps in our current services for the mentally ill. The stigma and rejection is one thing, but he feels that even the standard of medical treatment needs improvement. At one public hospital, where he was treated, he was seen by a different doctor at every appointment, as he was a subsidised patient. He also feels that in that hospital, the very ill patients were mixed with the less ill patients. As a result, his condition did not improve. He has since changed hospitals and he feels better now. His own illness was left untreated although he was ill since he was a teenager and, as his family did not understand that the extreme mood swings were signs of mental illness, he got treatment only when he was in his 30s. When he was finally treated years later, his condition was actually quite bad. He now pours most of his energies into his art work but he finds it difficult to get a place to advertise his drawings for free. His family is suffering from financial difficulties as his wife does not earn enough to support the family and he worries about his children’s future.

This man’s journey of anguish and pain is typical for sufferers of mental illness. They suffer many setbacks. Many find the cost of treatment a drain on their resources but, if they stop treatment, they will suffer a relapse, which worsens their condition. Many cannot hold proper jobs as the stigma against them is still very strong. Many need temporary shelters but there is not enough of such facilities. Many cannot cope on their own and need support. Many parents with children suffering from mental illness worry in case they die and there is no one to take care of their children. Their problems require a multi-agency approach involving not just MOH but also MOM, MOE and MCYS, even maybe MHA, with very strong community support in order to put in place a more comprehensive framework to assist them, as well as an extensive public education programme to remove the stigma and prejudices that they have to endure and to help our population understand the critical importance of seeking treatment early.

Could the Minister please give us an update on what is being done to improve our mental health programme and assist them?

Mrs Josephine Teo: Madam, last week, during the Budget debate, several MPs spoke on the implications for Singapore, if indeed our population grows to 6.5 million. I think the number of 6.5 million has captured the public's imagination. Regardless of when and how we will arrive at 6.5 million people, with increased population density and the faster pace of economic restructuring, stress levels can be expected to rise and, as the Minister has said earlier, in a way, we will have to move away from a more product-focused type of system to one that is focused more on the varied needs of the patient, and I think mental healthcare is one of those growing needs.

This stress will manifest itself in many ways, from neighbourly disputes, breakdown of marriages, higher incidence of elderly living alone or ending their lives prematurely, all of which are very sad, to even just poor road behaviour, including speeding and reckless overtaking. Some school children nowadays also say that they are stressed. The language of stress is very common amongst and very well used by children. A migrant society like ours that is fast-paced and becoming more crowded by the day must pay attention to the quality of mental healthcare and there is no turning back to the days of the leisurely kampong . So we need to ask people to learn to deal better with the stresses in our lives. In some ways, we are already doing so, eg, through ensuring that there are enough green spaces, making our cityscape more pleasant, keeping traffic relatively smooth. I have several questions for the Minister.

(1) How much of the Ministry's budget is allocated to support mental health promotion and care?

(2) Do we have enough trained counsellors, psychologists and psychiatrists in Singapore? If we do not have enough, is there a plan to increase the supply, either through training or augmentation from foreign sources?

(3) Does the IMH have sufficient capacity to cater to demand which, over time, could be expected to rise perhaps proportionately more so than other healthcare services?

(4) Can the Ministry step up efforts in mental health promotion? For example, can we adopt a more holistic approach to tackle the issue? One of the ways perhaps is to work with the MOE to equip our children from young with coping strategies.

(5) What steps would the Ministry be taking to ensure that long-term care for mental health patients remains affordable?

Mr Low Thia Khiang: Madam, I would like to ask why the Institute of Mental Health suspended its night outpatient clinic. Previously, mental patients who are working in the day could go to the night clinic for their regular follow-up treatment. When the night outpatient clinic is not available, patients would have to ask their employers for leave or time off to seek treatment during the day. In doing so, they would have to reveal their condition to their employer, which may affect their employment prospects. This is because mental illness today is still a very much misunderstood illness. I would also like to ask the MOH to consider the possibility of training polyclinic doctors who handle mental patients so that their follow-up can be done at polyclinics.

Next, I understand that there is this early psychosis intervention programme to treat newly-diagnosed psychosis, as early intervention is a key factor in effecting management of the illness. I would like to know what the programme has achieved. I also understand that some patients are not complying with the anti-psychotic treatment because conventional therapy brings with it some side effects. Although there is new treatment on the market with lesser side effects, these drugs are expensive. Are there available measures to help farm the treatment of patients with good prognosis or who respond well to the new treatment? I understand that this group of patients can be treated effectively to a stage of continuing employment, thus helping them to be economically independent.

It is difficult for people who are suffering from chronic schizophrenia to take on complicated work tasks. I would also like to ask whether there are assistance schemes available to maximise employment of Singaporeans who suffer from such illness. How is the Ministry helping fellow Singaporeans to understand and to be aware of the nature of mental illness? Are there public education programmes to help the public and family members of the patients to better understand mental illness and to foster a positive attitude among Singaporeans to be inclusive and not shun away from fellow Singaporeans who suffer from mental illness?

