Committee of Supply – Head O (Ministry of Health)

Transforming Healthcare in Singapore

Dr Chia Shi-Lu (Tanjong Pagar): Chairman, I beg to move, "That the total sum to be allocated for Head O of the Estimates be reduced by $100".

We are now just two years away from the year 2020, and I would like to begin by asking the Ministry of Health (MOH) to give an update on the progress of the Healthcare 2020 Masterplan.

The Budget Statement which was delivered last week, gave us a stark reminder that although Singapore may be one of the healthiest nations in the world with a healthcare system that is admired by many, and Singaporeans may be amongst the longest living, but with our ageing population and a growing chronic disease burden, healthcare expenditure is rising, and it is rising very quickly. The MOH's operating Budget has risen from $5.87 billion in financial year (FY) 2014 to almost $9 billion for FY2018.

In an effort to maintain the relevance and sustainability of our healthcare system, MOH earlier outlined its chief strategies to transform our healthcare system to meet the challenges of the future with three key shifts. The first was moving beyond healthcare to health; the second, moving beyond the hospital to the community; and third, moving beyond quality to value. I would like to comment on these proposed shifts.

First, moving beyond healthcare to health. Over the past few years, the focus on health promotion and maintenance has been unrelenting and I applaud all Singaporeans for rising to this challenge. The call to arms to fight diabetes has reverberated through our society. We are all exercising more, eating more brown rice, for instance, saying "no" to sugar and "no" to over-eating.

I appreciate the many initiatives and the nudges that we are making to make Singaporeans choose a healthier lifestyle. For instance, where I work, all of the kopitiams and coffee-shops no longer put sugar in their beverages of coffee and tea. If you want to, you actually have to add it yourself. It is initiatives and small little measures like these that will help our fight forward.

I look forward to more initiatives from MOH and the Health Promotion Board (HPB) to promote healthy living in Singaporeans. As in every battle, it would be a mistake to step back when the tide is in our favour. I would like to request an update from MOH regarding its strategies for promoting healthy lifestyle choices amongst Singaporeans.

Second, moving from hospital to community. I have voiced my strong support for the right citing of medical care to the community wherever possible and, for this to be possible, we have to continue strengthening both our primary care and intermediate and long-term care (ILTC) sectors.

I will speak on primary care transformation later. But at this juncture, I would just like to ask: are our efforts to increase ILTC manpower and infrastructure on track, as detailed in the 2020 Masterplan?

This call to shift from hospital to community also heralds another key theme that was announced in this year's Budget Statement. Many Members have already spoken on this, but I was heartened, like the rest, by the announcements that health and social services will be more closely integrated. This is because there is clear evidence from around the world that the health of an individual is closely related to one's socioeconomic status. The wealthier also tend to be healthier.

A recent study from the United States (US), using data from the Centres for Disease Control, confirmed that people with higher incomes lived longer and had better health scores in virtually every parameter. One commentator went so far as to suggest that "being rich is the best healthcare plan that America has to offer".

Closer to home, as Member Dr Tan Wu Meng had alluded to in an earlier speech, a study in Singapore also noted that if you use public rental housing as a measure of socioeconomic status, then this, in itself, is independently associated with increased hospital re-admission risk, and being a frequent hospital admitter and also an Emergency Department user.

There could be many reasons why people with lower incomes have poorer health scores. The most obvious would be access to healthcare, but this is probably less true in Singapore than in other countries because our comprehensive healthcare system with universal coverage and very targeted subsidies has tended to flatten inequities in medical coverage. What then about other factors?

Poorer health has also been associated with educational level which, itself, correlates with lower income. People with lower educational status, however, are not necessarily less knowledgeable about health, compared to those with higher education. Allow me to elaborate with two examples.

We all appreciate that one of the most important paths to good health is to exercise good food choices. One study looked at why children coming from wealthier, better-educated parents grew up preferring healthier foods and were ultimately healthier. It is important before we go in to understand that where children are concerned, research has shown that kids might actually need to try a new type of food, about eight or up to 15 times, before they can accept it and perhaps grow to like it.

So, what the researchers found was that while parents from all backgrounds understood which foods were healthy and which were not, eat more vegetables, less fried foods and so on and sweets, parents who were less educated and with lower incomes often did not persist in offering healthier foods to their kids. This could be because of the steep upfront cost in introducing these foods to children.

Let us take vegetables, for instance. If a parent who is already working within a tight budget and time is short and a child refuses broccoli, for instance, then they will be less likely to persist with it because the child will probably refuse and it will end up on the floor. They would soon give up and say, "Okay, maybe we will just give them the chicken nuggets that they are clamouring for". A family which is wealthier may perhaps have the luxury to be able to continue offering this food, even though the broccoli ends up on the floor 10 or 15 times, until the child learns to appreciate it.

In line with this, let me call on the Ministry to continue working with MOE and our schools to ensure that only healthy foods be served to our children. I understand the constraints that some families will face in regard to food choices at home, but I hope that our schools can play a bigger role towards inculcating healthy eating habits in our young. I feel that this should actually start at the preschool level, rather than just at the primary school level.

Another example closer to home. Some years ago, a team from the Saw Swee Hock School of Public Health worked with myself and my grassroots volunteers to conduct a health survey in one area of Queenstown. This survey reached out to almost 3,000 residents and was conducted over a period of about a year. It was a very good study but, I think, one repeated observation that I got was that residents who had higher educational levels were less likely to smoke and they were more likely to go for health screening, such as colonoscopy for colon cancer, mammography for breast cancer and pap smears for cervical cancer.

The researchers actually found that this difference was not due to any knowledge gaps. If you ask people from all educational levels whether they knew what mammography was and why it was important, I think the knowledge was the same. Whether you came from a low or high educational background, you understood the importance of it. It was just that those from higher educational levels actually made that extra effort to go ahead with the screening.

Thus, it is clear that an important determinant of health inequity is also social inequality, and as we strive to be a healthier country, we should never lose focus on enhancing social mobility and reducing social inequities. In the meantime, I hope that this new compact between our social and health services will allow us to dive deep into the social circumstances of our lower-income fellow Singaporeans to give them the support that they need to achieve a long and healthy life.

I hope that the Ministry would be able to share more about the proposed integration of health and social services, as I feel that this would go a long way towards flattening the social gradients in the health of our population.

Finally, from quality to value. It is a tricky subject, because what is value in healthcare? Just as the quality of health services is sometimes difficult to quantify, what represents good value in medical care?

