BUILDING OF MORE NURSING HOMES

7.51 pm

Dr Lily Neo (Kreta Ayer-Tanglin): Mr Deputy Speaker, Sir, I would like to consider the need for more nursing homes to be built in Singapore as a matter of urgency and also to evaluate the grounds for accelerating rather than shelving plans for building more nursing homes during the current economic climate.

I was perturbed when the Straits Times published the shelving of redevelopment plans for the Kwong Wai Shiu Hospital and Nursing Home recently. The Ministry of Health is still committed, in principle, to fund the proposed redevelopment of the project. However, the funds will only be made available for the project in the next year or two. This will necessarily cause the project to be shelved for the moment. The reason given for this course of action was that the total budget allocation for development projects for the next few years has been cut because of the current economic downturn.

I would like to beseech the Ministry of Health for a reappraisal of the situation and seek a positive response for a change in direction and emphasis towards this area of healthcare. Sir, I would like to try and influence the decisions of this House and the Minister for Health with the following reasons:

(1) We are facing a shortfall of nursing-home beds now. There are about 4,700 nursing-home beds available while, in fact, we need about 6,000 beds. We are short of 1,300 even as of now. The need for more nursing-home beds will increase exponentially due to our fast-ageing population. It has been suggested that we will meet an increase in demand of about 22,000 such beds by the year 2030. There is really a need for this big task of providing a further 15,000 nursing-home beds within the next 30 years. There is a need to expedite rather than to shelve the building of more nursing homes in spite of the current economic downturn. I would urge the Ministry of Health to seriously give this area more weightage and increased consideration.

(2) The cost of maintaining a patient in an acute hospital is about S$290 per day, whereas the cost of maintaining a patient in a nursing home is about S$25. It does make economic sense, therefore, to make sure that there are enough nursing-home beds for patients to be placed out from acute-hospital beds. Presently, on any given day, there are 120 "overstayers" in our acute hospitals. These patients who are well enough to be discharged from the acute-care hospitals do require further care. However, they should ideally be sent to nursing homes. Not only do they deprive other acutely ill patients of beds in the acute hospitals, they are also costing the country S$1.6 million per year. Sir, this is unnecessarily wasteful.

(3) Nursing-home beds are for patients who are not fit to be discharged to their own homes. They still require special daily care and they are dependent on others for daily routines. If these patients are forcibly returned to their own homes, the burden on their family members will be tremendous. Many of these patients are indeed frail and elderly. It will be disastrous if we cannot cater for them in the future. Mr Deputy Speaker, Sir, I foresee problems arising from an increasing number of the aged with a decreasing number of the young looking after them. Problems will also arise because there will be fewer care-givers at home due to an increase of dual-income families.

(4) There will always be those who argue that substantial numbers of people would prefer home care rather than institutional care and that the necessity for even more nursing homes begs justification. The truth is that, although home care may be preferred, it may not be ideal for many. One or more family members would have to stop work and stay at home to take care of these dependent patients. Healthcare personnel such as doctors, nurses, and physiotherapists would have to go from house to house to check on the patients. This would mean fewer patients seen each day and higher opportunity costs.

(5) The nursing homes in Singapore are usually built and run jointly by the voluntary organisations and the Government. There is a need for constant and conscientious effort to woo more voluntary organisations to participate and help in this area of healthcare. Such organisations do not come on stream as and when we like them to. Therefore, there are no guarantees that we will be getting a constant and continuous stream of them as and when the demand arises. Sir, I feel that it would be prudent that we do not turn away any offers from these organisations even, and especially, during these difficult times.

(6) It is a prerequisite of the voluntary organisations that they take on some of the building and running costs of the nursing homes. These costs, which usually run into millions of dollars, have to be raised through annual fund-raising projects. Money from well-wishers are an important source of funds and it is wise to stagger fund-raising projects so as not to overburden the well-wishers and thus jeopardise the smooth running of existing nursing homes.

(7) We should capitalise on this economic crisis and take the opportunities presented by cheaper building and construction costs. This is, in fact, one of the appeal reasons put forth by the Kwong Wai Shiu Hospital and Nursing Home. A rather valid reason indeed and it should support the request for the Ministry of Health to repeal earlier decisions. Prime Minister Goh, only a few days ago, said that his own feeling was that this year was going to be a tough year. The Government would look towards spending on infrastructure to keep the economy going. Building more nursing homes would fit nicely into this strategy and would alleviate the shortage we face at present. Therefore, it would be better that we accelerate rather than shelve the building of more nursing homes now.