Assessment for Eldercare Services

Assoc. Prof. Kalyani K Mehta (Nominated Member): Madam, this budget cut emphasises the need for a single comprehensive assessment process which will ensure that older people receive appropriate, effective and timely responses to their health and social care needs, and that professional resources are used effectively. Currently, in Singapore, there is a great deal of duplication of resources as well as delays when older persons are referred from one agency to another, because each agency has its own assessment procedure. For example, when an older patient is referred from a hospital to a nursing home for step-down care or from a community hospital to a case management service where there is not only unnecessary delay but also frustration on the part of the caring families. If there are family relationship problems, the delays could cause rapid deterioration of the older person's physical and/or mental well-being and, in some extreme cases, even elder abuse.

With the rapid greying of Singapore's population, we need to implement ways to increase the effectiveness and efficiency of our service sector. Health and social care are inextricably linked to the total care system for older people. Hence, health and social sectors will be required to work closely together, if such a single comprehensive assessment system is implemented. This will enable the development of a seamless delivery of services for the elders, a goal that has been mentioned in earlier reports on ageing population.

On top of that, quality of services for the various sectors would be better monitored. Currently, we have a situation where there is much disparity between the care rendered by nursing homes in the private sector as compared to voluntary welfare homes. I have members of the public voicing views like: "We pay more at the private nursing home but the quality of care received is even worse than the VWO nursing homes. But there is no space in the VWO nursing homes." I want to cite a recent article on 31st January 2007 in Today which was entitled "Where did the bruises come from?", a case reported of a 96-old-year gentleman in a nursing home mysteriously suffering from severe bruises. Subsequently, he died at Tan Tock Seng Hospital. Members of the House, can you imagine the anguish of the adult children who have made a police report? When questioned, the nursing home staff said they had no idea how it happened. I have not read any further articles on this episode. I was surprised that there were not many letters in the Forum page regarding such an unfortunate death. It makes me wonder if there is a societal attitude of paying less attention to violent death of elderly as compared to violent death of a young adult. It would be a negative reflection of our value system if it were really so. I would like to know from the MOH, an update, if possible, on this episode.

Madam, as a responsible and developed society, we need to be concerned not just about availability and accessibility of services but also the quality of care provided. Quality assurance and accountability to taxpayers, whose money is used to subsidise the patients in nursing homes, are at stake here. A good assessment provides the blueprint for a well thought out care plan.

Currently, there is an international initiative underway that seriously promotes such streamlining of processes of service delivery in several different contexts, such as home care, nursing homes, day care, home help, and so on. It is called "InterRAI", with R-A-I representing Resident Assessment Instrument. It is a not-for-profit organisation aiming to improve the care of elderly worldwide. The Minimum Data Set (MDS) Version 2.0 is now being implemented in more than 20 countries, including the US, Canada, Japan, Hong Kong, and so on.

The main objective for developing this instrument was to introduce the idea of a comprehensive assessment as the foundation for care planning. Once the initial assessment has been made by a trained assessor, the information can be shared by all the relevant service providers. And because it is a standardised instrument, all the different professionals concerned with taking care of one patient have the entire set of information for them. In countries where there are different Ministries looking after their healthcare and social needs of older people, the information on health may not be accessible to the professionals in the social sector, and vice versa. Unfortunately, the patient or the client suffers, of course, due to the structure of the systems.

In Australia, there is an Aged Care Assessment Service (ACAS) which is highly developed. They use the Resident Classification System (RCS) across the board and funding available to each individual patient is calculated on the full assessment. In England, a different model has been launched for this purpose.

We can see an international trend for a standardised comprehensive assessment, so that not only do we reduce wastage of resources but efficiency and efficacy of services to older populations are increased. In the long run, we hope the quality of care

and best practices in gerontological care can be improved.

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Accreditation can be introduced to distinguish the better care providers from the ones with poor quality. A single assessment process helps to address gaming or strategies used by nursing home managers to cherry-pick the applications. Research based on the data that is collected over time using locally derived outcome measures or KPIs would assist us in identifying which method of care is effective or ineffective. In this way, research and improvement in services and policies can become a dialectical process.

I shall cite the case of Hong Kong to illustrate a country that has adopted this idea. A colleague, Prof. Iris Chi from the University of Hong Kong, started talking to the Hong Kong Bureau of Health and Welfare a few years ago about the need for such a standardised instrument in order to streamline the long-term care service system there. After much consultation and review of the pros and cons of introducing InterRAI, the Hong Kong government decided to introduce it in small steps. For government and non-profit providers, this assessment is available free of charge. At first, a simpler version of the instrument, which is referred to MDS, was launched. As there was a heavy backlog of older people waiting to get into nursing homes, the homecare protocol was used so that while waiting, these people could be assessed and helped by community-based services. In fact, the homecare protocol is also used to educate families in cases where nursing home admission is not required.

It is recommended that the assessment be re-administered annually as well as whenever a major crisis has occurred. The beauty of RAI version II is that not only medical information is elicited, but also data on social, financial, functional, psychological, nutrition, dental, care-giving and service utilisation is also collaborated.

For the information of the House, I am aware that there is a waiting list in the ICS of about 40 elders who are waiting for a place in nursing homes in Singapore. In our Singaporean nursing homes and sheltered homes, mainly the physical needs' fully shelter safety are met. In our nursing homes, their medical needs are addressed. However, their psycho-social needs, such as need to be treated as an individual, need to be mentally stimulated, need for self-worth, are often not met, except for those nursing homes that employ a professional social worker. There is a strong need to increase the professionalism in our eldercare services.