Of course, value is important because, if we are counting our pennies, we have to ensure that healthcare remains affordable by ensuring that we get the best outcomes for the lowest financial outlay.

Budget 2018 is frank and upfront about the financial pressures that our nation is likely to face over the next decade, and healthcare spending is one of the areas that will see the greatest increase in public spending. Value-driven healthcare policies could be a significant avenue of ensuring the sustainability of our system.

Our healthcare institutions were recently reorganised from six clusters to three. This was announced last year. Can I ask if this has led to any desired gains in efficiency and value of care delivery?

I have also previously asked for a body to be set up to evaluate not only the efficacy, but also the value of various medical and health-related interventions, whether diagnostic or therapeutic. I am glad that we now have the Agency for Care Effectiveness (ACE), and I call for ACE to play a bigger role in our quest for value and clarity in our healthcare spending.

Some interventions may seem very promising but with uncertain benefits, and they are controversial. For example, for things like hypertension, hyperlipidaemia, at which point do we actually choose to treat otherwise healthy individuals with medications, new technologies, remote consultations? Some studies have shown that although it is easier, but it tended to increase the utilisation of services with no discernable improvements in health outcomes.

In conclusion, the health check for our healthcare system is good for now, but just as our economy needs to transform itself to position itself for the future, so, too, does our healthcare system, which needs to see through its transformation to continue serving our country well beyond 2020, and, in fact, beyond 2030. Thank you and I beg to move.

Question proposed.

The Chairman: Mr Gan Thiam Poh.

Infrastructure Plans

Mr Gan Thiam Poh (Ang Mo Kio): Chairman, in Mandarin.

(In Mandarin): [Please refer to Vernacular Speech.] A good healthcare delivery system has to be supported by robust infrastructure. I would like to ask the Minister about the progress of the development plans for our primary and secondary care infrastructure.

Will the Minister share updates on the investments for ILTC? How do we make sure that we have enough beds in our hospitals, nursing homes and care centres to meet the increasing demand of our ageing population? Will the upgrading and expansion of our current infrastructure be enough to meet the targets set in the Healthcare 2020 Master Plan?

In addition, how will the Ministry be integrating "smart" technology into our healthcare infrastructure to boost care delivery standards and efficiency, and to reduce costs?

Quality Care and Patient Safety

Ms Sylvia Lim (Aljunied): Sir, over the years, I occasionally encountered residents dissatisfied with the quality of care received at our public hospitals. Their grievances range from an unexpected death in hospital, to a physical accident while conveying a patient, causing patient injury.

In cases of unexpected death, the Coroner and the Police are likely to be activated, ensuring a strong measure of independence into the inquiry. However, in non-fatal cases, the hospital is usually the one which conducts an investigation or review into the incident.

As the hospitals are investigating their own handling of patients, a question that arises would be: what safeguards are there to ensure there is independence injected into the review process? How far is input from patients or next-of-kin sought in such investigations? Will the patient or his representative have the opportunity to contradict evidence presented by the staff? What role does the Ministry itself play in ensuring that hospital investigations are fair and transparent to patients?

In a 2004 article entitled "Quest for Quality Care and Patient Safety", MK Lim of the National University of Singapore (NUS) Faculty of Medicine noted that Singapore had more than 10 years ago, moved to a broader concept of quality assurance in healthcare that included the monitoring of clinical indicators and medical errors. According to him, what was lacking then included public involvement and patient empowerment. Have we made any improvements in these areas?

I am aware that MOH has since moved on and now has a healthcare performance group that oversees clinical quality and care effectiveness. Could the Ministry tell us more about the priorities of this group?

Finally, the United Kingdom (UK) in 2017 set up its Healthcare Safety Investigation branch, an independent body to conduct no-fault reviews of incidents to enhance patient safety and knowledge sharing across healthcare institutions. How are we doing this here?

Personalised Medication and DNA Edit

Mr Low Thia Khiang (Aljunied): Chairman, Sir, personalised medicine which involves the customisation of medical treatments to specific patient groups based on genetic profiles, seems to be a fast-emerging field of clinical research and application in Singapore. But I believe the general public knows very little about this.

There is, for example, the National Precision Medicine Initiative, which appears to need supercomputing resources to gather the genomic information of the whole Singapore and Southeast Asian populations to determine genetic risk and other personalised treatment.

Can the Minister share more about the National Precision Medicine Initiative and whether MOH has oversight of the Initiative and its programmes? What is the long-term plan for the development of precision medicine in Singapore? Will a national registry of genetic disorders be developed? If so, how will it be used and how will the data be shared, nationally and internationally? Does precision medicine research here involve deoxyribonucleic acid (DNA) editing? If so, what are the bio-ethical rules governing the research?

4.15 pm

In March last year, MOH announced that the standards for the provision of clinical genetic testing were being drafted and would be ready as a code of practice by late 2017 before becoming enforceable in late 2018. Is the Ministry still on track with this timeline?

It was reported in The Straits Times in August last year that hundreds of patients have already benefited from personalised medicine treatments in Tan Tock Seng Hospital, KK Women’s and Children’s Hospital (KKH) and Singapore General Hospital (SGH). I would like to know how will ordinary Singaporeans benefit from precision medicine and how will the Government manage the cost of its widespread usage.

The Chairman: Assoc Prof Fatimah Lateef. Not here. Dr Chia Shi-Lu, please take both cuts together.

Healthcare Insurance Taskforce

Dr Chia Shi-Lu: Sir, the objective of the Health Insurance Task Force (HITF) is to study ways of improving private health insurance in Singapore in order to achieve more efficient and sustainable outcomes for our healthcare system. This is important as close to two-thirds of Singaporeans currently have an integrated health insurance plan.

In its report that was released in 2016, HITF had recommended a few things, the first being the publication of medical fee benchmarks to help raise price transparency so that patients can make more informed choices. The fee guidelines are expected to be published sometime this year. The intention is to rein in escalating healthcare costs and ensure that medical services and goods remain affordable and accessible to all Singaporeans.

The second recommendation was that HITF noted in its report that there were private insurance features and riders that "provide policyholders with 100% coverage without any co-payment", and they expressed their concern that the absence of co-payment may encourage both over consumption and over servicing in regard to medical care. And I note from the report in today's papers that the six Integrated Shield Plans (IP) insurance have appealed to MOH to make co-payments compulsory.

Finally, HITF also made other recommendations to manage IP claims costs, such as the use of a panel of preferred providers and pre-approval of claims. What is the status of MOH's review on the HITF's report and recommendations?