(8) The shortage of nursing-home beds will be compounded next year when the Ministry of Health introduces a new funding system for our public hospitals. Presently, public hospitals are funded on a per-patient-day basis. In other words, the longer the patient stays in hospital the more the hospital gets. This is to change when funding will be based on diagnosis of diseases and the resources required by patients. The funding mechanism is derived from a system of case and disease classification termed Casemix and Diagnosis Related Groups (or DRGs) The introduction of Casemix and DRGs is to help hospital administrators and doctors to contain healthcare costs. This system will certainly pressurise the acute-care hospitals for discharge of low-funded or non-funded DRGs cases to the nursing homes. The demand for nursing homes will undoubtedly increase.

(9) The financial burden upon the "no-choice overstayers" in our acute hospitals will also be multiplied when the Ministry of Health introduces the new system next year. This is because the use of Medisave will also be based on the Casemix and DRGs Classification. The patients will have to pay for the expensive acute-beds with meagre Medisave deductions. They will need to fork out much cash for "overstaying" in such acute-care beds due to a forced circumstance. They suffer for not having the choice of transfer to a ten times cheaper alternative - a nursing home.

Mr Deputy Speaker, Sir, having said the aforementioned, I would like to stress the importance of a couple of related issues which also warrant our attention. We need to ensure the reduction in demand for beds in our hospitals and nursing homes. We will also need to look into alternative and additional ways for patients to have funds for out-of-hospital expenses. Let us consider these two issues:

(1) You will agree with me that we should practise the "prevention is better than cure" policy, as far as healthcare is concerned. Sir, "preventive healthcare" is the key to success in coping with future healthcare problems. Revamping and investing well in this area will reap us abundant rewards in the future. There is still a lot that can be done. Prevention of disease and promotion of healthy lifestyle should be targeted at everyone. Due to time constraint, I would not go into the details. The topic of preventive healthcare alone will merit another adjournment motion by itself!

(2) In the area of healthcare financing, there is still something amiss despite Medisave, MediShield and Medifund. To repeat what I suggested in this House, we need a co-payment insurance scheme to cater for long-term care outside hospital settings. I would call this "Medicare". "Medicare" will provide for burdensome and chronic but non-institutional care. In some instances, this may actually be the preferred alternative care - "home-care". This will reduce the load placed on hospitals and nursing homes. Presently, the facility to use Medisave only for hospital and nursing home admissions is an important consideration causing many patients to favour institutional-care instead of home-care. This, again, is a waste of expensive resources.

Mr Deputy Speaker, Sir, let us give special attention to these seemingly remote issues, even as we cope with this economic crisis. It is far-sighted vision and far-reaching preparation, the hallmark of the PAP Government, which will prevent and cushion Singaporeans from catastrophes in the future.

The Senior Minister of State for Health (Dr Aline K. Wong): Mr Deputy Speaker, Sir, my Ministry is not shelving the development of nursing homes. On the contrary, we are expediting and building more nursing homes. Let me explain.

My Ministry is fully aware of the need to plan for the long-term care facilities for the elderly sick. Not every sick elderly person requires institutionalisation. According to a study done by the Ministry of Health a few years back, our estimate is that only about 3% of the total elderly population aged 65 years and above need some form of institutional care. MOH has been actively working with the Voluntary Welfare Organisations (VWOs) to build nursing homes and help those who are interested in doing so. Indeed, I agree with the Member, Dr Lily Neo, that nursing homes by far are a cheaper alternative to having patients staying unnecessarily long in our acute hospitals. Irrespective of the Casemix formula of funding hospitals, which is actually still at the trial stage, there is need for us to provide the cheaper alternative, that is, in terms of nursing homes for the elderly patients.

However, many VWOs have problems implementing their projects on time. The length of time taken for a project to be approved for funding is dependent on the VWO's proposal meeting MOH's guideline on the setting up of nursing homes and also the obtaining of the necessary approvals from various Government departments. The average time taken for a project plan to be finalised is around two years. But there are often delays in the planning and design phase carried out by the VWOs, and these are due to several factors. Firstly, the VWOs tend to far exceed the space norms for approved facilities and they often want to include facilities which turn out to be not eligible for Government funding. So, much time has to be spent at meetings with the VWOs and their architects to assist them to revise the plans until they meet the MOH's requirements. The other reasons for the delays include delay in identifying suitable sites, the time required to assess community reaction, the formal allocation of site and the need to coordinate with various other agencies on the plans, such as with the URA, Land Office, PWD, LTA, and so on. The construction itself takes another 1.5 to two years. So under the present procedures, the minimum time required is 3.5 to four years for a development project to be completed. We have reviewed the process with a view to expediting the time required for project approval.

It is true that presently we have a shortfall of nursing home beds. However, according to our latest projections, we should be able to correct this shortfall within the next five years. Let me elaborate. At the end of 1998, there were around 4,600 available nursing home beds. The shortfall was 1,600 beds. This shortfall is higher than the 1,300 beds quoted by Dr Neo, because she was referring to 1997 figures. The background is that between 1996 and 1998, there were only four nursing home projects (two were new homes and two were replacement homes) which were completed. And this added only 450 beds to our supply of beds. So there was a slight increase in the shortfall.