On Social Workers' Day, 20th January this year, Minister Vivian Balakrishnan stated in his speech that he would look into greater professionalisation in the social service sector. My proposal may be in tandem with his goals too. With our population ageing rapidly, the importance of providing good medical and social care in Singapore, I feel that the Health Minister has brought many positive changes into the Singaporean's healthcare system. I applaud his efforts to enable ordinary Singaporeans to assess outpatient treatment for major chronic illnesses through Medisave and increasing their cap for hospitalisation expenses and MediShield. I would be grateful if his Ministry studies my suggestion of a standardised single comprehensive assessment and a study team may be set up to look at the various models in different countries and choose the model that suits us best and work collaboratively with MCYS.

It will take a few years to set it up and get it running, hence, the urgency. I am aware that this idea may not be new to MOH or MCYS. However, if some plans are already underway for such an idea, I would request the Minister to update the House on its status.

Elderly Depression and Suicide

Ms Irene Ng Phek Hoong (Tampines): Madam, last year, I attended a funeral wake of a resident who committed suicide. He was 92. He suffered from gangrene caused by diabetes. His doctor told him that his leg had to be amputated. He could not take the news. He woke up one night, looked out the window and jumped out of his flat. He was depressed. His family was devastated.

Madam, every year, about 65 elderly residents commit suicide. Singapore has one of the highest elderly suicide rates in the world with about 25 in every 100,000 of our elderly killed themselves each year. While the family is the first line of care, medical staff in hospitals are better-placed as gate-keepers to spot depression in our elderly sick and to identify potential suicide victims. Medical staff should be trained specifically to recognise such symptoms and to intervene quickly.

Sir, in Hong Kong, which also has higher elderly suicide rates, its Kwai Chung Hospital has a Elderly Suicide Prevention Team. Last year, it started a support group to help elderly patients face their illness and to persuade them to receive treatment. The hospital recognised that many elderly refused to seek help, due to a lack of awareness about depression. So, it roped in nurses and also former patients, in their 60s and 70s, to motivate them to stick to treatment.

With our elderly living longer, we need such proactive suicide prevention measures in our hospitals as part of a holistic approach to address this problem. As the elderly is the fastest growing group, we can anticipate more late life suicides in absolute numbers if we just keep to the status quo. I would urge the Minister to urgently invest more in services for geriatrics support and mental health. There is also an urgent need for more medical social workers trained in caring for the elderly. VWOs reported a sore lack of such medical social workers despite an ageing population that needs more such services.

I would also urge hospitals to work more closely with the family and the community in preventing elderly suicides. I had often wondered, if the doctor treating that elderly man with gangrene, had sent him for counselling, would he have coped with his situation better? If the medical social worker had spotted his depression and helped his family to care for him, would he have woken up one night, looked out the window, and jumped?

Sir last night, I attended another funeral of a resident. He died at age 74 of lung cancer. In the last three months of his life, he suffered great pain and his children took turns to keep an eye on him throughout the night as he could not sleep. During the day, he had the support of the community. For many years, he had been active as a grassroots leader. And right till the day before he died, he still insisted on going down to the RC Centre.

So last night, his family made a request, "Can we allow his body to be taken around to the RC Centre as part of the funeral rites, to give him one last look at the place?" This was arranged. As all of us - wife, nine children, 17 grandchildren, grassroots leaders and residents - paid our respects to him. I thought this was a touching tribute to a life well lived. It was also a graceful way to leave this world.

Our elderly, especially those with chronic and terminal illnesses, need our help to go gently into the night. And their family, hospitals, community, all of us, must do our part.

Support for the Disabled

Ms Denise Phua Lay Peng (Jalan Besar): Mdm Chairman, our healthcare system for the general population is, I believe, one of the best in the world. There are three areas I would like to ask the Ministry to consider in support of the disabled in Singapore.

One, help those who have previously been excluded from MediShield. I applaud a new opt-out feature of the MediShield plan to immediately cover all newborns, whether they are born perfectly or not. I thank the Minister for that. I speak now for the thousands of children, youths, adults born with congenital conditions, but have missed this window and the Minister's good news. These citizens are still excluded and deprived of the 1M of the 3Ms scaffold that typical Singaporeans enjoy.

Madam, I urge the Government to ensure the national insurance vendors, like NTUC Income and so forth, to make sure that they are educated on the major disabilities. Advise insurers to assess the risk factors before conveniently refusing the medical coverage or upgrade request of citizens who are disabled or who have special needs. I was recently told of a teenager with Asperger's syndrome was refused medical insurance coverage upgrade when his mother honestly reported that he has some form of mild disability. He is at no greater risk than someone who is typical.

Two, I hope that Minister also consider underwriting the basic hospitalisation and surgical benefits provided to any citizen, extend it up to the ceiling under the same scheme for those who were rejected by commercial insurers. This "self-insurance" benefit is a practice that is adopted by progressive firms for their employees who, for some reason, are rejected by their insurance vendors.

Next, I would like to urge the Ministry to allocate resources for applied research and educate families with special needs children. Many parents with children born with congenital or developmental problems are bombarded with advice on how to help their children. In their desperation, they try all kinds of treatment options - some without any evidence base - and some very expensive. Some people without proper training and credentials have set up clinics and promised cures for these desperate parents. It would really be great if the Ministry should allocate resources to the CDUs and CGCs in hospitals to ensure some basic applied research is done and aggressively educate parents on the validity of these various treatments for those born with common developmental problems, like global developmental delay, speech delays, autism, hyperactivity and so forth. This will save many children who are put through treatments which are not just a waste of money but also precious time that could have been used to improve their prognosis better. I firmly believe that this will not cause a dent in the Ministry's budget and it will help many of these children.