MediSave for Outpatient Treatment

Over the years, MOH has liberalised the use of MediSave for outpatient medical costs, and I would like to ask if MOH would consider further enhancements to the Chronic Disease Management Programme (CDMP) and also the Flexi-MediSave Scheme, which allows the elderly to utilise more of their MediSave for outpatient medical expenses. Will the Ministry consider raising the Flexi-MediSave sum? Would MOH consider liberalising the use of MediSave for the cost of other allied services, such as physiotherapy, or perhaps the use of consumables for chronic conditions like heart disease and diabetes?

As I often call for during the COS debate, I would like to ask the Ministry to include more chronic conditions under CDMP. I have always felt that this is an excellent programme and feel that it should be expanded wherever possible. Including more conditions beyond the 19 already included will reduce the cash outlay required and encourage patients to be more compliant with treatment.

I would also like to renew my call for the CDMP withdrawal limit to be calibrated to the number of chronic conditions that a patient has. Thus, a patient suffering from three chronic illnesses should perhaps be allowed to withdraw a little bit more than a patient who only has one chronic illness.

MediSave Flexibility for Special Needs

Mr Zainal Sapari (Pasir Ris-Punggol): Sir, in Malay.

(In Malay): [Please refer to Vernacular Speech.] Raising special needs children comes with a lot of challenges. Undoubtedly, it can be financially straining to families and parents who are taking care of these children. Even though Singapore has a support system that helps to lighten their load, there will still be occasions where it can be financially draining, especially when paying for the costs of medical treatment for these special needs children.

Recently, one of my residents with moderate income had to postpone the basic dental treatment for his special needs children due to the high cost since the children had to be administered with general anaesthesia. These problems do surface when caring for special needs children.

Would MOH look into the possibility of allowing such parents to tap on their MediSave account to pay for the outpatient treatment for those who have special needs children, if the bill exceeds a certain amount?

Improving Management of Chronic Disease

Mr Louis Ng Kok Kwang (Nee Soon): CDMP is meant to allow patients with chronic conditions to use MediSave and reduce out of pocket expenses. However, it currently covers only two auto-immune conditions, that is, rheumatoid arthritis and psoriasis.

Members from the Auto-immune Illness Support Group Singapore have bravely shared with me about their conditions, which are lifelong, chronic and not curable. They can only manage their symptoms by regular doctor visits and long-term medications, without which it can result in serious complications and prolonged hospitalisation. Because of individual reactions to medications, some have no choice but to take high-cost, non-subsidised medications.

Based on an internal survey by the group, there is a huge range and no single most common auto-immune condition. Will the Ministry consider including more auto-immune conditions into CDMP, allowing patients to use their MediSave and relieve their financial burden?

Pricing of Vaccines

Mr Leon Perera (Non-Constituency Member): Mr Chairman, Sir, some vaccines, like pneumococcal and human papillomavirus (HPV), are not subsidised but can be paid for using MediSave. Minister Gan said, in reply to Mr Low Thia Khiang at last year's COS, that Government MediSave top-ups can be used to pay for vaccines.

However, many Singaporeans may not want to use MediSave for vaccines, preferring to keep the MediSave for bigger bills incurred later in life. The HPV vaccine, for instance, can prevent most cervical cancers, saving lives and cost, but only about one quarter of Singapore women are vaccinated.

I have two suggestions. Firstly, can ECI consider studying and quantifying the marginal benefit in disease incidence and marginal long-term cost saving for the Government in healthcare subsidies, MediFund and so on from the increased vaccine take-up that a bigger subsidy for the vaccine price would bring?

Secondly, can MOH study, by way of perhaps a trial, to what extent lowering vaccine prices through targeted Government subsidies for key vaccines would result in higher take-up of the vaccine?

Based on these two actions and their results, my suggestion is that MOH can introduce targeted subsidies to greatly reduce the price of vaccines if there is evidence that this would stimulate higher take-up and not only reduce disease incidence later in life but reap long-term cost savings for the Government.

Caregivers of Mentally Disabled Persons

Mr Murali Pillai (Bukit Batok): Sir, I wanted to start off my speech by stating that this is the third time I will be speaking on this topic in Parliament and I hope that I would be third time lucky. But as it turns out, I do not have to implore for a third time.

Senior Parliamentary Secretary Assoc Prof Muhd Faishal Ibrahim announced in this House just about two hours ago that from 1 April 2018 onwards, the Ministry of Social and Family Development (MSF) and MOH have agreed to use an additional yardstick, in the form of MSF's Client Assessment Form, to evaluate the level of support a mentally disabled person requires to perform Activities of Daily Living (ADL).

This, in turn, will determine the eligibility of caregivers of mentally disabled persons to qualify for a foreign domestic worker (FDW) levy concession of $60 per month or a grant of $120 per month. MSF estimated that about 1,000 caregivers will benefit from the enhancing of the system. I welcome the announcement.

With the implementation of the new system, we would be removing an anomaly that has previously existed. Depending on circumstances, many mentally disabled persons are effectively in the same position as young children as they can only perform ADL under supervision. Yet, their caregivers did not get the levy concessions and grants that caregivers of young children did. I am sure these affected caregivers will warmly welcome this announcement.

Assoc Prof Faishal announced that the evaluation of support level for mentally challenged care recipients will be done at Day Activity Centres and Therapy Hubs. It seems to me that appropriate resources and tools would have to be provided to the Day Activity Centres and Therapy Hubs so that they can better assess the mentally challenged care recipient's needs level. The officers would have to contend with a wide spectrum of mental conditions, too. I would welcome MOH's elaboration on the system that will be implemented in three weeks' time. Without a doubt, though, we are moving in the right direction.

The Chairman: Assoc Prof Daniel Goh, can you take both cuts together?

Mental Health Support in Heartlands

Assoc Prof Daniel Goh Pei Siong (Non-Constituency Member): Chairman, Sir, we have many agencies and programmes promoting mental well-being and assisting Singaporeans with mental health issues. The National Council of Social Service (NCSS) publishes the Mental Health Resource Directory on its website. The Directory is 60 pages long and there are 11 helplines listed in it. By 2021, the Agency for Integrated Care (AIC) will manage 50 community outreach teams to raise awareness of mental health, identify those at risk and conduct preventive care programmes. Also, by 2021, the Mental Health General Practitioner (GP) Partnership Programme run by MOH will partner 180 GP clinics to manage patients with mental health issues.