We are stepping up our assistance to the VWOs. And we are currently working with 12 VWOs to build nursing homes to meet this shortfall. These projects are already in various advanced stages of development. Between 1999 and 2001, there will be nine new and replacement projects which will be completed, adding another 2,000 beds. This would give a total supply of around 6,400 beds. When this is compared to the projected requirement of 6,750 beds, the shortfall will be reduced very significantly to only 350 beds in two years. With more nursing home projects coming on-stream between the year 2002 and 2003, there will be another 1,000 beds added to the stock, and this will, in fact, wipe out the shortfall. There will be no shortfall by the year 2003. The total supply of available beds by the year 2003 will be 7,400, which is in contrast to an earlier estimate we made in 1997, that only 6,600 nursing beds would be available.

The revised figure is made possible because last year, we reviewed the nursing home building programme and re-prioritised the projects to ensure that those that could be moved ahead faster would receive higher priority for funding. New nursing homes that would add more nursing home beds compared with replacement or upgrading projects and those that could be put up at a lower cost received priority funding. As a result of our re-prioritisation exercise, we were able to increase the number of nursing home beds available by the year 2003 from 6,600 to 7,400. As I have said, by the year 2003, we do not expect any shortfall and we would maintain this balance. Furthermore, we have begun to work with other VWOs on planning for nursing homes to come on-stream beyond the year 2003.

The Member mentioned that there would be a requirement of 22,000 nursing home beds by the year 2030. But this is more than 30 years down the road. With the new momentum that we have created, we are confident that by that time, we would be amply prepared to meet the projected demand.

I would like to say that besides nursing homes, we are also stepping up the provision of other long-term care facilities, such as community hospital beds and chronic sick beds. By the year 2003, there would be an increase of 800 community hospital beds and chronic sick beds. Currently, there is no shortage of places at the day rehabilitation centres. However, there is a need to provide home care services. As the Member so rightly pointed out, some patients could be taken care of at home and it might be better for them to be cared for by family members or care-givers. So MOH is encouraging more VWOs to provide home-care services for the elderly sick.

The Government will continue to provide financial assistance to VWOs for the development of facilities and services for the elderly sick. I would like to stress that funds provided by the Ministry of Finance have not been reduced, despite the economic downturn. Between 1996 and 1998, we have provided $33.4 million to nursing home projects. Between 1999 and the year 2001, we will be providing $131 million. If you take into consideration the other long-term care facilities, such as community hospitals and chronic sick hospitals, then, from now till the year 2003, MOH expects to spend $235 million to assist the VWOs to build these long-term facilities.

The case of the Kwong Wai Shiu Hospital, as we explained in the written answer to the Member already, is that originally, they had a very grand plan of building a 1,500-bed convalescent hospital cum nursing home. We went back to them and asked them to reconsider the plan. We asked them whether this was realistic in terms of the resources and so on. The redevelopment plan is now still at the concept stage and is being revised. Once the details are firmed up, we will be able to work out the funding details. So we are asking them to revise the plan and to be more realistic and more effective so as to meet with our requirements.

I would also like to say that MOH is not only concerned with the availability of long-term care services. These services must meet certain standards set by my Ministry for obvious reasons, like physical standards and quality of care provided for patients. We have drawn up guidelines on physical facilities and the staffing ratio already. Guidelines on care standards are also being developed. Once these are developed, they would apply to all the nursing homes and other long-term care facilities.

It is important to ensure that individuals are able to finance their own long-term care needs, especially during old age, and this is apart from Government subsidies and the subsidies provided by the VWOs through their fund-raising efforts. We recognise and appreciate the efforts put in by the VWOs in raising funds, in providing the services, in running the homes and community hospitals. In fact, we are deliberating on how we can help them to reduce their load of fund-raising. We are also considering how individuals and families could be helped, apart from Medisave and MediShield, to finance their share of long-term care.

The Inter-Ministerial Committee on Healthcare for the Elderly has considered the suggestions which have been put forward by its members and by members of the community. Its report and recommendations will be released soon. So I would not disclose further details on these financing aspects.

Finally, I agree with Dr Lily Neo, I agree very much indeed - and this has been the emphasis of my work in the Ministry in the past years - that everybody, whether young or old, must put emphasis on leading a healthy lifestyle. This is the best way to cut down the burden of his own healthcare costs, the burden to his family, to the community and, eventually, also to the Government, because the Government heavily subsidises healthcare.

I would like to conclude by saying that we are committed to ensuring that the elderly have access to affordable long-term care, but health is also very much in our own hands.

Question put, and agreed to.

Resolved,

That Parliament do now adjourn.

Adjourned accordingly at Nineteen Minutes past Eight o'clock pm to Friday, 26th February, 1999.