Lastly, I would like to ask the Ministry to consider developing Singapore into a regional centre of excellence for disability treatment, especially in disabilities that are reportedly on the rise, eg, developmental conditions of children, mental illnesses and geriatrics in the area of medical tourism, instead of playing the same space of lasik treatment, cosmetic injuries, botox, and so forth, like in some other countries in ASEAN. Nowhere is demand so strong and supply so weak in disability medicine, and this is a great opportunity for us to go into. As our neighbouring countries become more affluent, the attention they give to disabilities will be greater and Singapore should be well poised for the lead here.

Community Health Screening Programme

Mr Ang Mong Seng: ( In Mandarin ): [For vernacular speech, please refer to Appendix A.] Mdm Chairman, the grassroots organisations of Bukit Gombak has spearheaded a health screening programme for all elderly residents of Bukit Bombak constituency since 1999. This scheme has been very well received by our residents. In 2000, MOH implemented a health screening programme at the national level, and has extended this programme to all various constituencies in Singapore. It has since become an important healthcare management regime for our residents.

However, over the past two years, there has been a decrease in the number of elderly people going for health screening. Feedback shows that the elderly people are afraid of finding out their health screening results. They fear to be confronted by test results indicating that they have contracted chronic diseases such as high blood pressure, high cholesterol and diabetes, etc. Such chronic conditions require regular follow-ups and treatments, and the cost of treating these chronic diseases, over the long run, can be extremely costly. As such, many of them are unwilling to come forward for the health check-ups. This certainly defeats the purpose of the health screening programme.

In this regard, I would like to ask the Minister if MOH is able to formulate an affordable healthcare package for our elderly folks. This can help to lessen their financial burden for step-down care services, and hopefully they can come forward voluntarily for health screening organised by the grassroots communities. Regular health screening will also help in the early detection of chronic conditions and thus achieve the purpose of implementing the health screening programme for our elderly.

Traditional Chinese Medicine

Dr Ong Seh Hong (Marine Parade): Mdm Chair, I declare my interest as an employee of Ren Ci Hospital which also provides Traditional Chinese Medicine (TCM) service.

Madam, the past two decades have seen a growing configurance of several trends, TCM doctors approaching TCM on a more scientific basis, western doctors and researchers recognising the potential of Chinese herbs and patients becoming more open to non-western practices.

China is clamouring to modernise its vast TCM infrastructure and increase its market share. Hong Kong and Taiwan are hoping to leverage on their Chinese heritage to become TCM hubs. Western pharmaceutical giants are in search of TCM partnership in the lucrative world market of herbal medicines estimated to grow to $12 billion over the next 10 years.

Given our Chinese heritage, good location, medical tourism hub status and high medical standards, Singapore should seize the opportunities to develop into a TCM hub. We have done some good work so far. The Traditional Chinese Medicine Act was passed in 2000. I must commend the TCM Practitioner Board for putting up the regulatory framework which ensures only properly trained and qualified TCM practitioners are allowed to provide consultation and treatments to the public.

However, I feel that much more can be done. One such area to promote is specialised TCM practice. Unlike western medicines that have an established history of well structured training and practices, the development of TCM in Singapore has been left in the hands of the private and voluntary sectors. Hence, we only have a handful of well-established TCM institutions, like Chung Hwa Free Clinics, Public Free Clinics, Thong Chai Medical Institution and the affiliate teaching facilities.

While they provide good services, we do not have expertise in specialised field or in research development.

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We need to import specialists. To this end, the TCM Board can play a facilitator role.

Currently, TCM Board's policies do not augur well for institutions wanting to bring in foreign experts to set up specialist centres. For academically-qualified foreign TCM doctors, the Board's criteria requiring "at least eight years of experience and holds at least the post of "Deputy Head", complete three years of TCM clinical attachment under conditional registration at an approved local institution" are, at best, restrictive. In comparison, a Singaporean with similar qualifications only needs to complete one year of clinical attachment. This disparity smacks of double standard.

I was equally befuddled by the requirement that for each foreign doctor hired at each individual clinic, there must be at least three TCM physicians on full registration, which under current system, means only Singaporeans. This sounds like a protectionist quota system. As it was introduced after February 2006, it is also unfair to practitioners and clinics set up before the new regulations.

So I urge MOH to review its policies and welcome more highly qualified and experienced TCM experts to come and practise in Singapore. This will raise the standard of TCM and help us in our pursuit to be a TCM Hub.

Influenza Pandemic Plan

Dr Lam Pin Min (Ang Mo Kio): Madam, an influenza pandemic is a large scale epidemic of the influenza virus, such as the 1918 Spanish Flu, 1952 Asian Flu and the 1968 Hong Kong Flu. The WHO warns that there is a substantial risk of an influenza pandemic within the next few years. The strongest contender will be the H5N1A Avian Flu virus which is rapidly mutating and could mutate into a variant that transmits easily between humans. The influenza pandemic of 1918 killed about 50 to 100 million worldwide in just 18 months, dwarfing the bloodshed due to the First World War. Interestingly and ironically, in those dark times, children would skip rope to the rhyme, "I had a little bird. It's name was Enza. I opened the window and in flew Enza."