With these programmes and resources, we have the elements of a mental health support system in place in Housing and Development Board (HDB) estates. By themselves, the programmes and resources can be too complex for a person with mental health issues to navigate. The next step, thus, is to bring the elements together and integrate them to build a system that is easily accessible to people with mental health issues or their family, with a No Wrong Door policy to direct persons to the most appropriate help.

I have two questions in this regard. Just as AIC has been designated as the central agency to coordinate diverse senior care services to better deliver care to our seniors, should there be a central agency to coordinate mental health care services? Secondly, we already have an accessible network deeply embedded in HDB towns that coordinate the delivery of services to residents. This is the network of Social Service Offices (SSOs) under MSF. Would it make sense for MOH to partner MSF to leverage the SSOs to coordinate mental health care services in the heartlands?

National Dementia Plan

Dementia is the most prevalent neuro-degenerative disease that affects an estimated one in 10 people aged over 60. There were over 40,000 seniors suffering from dementia in 2016. This is expected to rise to 92,000 by 2030. Dementia poses significant health and socio-economic burdens to patients and caregivers and to society as a whole.

I would like to propose for the Ministry to seriously consider a National Dementia Plan that systematically addresses the needs of dementia patients, promoting public awareness and improving the quality of healthcare, social care and long-term care support and services for all affected. Countries like Korea, Japan and Australia are implementing similar high-level plans, making dementia a public health priority. These plans include accessible early detection services, access to information, pre- and post-diagnosis care and support, as well as supporting people with dementia in aged communities to remain socially engaged and active.

In 2016, AIC was discussing plans with stakeholders to develop a national registry of dementia patients so that they can be more easily located if they go missing and their caregivers contacted. However, these plans were put on hold last year. Would the Minister give an account of why the plans were put on hold? Were there issues with getting the consent of families? Were there issues with implementation linked to the registry held by the Neighbourhood Police Centre in Yishun, as part of the dementia-friendly community initiative launched there in 2016? Would the plans for a national registry be revived?

Mental Health

Miss Cheng Li Hui (Tampines): Sir, with an ageing population, we will see an increase in the number of Singaporeans with dementia.

There are a few types of dementia and it is possible to lower the risk of dementia through lifestyle choices and habits, such as staying mentally active, socially engaged and physically active. Knowing the warning signs and symptoms of dementia can help patients and their families discover their condition earlier and help them better manage.

MOH has previously launched a few dementia friendly communities (DFCs) where the community at large knows what dementia is and better support the persons and their caregivers. Can MOH give us an update on DFC's efforts and what plans does the Ministry have in the pipeline to further enhance our current efforts to better cope with the higher number of Singaporeans with dementia?

Community Mental Health

Ms Joan Pereira (Tanjong Pagar): Chairman, with an increase in our ageing population, more seniors will be facing mental health issues. They may suffer from depression, memory loss and dementia. This poses a challenge not only to the seniors but also to their caregivers and family members. Their mental illness can result in their being isolated from the society.

We are already seeing cases of our elderly living alone, perhaps because the spouses have passed on, and gradually they go into depression and some would be gripped by dementia. Some have no relatives or friends to care for them. They become dependent on social workers and the community volunteers to give them the support in their twilight years. We need to prepare ourselves for more of such cases, as improved medical care is seeing people living longer lives.

How is the Ministry making mental health services more accessible to support these seniors with such conditions? Also, how can their caregivers and their family members be better supported?

The Chairman: Assoc Prof Fatimah Lateef. Not present. Dr Chia Shi-Lu.

Productivity/Innovation in Healthcare

Dr Chia Shi-Lu: Sir, due to our ageing population, the demands upon our healthcare providers are expected to escalate. As this is a labour-intensive sector, our manpower shortage has to be overcome through enhancing productivity and innovation. How is MOH encouraging innovation and spurring productivity in the healthcare sector? Would the Minister elaborate on process improvements which have contributed to better patient care and experience and boost productivity gains in different segments of our medical sector?

Tremendous gains are being made every day in the fields of robotics, artificial intelligence (AI), big data analytics and the Internet of Things (IoT). These have the potential to vastly improve healthcare delivery and outcomes. How are we leveraging such positive disruptions in healthcare services for Singaporeans? Would the Minister share an update on the investments the Government is making to boost automation and tap upon new and innovative technologies to provide quality, affordable healthcare?

4.30 pm

Increasingly, the healthcare sector will have to work closely with diverse fields, such as information technology (IT), engineering and biotech, to come up with innovative healthcare solutions but, at the same time, without losing the human touch. What are some of our local success stories in innovative research and cross-sector collaboration?

Silver Towns

Mr Leon Perera: I declare that I am the Chief Executive Officer (CEO) of an international research consultancy whose Korean arm has researched this subject.

Mr Chairman, the Korean Silver Town model is worth a closer look since it is a roughly S$10 billion industry and it has had a long runway in Korea, evolving over the decades. In Korea, private sector Silver Towns emerged in the 1990s. Initially, they were driven by big conglomerates or chaebols, which developed a site for senior residences but also built in proximate facilities like retail, personal services, sports and recreation facilities and even, in some cases, childcare and play facilities for the grandchildren when children visit their parents.

The Korean Silver Town model emphasises high-rise, high-density living, integrating smart technology, which is a little different from the assisted living and retirement community models seen elsewhere. Silver Towns in Korea have since evolved. There are different Silver Towns in Korea with different mixes of facilities catering to different price points.

Silver Towns embody a balanced point between, on the one hand, personal independence and freedom to seniors and, on the other hand, the presence of medical staff, facilities and the most structured daily routine administered by professionals for those seniors who need it, such as those having dementia.

I do not suggest Silver Towns as a substitute to seniors staying with their children. However, for some seniors, this is not possible while, for others, this is not desirable. So, Silver Towns could be part of the ecosystem, catering to the needs of our seniors, offering one option for living arrangements. Lest I be misunderstood, I do not advocate that Silver Towns be run by the Government, as some are in Korea, or come with 100% subsidies.

The roadmap to this could be, after the concept has been studied, to issue a tender to invite master developers to build and operate a Silver Town. A pilot project could be used to test demand. Means-tested subsidies could perhaps be applied in some cases.

The Government could also nudge Silver Towns to become testbeds for the trial of new, disruptive concepts catering to the senior community and make it convenient for non-government organisations (NGOs) to target and trial programmes aimed at seniors.

Sir, Korean Silver Towns are not without their negative points, but I hope that the Government will study this idea further.