The origin of this influenza variant was not precisely known till evidence from a recent reconstruction of the virus suggested that it jumped directly from birds to humans. With advanced medical knowledge and surveillance, we do not want similar catastrophic event to happen again, at least, not at that magnitude. While we have succeeded in coping with SARS in 2003, the threat of an influenza pandemic continues to loom worldwide, making our national surveillance system and preparation for disease outbreaks even more crucial and important. I would, therefore like to ask the Minister for an update on its influenza pandemic plan which was drawn up in 2005 and ask him how prepared are the public and private medical sectors in coping with the impending outbreak. In addition, as part of the preparation, the Ministry has stockpiled huge supplies of anti-virals and vaccines. Would the Ministry update us on its stockpiling policy and the disposition of soon-to-expire and expired anti-virals and vaccines?

The Minister of State for Health (Mr Heng Chee How): Madam, I thank Members for their valuable comments and suggestions.

Dr Fatimah Lateef asked for the outcomes of our health promotion efforts. Since its establishment six years ago, the Health Promotion Board has focused on motivating Singaporeans to lead healthier lifestyles so that they may live long and well, and with peace of mind. Its key initiatives include: the annual National Healthy Lifestyle Campaign; collaboration with hawkers to offer healthier choices at hawker centres, restaurants and school canteens; working with food manufacturers to make healthier food products (such as fortifying food with nutrients like calcium); as well as working with corporate and community partners to encourage chronic disease prevention and management, exercise, smoking reduction, stress management and mental and emotional health.

Surveys show Singaporeans have become more healthy. The public's awareness of the importance of healthy living has risen and more are adopting healthier lifestyles compared to a few years ago. The prevalence of hypertension, diabetes and smoking has decreased while the proportion of Singaporeans who exercise regularly and who eat more vegetables and fruits has increased. Smoking prevalence decreased from 15.2% in 1998 to 12.6% in 2004.

Students benefit from the efforts of the School Health Services. Immunisation coverage is high at 95%. The DMFT (Decayed, Missing and Filled Teeth) index of 0.72 is among the best achieved by developed countries. The "CHERISH" Award, introduced in 2000, encourages schools to establish comprehensive school health promotion programmes. Since the inception of the "CHERISH" Award, the number of schools that achieved the award has increased from 84 in 2000 to 276 in 2006.

As for the workplace, the HPB facilitates the setting up of workplace health programmes by employers. To this end, the HPB has provided grants of up to $5,000 to companies that implement and sustain workplace health programmes. HPB also works closely with the Singapore National Employers Federation (SNEF) and the NTUC to organise regular talks and dialogue sessions with business and union leaders, HR personnel and workplace health facilitators. Surveys show that the number of private sector companies with a comprehensive workplace health programme increased from 32.6% in 998 to 45.1% in 2003. Benefits from such programmes include improvements in the health profile of workers - more workers are now exercising, fewer are overweight, leading to a reduction in medical costs per employee and reduction in medical leave taken in these companies. So HPB will continue to pursue these initiatives.

Mr Yeo Guat Kwang reminded us not to forget about older workers. I fully agree with him. If employers think that older workers would inevitably incur more healthcare costs and, thus, are more costly to employ, then they will be less willing to employ older workers. In the light of an ageing workforce, we must do more to help older workers maintain and improve their health, so as to enhance their employability. One key area is the management of chronic diseases. As persons in middle age stand a higher risk of getting these conditions, early detection, treatment and management will directly reduce the damage, suffering and lifetime medical costs to both employee and employer.

Going forward, HPB will be stepping up its collaboration with the NTUC through the new U-HEALTH (Union-Helping Employees Achieve Lifetime Health) initiative. Under this initiative, the HPB and NTUC will spearhead regular health chronic disease screening for workers. For the workers who suffer from diabetes, high blood pressure and high cholesterol, they will be helped with follow-up treatment. NTUC has already secured the commitment of 30 companies to pilot the programme. Once this pilot is proven effective, it will be ramped up. And as the health of workers improve, their employability and prospects for employment or re-employment will correspondingly strengthen.

Madam Halimah and Mrs Josephine Teo asked about mental health initiatives. I agree with them that good mental health is important for the well-being of individuals and their families and for society at large, especially in an increasingly fast-paced environment. To meet the challenges in this area, the Government has set up a National Inter-Ministry Workgroup, headed by the Permanent Secretary of Health, with representation from employers and unions, to look comprehensively into intersectoral issues related to mental health. The National Mental Health Blueprint recently drawn up by the MOH describes the national strategy for the prevention and treatment of mental diseases, including dementia. Under the Blueprint, MOH will train more mental health specialist doctors, nurses and healthcare professionals to meet expected demand. This will be done through increasing specialist training places, offering training scholarships and including a mandatory posting in psychiatry for family medicine trainees. Mental healthcare training will also become a regular part of GP partnership programmes to help strengthen such services at the primary care level.