Nursing Homes

Miss Cheng Li Hui: Sir, in the past, nursing homes were mainly operated by voluntary welfare organisations (VWOs). Recently, private companies have been taking over the operations of nursing homes. How does the Ministry ensure that nursing home prices are kept at an affordable price?

My main concern is whether the objectives and goals of the private companies are able to be aligned with the business model of the nursing home. If the profit maximisation approach is adopted by these companies, then we could see the undesirable rise in charges that will inevitably drive up the cost of nursing care.

When needed, how does MOH get the private nursing homes to meet changing trends to include new services that the nursing homes might not previously have, services, such as home personal care, home nursing or nursing posts to help residents change bandages and so on?

Successful Ageing

Miss Cheryl Chan Wei Ling (Fengshan): Sir, accessibility and affordability are key in giving Singaporeans greater peace of mind about healthcare. But much of these actions are augmenting the support rather than preventive. As we extensively focus on how to enable the Baby Boomers to age in place, we must begin thinking of strategies to ensure that the Generation X/Y is managing their health on a different trajectory, a trajectory where the starting point of their mental and health state are healthier, with lower dependence on medication and the need for longer-term care needs in future.

It is common knowledge that we must eat well and exercise frequently to stay fit. But apart from health campaigns or one-off activities like the National Step Challenge, Let Us Beat Diabetes, how has MOH engaged the Generation X/Y on a continuous basis to ensure that we have a future ageing population that is healthy?

I say we need longer-term plans. First, on exercising. Given the busy schedule of our young working adults, accessibility to exercises is critical. The community exercise initiatives by HPB and Active SG are encouraging. It not only provides exercise options close to their homes but also encourages community bonding. Is there any plan for MOH to keep this interest towards a healthy lifestyle more sustainable?

Second, healthy eating habits. Variety and ready availability of food choices today have spoilt our consumers at a young age. With their busy lifestyles, more families are dining out and consuming more, as shown in the National Nutrition Survey. While food preference may be individual, some policy adjustments can help with mindset change in dietary habits. Some areas for consideration I would like to put up are: (a) types of ready-processed food allowed to be sold in vending machines near the residential neighbourhood, medical facilities and Institutions of Higher Learning (IHLs); (b) proportion of meal sizes sold in hawker centres and food courts at commensurate prices; and (c) inculcating the concept of discipline in healthy food intake rather than mere caloric value of every bite.

As we understand there is a growing need for caregiving support to our elderly, we are constantly looking at ways to supplement this network of caregivers. This effort can enhance the supply and we must continue doing so. But as we extend this support through FDWs to future robots, we should not forget the human touch. The emotions and human interactions remain the backbone of caregiving.

I would like to highlight a specific group which MOH can consider tapping upon. There is a pool of low-income women and single mothers, estimated to be 25,000, representing a third of Singapore's unemployed population. Some of them had roles of caregiving to their families, and certainly many still bear the brunt of caring for their own children. Their unfortunate family circumstances aside, these women require the necessary skills to gain confidence and rebuild their lives. But beyond themselves, what we can potentially change here is the provision of employment and lifting their families out of poverty in a dignified way.

There are VWOs like Daughters of Tomorrow (DOT) which began in 2017 to provide professional training skills for these women in eldercare services. They have successfully placed them in the eldercare sector or as freelance caregivers. With the strong push for Community Network for Seniors (CNS), MOH can assist by working with these VWOs to identify a pool of known resources and accelerate the training of the individuals through funding or fill the gaps in resource deployment. As a start, these beneficiaries can be assigned to work within the community where they live in. The benefits are two-fold, as they can manage caring for their family and also be gainfully employed. Over time, I hope these women will also have more options in employment and can better care for their own elderly at home and be financially independent.

Lastly, Seniors' Mobility and Enabling Fund (SMF). Today, SMF provides the seniors with subsidies for assistive devices and homecare items or transport. But there are those seniors whose annual value of property do not fall under the current criteria and may also face challenges. With the advent of technology, we should look beyond direct subsidies into social outcome to benefit the larger group of seniors. For example, social partnerships with the private sector in creating environment and alert tools from remote operating centres that can deploy assistance to those seniors in need. Or to provide home-based care products and services, where it also monitors health and movement conditions of seniors.

Another way is to create new funds for app developers who can create socially engaging apps aimed at active agers or to draw experience from those who understand the mindset of how an elderly reacts, for example, like Mdm Masako Wakamiya, 82 years old, who is one of the world's oldest app developers. We should creatively generate options and create accommodative relief for individuals and families, rather than one where individuals are more likely to become supplicant recipients of charity.

The Chairman: Ms Tin Pei Ling, can you take both cuts together?

Digital Eldercare

Ms Tin Pei Ling (MacPherson): Sir, with Singapore undergoing rapid ageing, it is not only important that we set the right policies, put in the right resources and organise ourselves the right way now, but we should also start exploring solutions that can help more seniors age gracefully and live independently in the comfort of their own homes and communities.

With an ageing population, there may soon be a point in time when there are more who need care than those who can care. Other concerns also include seeing more with age-related disabilities and loneliness, as more elderly outlive their family members or as more choose to remain single.

While the human touch in eldercare can never be fully substituted, we can leverage technology to mitigate some of these concerns. By leveraging technology and AI more effectively, we can drastically change how care is provided and help even more Singaporeans age in place.

At present, many of the technology-related pilots conducted are focused on making the living environment more enabling, which is the right thing to do. I am also aware that there are some solutions, such as telemedicine and marketplace applications, to help seniors live more conveniently. But I hope we will also start exploring solutions that can provide effective and transformative interventions to help individual seniors live independently.

Take Japan as an example. Japan is even further ahead of us in terms of ageing. They have an increasing number of elderly with a decreasing number of working adults. They suffer severe labour shortage, especially in eldercare nursing. Yet, they reinvented how the elderly can be cared for by leveraging technology and AI. From Toyota's Robina and Humanoid, Honda's ASIMO, Tokai's RIBA to AIST's PARO, which is a very cute seal, Japan has a full range of robots that can help the elderly with household chores, to get out of bed, conduct conversations complete with emotions and even help paraplegics walk again. Imagine if these solutions are available to us in Singapore, many elderly whom we used to think can only be cared for in nursing homes, can now lead a fairly independent life in their own flats.

Alas, while these are possible and already in existence, it is still not known if these solutions can be exported and at what price. It would, therefore, be most ideal if Singapore can leverage our existing competencies in research and development (R&D) to develop digital eldercare solutions for ourselves.