MOH is also examining the possibility of assembling multi-disciplinary community teams to better serve the varied needs of different segments of society. These teams can comprise psychiatrists, nurses, social workers and other mental healthcare professionals and they will work alongside schools, community organisations and social services to help children, adults and the elderly achieve improved mental health outcomes. MOH and HPB will continue to promote greater public awareness about mental health through partnership with VWOs. HPB's own "Mind your Mind" education programme will also be expanded to give special attention to vulnerable groups such as the elderly and those facing crisis events. To foster positive mental health in our young, HPB will engage teachers and counsellors, parents as well as work through youth-centric media like the Internet.

Ms Irene Ng asked about depression amongst the elderly. Depression and the past history of attempted suicide are risk factors for suicide among the elderly. When such indications are picked up, health professionals refer the patients to the psychological medicine services and hospital medical social workers for assessment, treatment, counselling and support. We will explore additional ways to equip medical teams with the ability to help such patients with early identification of the symptoms so that proper and prompt intervention can take place.

Sometimes, medical problems cause a certain degree of disability in elderly patients which then becomes a source of stress and depression. In severe cases, that may also lead to suicidal tendencies. To minimise this likelihood, restructured hospitals have set up geriatric units to teach elderly patients and their caregivers how to take proper care in the light of those disabilities. Hospitals also work closely with community-based services and family physicians so that after an elderly patient's discharge from an acute hospital, active rehabilitation continues in a step-down care facility, if needed.

Dr Fatimah Lateef spoke on dementia in Singapore. Today, its prevalence in Singapore is 6.2 per 1,000 population. This is low compared to other developed countries in the Asia Pacific region, such as Japan and Hong Kong, with prevalence rates of 14.6 and 8.6 respectively. The prevalence of dementia in Singapore is expected to reach 12.3 per 1,000 population by 2020 as a result of the ageing of our population. We do not currently track detailed cost data associated with dementia but we can look into facilitating such studies. We recognise that well-formulated policies that tapped collaboration with private and community organisations can reduce the cost impact of the projected prevalence growth through effective interventions for people with dementia. We will consider ways of doing so.

Mr Low Thia Khiang asked about the support for IMH. Since the restructuring of IMH in October 2000, the Budget given to IMH to pay for subsidised services has doubled from $41 million in FY 2000 to $80 million in FY 2005. MOH has also supported new mental health initiatives introduced by IMH over the years. Examples included the Early Psychosis Intervention Programme (EPIP) which Mr Low referred to, in-patient psychiatric rehabilitation service, mobile crisis team and hotline service. Pioneered by the IMH, the EPIP has successfully shortened the time taken to detect, manage and treat patients with psychosis, and this has helped many more such patients to continue working. Our work in this area has been validated when IMH's EPIP received the inaugural "State of Kuwait Prize" for research in health promotion which was awarded by the World Health Organisation in May 2006.

MOH also provides proportionately more Medifund to IMH compared to other public hospitals because the IMH patients are on the whole more long-staying patients and many more do not have financial support from their families.

Mr Low asked about the night clinic service at IMH. IMH had piloted such a clinic but experience had shown that it had low volume and demand and, hence, the night clinic ceased to operate, so that the resources could be better focused elsewhere to help the patients. We will continue to monitor the patients' feedback when determining the feasibility of these services. But, at the same time, there is also a national network of GP clinics, fully-trained and equipped to help these patients. So, in terms of the hours in which they can do so, there are different avenues to do so.

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Assoc. Prof. Kalyani Mehta spoke on ways of assessing healthcare needs and of improving nursing home service standards. The MOH and MCYS presently use the Residence Assessment Form (RAF) to assess the nursing care needs of persons who require residential care in nursing homes or sheltered homes. The RAF is a concise 9-item assessment tool which can be applied easily and quickly by Eldercare professionals to determine care needs. It was introduced in 1993 and it was adapted from the Australian System of Resident Classification. In 1999, the RAF's use was extended beyond assessing the physical needs of residents to also assessing patients with dementia and psychiatric needs.

The InterRAI, which Prof. Mehta referred to, is an international scientific consortium of researchers, clinicians and policy-makers and they have developed a series of uniform assessment tools to assess and plan the long-term care needs of the elderly and disabled persons. Some countries have adapted the RAI for their use, eg, the US and Japan. Compared to the RAF, the RAI is more complicated. But, having said that, we are continually studying ways of strengthening our assessment system and we are presently in discussion with the InterRAI to assess the feasibility of adapting that instrument for use in Singapore.

I certainly share her views on the importance of maintaining and upgrading service standards within nursing homes and of collecting and making known comparative data, so that users and their families are in a better position to make those comparisons and choices. Prof. Mehta referred to a particular sad case of a death and that the police is investigating. I do not have details of that particular case to provide at this juncture.

Mr Ang Mong Seng asked about the community health screening programme. The "Check Your Health" community health screening programme screens for high blood pressure, diabetes and high blood cholesterol. Early detection and treatment is definitely better and cheaper than late detection. Hence, residents detected with such problems are advised to see their family doctors and be treated as soon as possible.

Recently, the conditions screened for under the "Check Your Health" initiative have been included in the Chronic Disease Management Programme. Patients may now use their Medisave to pay part of the cost of the treatment. The children may also use their Medisave to help pay for that treatment. So, this significantly reduces their out-of-pocket treatment cost.

Ms Denise Phua asked about support for the disabled. Currently, the same rules apply to all under the 3M system. In respect of Medisave, the disabled and non-disabled are treated alike and are subjected to the same withdrawal limits. My Ministry has just announced increases to some of these withdrawal limits, and the relief will extend equally to the disabled. While Medishield does not cover pre-existing illnesses or disabilities, disabled persons have been able to secure Medishield coverage for health risks unrelated to the disabilities themselves.

The reason why insurers do not insure against pre-existing illnesses or pre-existing disabilities is that it undermines the viability of the insurance product and causes it to fail. Insurance is to pool risks. In other words, it is to hedge against something which may or may not happen. If something has already happened, then there is no question of hedging. If an insurance cover includes things that have already happened, then there would be every incentive for people to wait until the condition develops before joining and there would be no incentive for the healthy to join or to stay on, and this is known in the industry as "adverse selection".

It is for this reason that my Ministry's approach is to persuade Singaporeans that it is critical for them to get themselves on to basic Medishield insurance as early as possible and to help them do so. So the initiatives just announced by my Minister pertaining to enrolment at birth, as well as at point of marriage, trying to cover the housewives, are a move in this direction. In this way, the population would have more protection against big medical bills before the onset of illnesses and disabilities.

Ms Denise Phua did make a point about educating the insurers, the way in which they would want to exclude coverage for certain illnesses or disabilities and how they relate to the disabilities themselves. In other words, are they being overly conservative in comparison with international benchmarks and practices? It is something that the Ministry will bear in mind in our ongoing discussions, dialogues and feedback to the industry and, certainly, through the process of dialogue as well as through opening up the insurance markets to more competition as time goes on. We do hope that the best benchmarks in the world would also apply in Singapore to the benefit of all, including the disabled.

As for Medifund - I am just completing the 3M description - that helps Singaporeans who, owing to financial difficulties, are assessed to be unable to afford their already subsidised treatment. This help extends to both disabled and non-disabled Singaporeans and the help is calibrated to the circumstances of each case.

Having described the 3M system that we have, my Ministry fully understands the additional difficulties faced by the disabled and we want to do more for them. We currently have a scheme called the Primary Care Partnership Scheme (PCPS). This scheme currently enables the elderly poor to seek treatment at participating private GPs for acute conditions like cough and colds and then pay polyclinic rates, which are clearly highly subsidised. We have decided to extend the convenience and benefit of the PCPS to the eligible disabled by the end of this year. Details will be announced in due course.

On research into intervention methods for common special needs, the Child Development Units, or CDUs, currently monitor the incidence of child development problems in Singapore. They also conduct some amount of research on diagnostic and intervention methods. They have plans to research into the areas of skills training and mediated learning for persons with special needs in time to come. I also agree that more education and information provided to parents of the disabled children would be most helpful.

As for disability medicine, rehabilitation services are currently available in various settings, including acute and community hospitals and day rehabilitation centres. The four community hospitals provide inpatient convalescent and rehabilitation care for patients after they have been discharged from the acute hospitals, while the day rehabilitation centres provide day programmes for persons with disabilities. There are about 30 of these day rehabilitation centres spread across the island.

Now, I move on to TCM. I agree with Dr Ong Seh Hong that developing TCM would enhance our position as an international medical hub and would also help with the SingaporeMedicine initiative. Singapore is well placed to do this because of our recognised strengths in Western medicine and our proximity and close links to countries like China and India, which have strong roots in traditional medicine.

Demand for complementary medicine is strong and growing. Just to give an example, I recently accompanied my Minister to visit the TCM clinic at Raffles Hospital. We were told that the demand there has grown very quickly over the last two years, perhaps tripling, and the facilities to support the use of TCM in inpatient settings have also been expanded to cope. We saw both Singaporeans as well as foreign patients at that clinic. I believe that successfully developing TCM in Singapore will give the patients, both local and foreign, additional good options to choose from.

Of course, in doing so, we must make sure that quality and safety are always maintained. The systematic training and qualifying of TCM practitioners will boost their credibility and give confidence to patients. Having foreign TCM practitioners of high standing come to practise in Singapore will also contribute positively to this capability building.

In this regard, the two main local TCM schools, namely, the Singapore College of TCM and the Institute of Chinese Medical Studies, started TCM degree courses in 2006, with my Ministry's encouragement. These courses are carried out in collaboration with respected TCM universities in China. The TCM Practitioners Board, which is the industry regulator, currently allows TCM practitioners with Bachelor's degrees from six approved TCM universities in China to be registered here and practise. The TCM Practitioners Act also gives the TCM Board the means to allow practitioners, whose qualifications lie outside the approved list but who are assessed to have outstanding skills and expertise, to register and practise in Singapore. But I take note of Dr Ong's feedback just now pertaining to the specific criteria and requirements and we would take that into consideration in terms of reviewing whether or not it is too tight in allowing this kind of practitioners to come into Singapore. Foreign practitioners currently form about 5% of the pool of registered TCM practitioners in Singapore and the total pool is about 2,000.

Dr Lam Pin Min asked for an update on our pandemic plans. Effective surveillance is important in detecting disease outbreaks early. MOH does this through continuous monitoring of news reports of disease outbreaks overseas and assessing the risk of these occurrences to Singapore, keeping the hospitals and doctors informed of developments and providing guidelines for detecting and reporting suspect cases, and enhancing laboratory capabilities and capacities for disease detection.