I understand that MOH had introduced a funding scheme to encourage innovations to solve elderly-related challenges. Therefore, I would like to ask for an update on the utilisation of funds to support R&D efforts and startups looking into digital eldercare solutions. Could the Government share some of the success cases so far? Could we accelerate developments locally and implement sooner than later?

With the drive towards a Smart Nation, how is the Ministry part of this effort and what other programmes or public-private partnerships might be available that can be utilised to further our agenda for seniors?

Design to Include and Empower

Sir, I have just spoken on the use of technology and AI to transform eldercare and enable more seniors to live independently in the comfort of their own homes and communities. I am also aware that the Government has been looking into ways to make our living environment more elderly-friendly with initiatives, such as City for All Ages, Enhancement for Active Seniors (EASE) and other general upgrading programmes. These are great efforts in retrofitting hard environments to become more enabling.

However, it is the details that often make the difference. Therefore, designing with the elderly in mind, ensuring that products, services and the real or virtual environment that we are immersed in are inclusive and empowering is important. We should design to include and empower our seniors. We must not design only with the "majority" in mind, who used to be younger, and expect the rest to comply or find their own solution. Even this "majority" is getting more mature. Moreover, what is designed for the elderly, surely must be suitable for the young, too.

Hence, we should conscientiously and actively apply elderly-friendly designs into all our hardware and heartware solutions. Currently, there are only two silver industry guidelines in Singapore. One is the "Guidelines for age-friendly homes" and the other is the "Guidance for digital devices and online services to be senior friendly". These are a good start, but we need to mainstream elderly-friendly designs much more and make them pervasive. We need to apply elderly-friendly designs to the development of common spaces, facilities, machine and application interfaces, workflows, public processes and more. The key is to make them pervasive such that seniors can move from setting to setting smoothly and live a completely normal life.

No institution or country so far has been an authority in terms of setting elderly-friendly design standards. Singapore can take the lead in setting elderly-friendly standards and be the authority in this area. We are already doing so much to get ourselves ready for an ageing population, I believe we should look into this area.

Therefore, I would like to ask if the Ministry will consider setting up an office that does research, set standards and audit public and private projects to ensure elderly-friendliness. Is there effort to train more students in elderly-friendly designs? And perhaps, would the Government consider creating specialisations for students to undertake in tertiary institutions?

The Chairman: Dr Lily Neo.

Preventive Healthcare and Community Care

Dr Lily Neo: Sir, I am happy that MOH will take on policy ownership for the spate of aged care services across both the health and social domains from April this year. This will enable the long-term needs of our seniors to be catered more comprehensively. As I have said in my Budget speech, I hope MOH will spell its objectives clearly for a good outcome.

The operation details will need a lot of consideration and supervision. It will need the considered effort of Senior Activity Centres (SACs), stakeholders and staff to come on board with a shared mission. Some centres may have become entrenched in their own ways of operation and MOH may face and need to address some resistance to change.

Will MOH adopt the concept of physical, mental and social well-being for the seniors in the Senior Cluster Network (SCN) so that these seniors can stay active and healthy through having daily balanced nutrition, physical activity and cognitive stimulation?

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Thus, daily meals and activity programmes must be provided with an aim in mind, that is, to assist these seniors remain in the community and ward off frailty, diseases and immobility.

May I ask MOH what kind of emphasis will be placed on these aged-care services? How many administrative staff and medical staff will be deployed to manage the present SCN? Are there enough personnel to take over the transfer from this April? Is MOH poised to train present and future personnel to provide for these aged care services? Will MOH be planning to provide SCN centres in more constituencies? Will MOH consider setting up SACs for every cluster precinct of 1- to 2-room flats as surveys have found that seniors who live in this type of housing tend to be more frail?

Community Aged Care Services will require many social and medical personnel, especially for seniors who are house-bound with partial or full disability. I hope MOH will spare no effort to provide these personnel as it will determine the outcome of these services. Could MOH train healthcare workers and consider using not only full-time paid personnel but also family members, community volunteers and so on? Healthcare aides can be trained for specific skills, like simple dressing of wounds, simple grooming, toe-nail cutting for non-diabetics using sterile techniques, assisting with feeding, catheter care, prosthesis use and so on. This will free up medical staff like the nurses.

I am also happy that AIC will act as the single agency on delivery of holistic aged care services to seniors across both the health and social domains. Many seniors living alone with medical conditions and mobility problems can be managed at home with these holistic services.

Like the one at Chin Swee, AIC assists with the nurses and healthcare aide team that look into the needs of the seniors daily in supervising their medical conditions and daily living essentials. A team of one nurse and five foreign healthcare aides, together with SAC staff and grassroots volunteers, can look after a few hundred residents. This has enabled residents to have lesser frequency of hospital visits and enabled them to stay in their own homes despite their illnesses and immobility.

With AIC under MOH being the agency in charge of SACs, I feel that we can achieve better preventive healthcare, meaning early detection and treatment with better follow-up of patients to achieve good outcomes in preventing irreversible medical conditions that result in permanent impairment in health and mobility. I hope that such models of care can be expanded quickly as we are fighting a tide of the increasing numbers of seniors who can benefit from such holistic care services.

There are health and social benefits in volunteering. It offers seniors significant physical, emotional and cognitive health benefits. Could MOH promote volunteerism in seniors? Could MOH provide a broader spectrum on the types of volunteering to attract more seniors? Can these seniors be reimbursed for volunteerism similar to the Pioneer Generation (PG) ambassadors?

I hope MOH will spare no effort in ensuring this new initiative takes off well, to enable seniors to stay healthier and happier and age more gracefully in place, living with their loved ones in their own homes, and in their familiar environment in the community.

The Chairman: Ms K Thanaletchimi, you have two cuts. Please take the first cut only.

Holistic Support for Ageing Population

Ms K Thanaletchimi (Nominated Member): Thank you. Sir, I welcome the integration of social support and health under AIC that comes under MOH. However, I hope the services provided are more holistic and sustainable.

I would like to call for the Senior Network Centre to be a one-stop service centre providing holistic services for seniors beyond social and health. Skills training with services for employment and employability and active ageing programmes can form part of this enhancement. The one-stop service centres should be easily accessible near to the homes of the seniors, and the programmes should be cost-effective and affordable.

It is important to care for the mental health of seniors. At age 65, some seniors may have retired or are about to retire. Besides the loss of income, these seniors may also feel less purposeful and bored without daily work to occupy their time. Willing seniors with capability to contribute can be assisted to transit into less demanding jobs with shorter working hours. With their new-found time on hand, some seniors may also be interested to pick up new skills or knowledge. This interest in lifelong learning should be encouraged and supplemented with learning institutions’ recommendation of courses based on individual interests.

This centre can also be a conduit to all relevant services that may be required by the seniors. Some examples include providing awareness of advance care planning, lasting power of attorney (LPA) and understanding of the various Government schemes, such as ElderShield, MediShield and the Community Health Assist Scheme (CHAS). The current PG Ambassadors can help to support this one-stop service centre for seniors.

The seniors who benefited from the service centre are also the best ambassadors to encourage and guide other seniors to access the services provided. A volunteer network can also be developed among these seniors for them to give back in other areas of the community, such as healthcare.

It is essential for a well-established facility to be complemented by professionals. As such, it is equally important to ensure that the support staff running these service centres are adequately equipped to support seniors, attend compulsory training in basic geriatric services, have relevant language proficiency and are able to identify mental health issues among seniors.

The initiative to integrate the SCN and AIC will surely help to streamline and consolidate the services provided by the respective agencies to better support seniors in Singapore. However, will there be current jobs at risk or new jobs created with this integration effort? What new skillsets are required to better prepare integrated AIC staff to better manage both social and health issues so that there can be cross-training and learning opportunities? Employees of SCN moving over to AIC must be engaged early and transited with no less favourable terms and conditions as a package. There must be efforts to integrate the employees of AIC and those from SCN for better team coordination and morale to serve the seniors better.

The Chairman: Minister for Health Gan Kim Yong.

The Minister for Health (Mr Gan Kim Yong): Mr Chairman, first, let me thank all the Members for their comments and the suggestions. With your permission, may I display a few slides?

The Chairman: Yes. [Some slides were shown to hon Members.]

Mr Gan Kim Yong: Today, Singaporeans are living longer and our Health Adjusted Life Expectancy, which estimates the number of years a person is expected to live in good health, remains one of the best in the world, at 72 years for males and 75 for females. Women always beat men in this.

But we cannot afford to be complacent. Our population is ageing rapidly, with a growing chronic disease burden. About three in four Singapore residents aged 65 and above are affected by diabetes, high cholesterol or hypertension or a combination of these three. If nothing is done, diabetes, for example, is projected to affect more than one million Singaporeans by 2050.

We want to not just live long but also live well. To do that, each of us must also do our best to adopt a healthy lifestyle. We also need a good healthcare system that is both accessible and affordable.

Dr Chia Shi-Lu asked about our progress on Healthcare 2020 which outlined our strategy to improve accessibility, quality and affordability of healthcare. We have made good progress but much needs to be done from now until 2020 and beyond.

Over the next few years, we will continue to add healthcare facilities across Singapore. To the north, we are developing Woodlands Health Campus, which will be ready progressively from 2022. Down south, we are developing Outram Community Hospital and the new National Cancer Centre as part of the redevelopment of the Outram Campus. In the north-east, we are on track to open Sengkang Hospitals later this year. The new Changi General Hospital Medical Centre in the east will also be ready this year. In the west, we look forward to the new Centre for Oral Health at the National University Hospital (NUH). Not forgetting the central region, where the Integrated Care Hub and National Centre for Infectious Diseases are being built at Novena.

Since 2011, we have added 1,700 acute hospital beds, 1,200 community hospital beds, and 5,300 nursing home beds. To support ageing in the community, we have also added 4,200 home-based and 2,900 centre-based care places. We have also grown our healthcare workforce by about 25,000, or about 36%, since 2011.

To ensure healthcare remains affordable to Singaporeans, we increased subsidies at outpatient clinics and enhanced CHAS for primary care, commonly known as the Blue Card and the Orange Card. In 2015, we introduced MediShield Life for inpatient care.

We are also investing in a future-ready workforce that will anchor the transformation of our healthcare system. Senior Minister of State Amy Khor will elaborate on our plans to grow and upskill our healthcare manpower later. We need to innovate and find new ways to deliver quality care to patients in a more effective and efficient way and for better outcomes. For example, at Pioneer Polyclinic, which opened in July 2017, patients are cared for by a team comprising doctors, nurses and allied health professionals. Having a regular primary care team will ensure better continuity of care for patients. This is one of the many initiatives that has improved the quality of care.

Sir, our continued investment in healthcare means higher National Health Expenditure (NHE). NHE has increased by more than 60% in five years, from $10.9 billion in 2010 to $18.9 billion in 2015. At 4.6% of gross domestic product (GDP), this is lower than most developed countries, but we expect this to rise over time as our population ages.

On the other hand, Government expenditure on health grew twice as fast, by about 120% over the same period, to fund infrastructure investments and to keep healthcare affordable for Singaporeans, by reducing their share of out-of-pocket expenses from about 40% to 30%. With the introduction of the PG Package and MediShield Life and the extended use of MediSave, the out-of-pocket for eight in 10 subsidised hospitalisation bills was below $100. But we cannot simply keep increasing subsidy or insurance payouts. Higher insurance payouts will result in higher premiums or higher subsidies will need to be funded. All these will be borne by Singaporeans eventually through higher premiums and higher taxes.

Therefore, we need to take a long-term view on this. Even as we implement Healthcare 2020, we need to look beyond 2020 and make three key shifts to ensure our healthcare system is future-ready. The Three Beyonds, which Dr Chia Shi-Lu reminded us about, provided the roadmap to a sustainable system beyond Healthcare 2020.

First, we are going Beyond Hospital to the Community. Over the last decade, we have increased our total spending in the primary care and ILTC sectors by close to four times, from $1.3 billion in FY2007-2011 to $5.1 billion in FY2012-2016. These investments reflect our priority to anchor care firmly in the community. As we continue to invest in community care, we also need to bring social and healthcare services closer to better serve our people. This has led to the formation of the Silver Generation Office (SGO) as well as expansion of Community Networks for Seniors (CNS), which I elaborated earlier in my speech on SG Cares.

Senior Minister of State Lam Pin Min will share later how we are strengthening primary care for the future. Six new polyclinics are being built under Healthcare 2020; two are already open, and four more to come by 2020.

We will add another six to eight new polyclinics by 2030. This is part of our commitment to ensure Singaporeans can access primary care closer to their homes. We are not just building polyclinics; we are also partnering private GPs through the Primary Care Networks (PCN) to offer subsidised team-based care in the community under CHAS.