Beyond surveillance and detection, prompt and correct response is equally important to retard and limit the spread of the outbreaks. In the latest review of the Pandemic Plan, focus was placed on bringing in the participation of private GPs and private hospitals to expand the healthcare resources available nationally to cope with demand during a pandemic.

MOH conducted exercises with public and private hospitals in April and May 2006 to test their preparedness for the avian and pandemic influenza. These were followed by a system-wide exercise in July 2006 that involved MOH, hospitals, polyclinics, GP clinics, nursing homes and relevant Government agencies. The lessons learnt from these exercises served to improve the design of the plans. Exercises will be conducted from time to time to ensure our continued preparedness.

On our anti-viral stockpile, we have now stocked 1.05 million courses of Tamiflu. They will be used to treat infected persons during an avian flu pandemic. The stockpile of Tamiflu was delivered to us in batches and the first batch will expire in 2008. While there is limited scope of rotating this Tamiflu with clinics and hospitals because there is overall very low usage, my Ministry will, nonetheless, do our utmost and look at different ways to minimise the stocking cost of this anti-viral stockpile, but without compromising Singapore ’s pandemic preparedness.

Mdm Halimah Yacob: Madam, I would like to seek clarification from the Minister on a couple of points and also to seek answers to a couple of points which I had raised but were not answered.

First, on the question about affordability that I had raised and the point that the current subsidy does not cover all the items on the bill. In fact, some of the items that are excluded can actually be expensive items. Would the Ministry consider including all the items, so that when we talk about a subsidy of 80%, we are actually talking about the subsidy of the total bill and not only some of the items on the bill? Because the items that are not included are expensive, this can cause hardship to the subsidised patient if he has to pay. For example, I gave an example of a cancer patient that has to use the colostomy bag, and some of the medications are not subsidised for these patients, whether they are in "C" or "B2" class wards.

My second point is on the SingaporeMedicine initiative. We are not at the stage yet where we are rapidly taking in foreign patients. Therefore, there is still scope for the public hospitals to think carefully on the structure that it has to put in place, to prevent possible conflict and also questions arising as to why are public resources being used for private patients. So, there is a clear need for there to be a better firewall to separate the two - service to public patients using public resources and private patients using completely private resources. I seek clarification on this point, ie, whether the Minister can think of this particular structure that I was talking about.

My third point is to seek clarification from the Minister on whether the level of subsidy for step-down care can be enhanced because currently there is a difference in the hospital subsidy and the step-down care subsidy.

My final point is on ElderShield. Can the Minister consider relaxing the qualifying criteria so that more people can be covered under it? Because if you increase the period and also the amount, but if the qualifying criteria remain rigid, people will not be able to come under it.

The Chairman: Mr Khaw, you have about four minutes to respond.

Mr Khaw Boon Wan: I probably will only be able to respond to one or two points, but we have time tomorrow to continue. Let me take the easier ones first.

On ElderShield - ElderShield reform is something I am committed to do and I want to do it, and I am glad that Mdm Halimah supports it in principle. The qualifying criteria are certainly one of the criticisms usually levied on ElderShield. For the information of the Members, right now, we require certain threshold. You have to cross the threshold and professionally what we do is we look for disability measurements, like inability to, say, bathe and feed yourself, and so on. There are six such criteria and the patient must not be able to do three things, then you qualify for ElderShield.

What I plan to do, going forward, is, for the basic product, we keep these three disabilities criteria. The reason is this. If you start lowering the threshold, that means easier to get payout, then your premium, unfortunately, will be quite high. So there is a trade-off. My actuaries are still doing the computations. Most likely, I think we keep to the basic product - three qualifying thresholds but as I have already shared with the public a few weeks ago, what I plan to do is we allow "rider". I used the term "rider", which has confused NMP Ms Cham just now. "Rider" has a technical meaning and actually "rider" is the wrong word to use. The better word I can think of is "supplement". So I am asking my colleagues in the Ministry of Health not to use the word "rider", but use the words "ElderShield supplements".

For the basic, it applies to everybody. But if you can afford and want better payout, you buy a supplement, like health supplements. So, basic ElderShield plus supplements. We leave it to the industry to develop different "supplements". So, some supplements could have two criteria, instead of three, but, of course, the premium will be higher. For some supplements, instead of paying just $300 or $400 a month, maybe they pay $800 a month or $1,000 a month, and some other supplements maybe, instead of just paying five years, they may pay six years or seven years, or even lifetime annuity, all at different pricing. I think that will make the whole ElderShield system much more diverse, which is really the theme of my speech this afternoon, ie, our needs are diverse, so we need a wide range of diversity.

On SingaporeMedicine in public hospitals and separation of local patients from private patients. Actually, the separation right now, which we are doing, is by class - C, B2, B1, A - and foreign patients or Class "A" patients really is one category. In other words, we do not subsidise foreign patients, just like we do not subsidise the Class "A" patients. I am not very keen to have a special block for Arab, another block for Koreans, etc, because I doubt the numbers are of such big numbers to begin with.

The Chairman: Order. It is 6.45 pm.

Thereupon Mdm Deputy Speaker left the Chair of the Committee and took the Chair of the House.

Mr Khaw Boon Wan: Madam, I beg to report that the Committee of Supply has made further progress on the Estimates of Expenditure for the financial year 2007/2008, and ask leave to sit again tomorrow.

Mdm Deputy Speaker: So be it.