Our second shift, Beyond Quality to Value, plays a pivotal role in ensuring sustainability. We adopted a multi-pronged approach to manage healthcare costs.

We set up the Fee Benchmarks Committee earlier this year to provide a reference to guide doctors in setting reasonable fees and to help patients to make informed choices on their care options. We established ACE to provide guidance on cost-effective drugs and treatment, and I thank Dr Chia Shi-Lu for supporting the work of ACE. We also introduced the Healthcare Productivity Fund to spur productivity improvement efforts in our healthcare institutions. But we need to do more.

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Mr Chairman, co-payment has been an integral feature throughout all our healthcare schemes, including MediShield Life as well as IPs. It plays an important role in ensuring our healthcare system is sustainable by emphasising personal responsibility in healthcare, by encouraging service providers to focus on appropriate and cost-effective interventions, and by nudging patients to make prudent decisions in healthcare services. This is important as it ensures that all stakeholders, including patients, have a stake in their decision.

As Dr Chia Shi-Lu pointed out, some private insurance policies offer zero co-payment coverage. They are called "full riders". Such riders encourage a "buffet syndrome" as patients do not need to pay anything when they receive medical treatment. It undermines the co-payment principle and dilutes the personal responsibility to choose appropriate and necessary care. This will encourage unnecessary treatment, leading to rising healthcare costs not only for those with such riders but for all of us.

Therefore, MOH has been working with the insurance industry and we have issued a set of new requirements to IP insurers which will be applied to all new rider policies. We will require them to have co-payment features going forward. Senior Minister of State Chee Hong Tat will elaborate more. This will encourage responsible behaviour by both patients and healthcare providers.

We will continue to review our healthcare financing policies to ensure that co-payment remains affordable, through targeted subsidies, MediSave use and for those who still have difficulties, MediFund will be a safety net. No one will be denied appropriate healthcare because they cannot afford to pay.

But ultimately, the best way to beat rising healthcare costs is to stay healthy. This is a focus of our final shift Beyond Healthcare to Health. Parliamentary Secretary Amrin Amin will give an update on WoD and detail how we are encouraging and supporting healthier lifestyles. We will create a supportive environment for Singaporeans to lead healthy lives, but each of us must do our part.

These three shifts will be a multi-year effort. To support these initiatives, we have taken the first steps to reorganise ourselves. Last year, I announced plans to reorganise the public healthcare system into three integrated clusters. I am pleased to report that the reclustering exercise has been successfully completed. I would like to take this opportunity to thank the unions and management for their support in this exercise, and all our staff who have worked very hard to ensure a smooth transition. That is the good news.

The bad news is that this is not the end. In fact, this is just the beginning of a long journey to create synergy and deliver better care for Singaporeans. Let me share an example. A patient, Mr H, 73 years old, was admitted to SGH after a fall last year. Besides rehabilitation treatment for his fall, he also needed to manage his diabetes and hypertension. Miss Siti Hajar, a Patient Navigator and experienced nurse from SGH, coordinated both his health and social care even after he has been discharged. Miss Siti visited him fortnightly and ensured that his chronic conditions are well-managed from home. As Mr H lives alone in his flat in Kaki Bukit, the CGH Community Care team – now part of the SingHealth team – was activated to accompany him for follow-ups at Bedok Polyclinic and arranged for home help services for him.

I am pleased to know that Mr H's condition has now stabilised, and the SingHealth team continues to provide him with strong support. This is what reclustering is all about – bringing healthcare institutions and the community closer together to provide good, seamless care for patients, such as Mr H, and many others.

Another example of this synergy is the new national integrated supply chain we are setting up. This goes beyond the Group Procurement Office currently run by SingHealth. It pools the whole supply chain's functions, including procurement and resources of the three clusters, together to achieve economies of scale, create greater synergy, develop new capabilities and evolve innovative supply chain solutions. This will yield system-level gains for patients, providers and staff. This will also help to mitigate cost increases and bring greater convenience to patients.

The transformation process must continue. Advances in medical science, increasing digitalisation and connectivity hold tremendous promises for rethinking healthcare.

In addition to progressive improvements, we also need to explore game-changing ideas. That is why we have set up the MOH Office of Healthcare Transformation (MOHT), to identify and experiment with bold innovations. MOHT will focus on longer-term ideas that can be scaled up for system-level transformation.

Some of these ideas will be tested at the health empowering Alexandra Hospital campus which the National University Health System (NUHS) will take over from the second half of 2018. Similarly, we will be initiating the master planning of NUH's Kent Ridge Campus in the West, to see how Kent Ridge can be best positioned to meet future healthcare needs. We have already started some development at the Kent Ridge campus. In 2013, we opened the NUH Medical Centre, and we will be opening the National University Centre for Oral Health next year. The master planning study presents us with the opportunity to plan ahead and reimagine how the future Kent Ridge campus, including the main NUH hospital building, which is more than 30 years old, can be rejuvenated to support current and future models of care.

At the end of the day, we must remember that the state of our health primarily depends on our choices. As far as we can, we must choose to live healthily. This is the key not just to a sustainable healthcare system, but a vibrant society and good quality of life.

Mr Mohamed Irfan is a good example. He is pursuing a sports diploma at Republic Polytechnic. Keeping fit is as much part of his work as it is his passion. Not only is he enjoying the benefits of better health, but he is also going the extra mile to influence others. He persuaded his family to start eating brown rice, more fruits and more vegetables and less fried food. Last year, he co-started a health programme, where he was the health coach. Every week, the group gathers to exercise. Mr Mohamed Irfan believes an active community can motivate individuals to sustain a healthy lifestyle. He exemplifies how taking ownership of one's health can have a ripple effect, to better the lives of many more.

Mr Chairman, I believe that by working together, each of us playing our part, we can bring about Better Health, Better Care and a Better Life for all Singaporeans.

The Chairman: Senior Minister of State Chee Hong Tat.

The Senior Minister of State for Health (Mr Chee Hong Tat): Mr Chairman, a key priority for MOH is to keep our healthcare system sustainable and affordable for this generation and future generations. I will elaborate on our efforts to achieve this outcome under the three Ps: Productivity, Partnerships and Prevention.

Let me start with Productivity. Dr Chia Shi-Lu and Mr Gan Thiam Poh asked how MOH encourages healthcare innovation and productivity.

We set up the Healthcare Tripartite Committee for Workforce Innovation and Productivity in 2016. The Committee has reviewed rules and policies based on ground feedback to streamline work processes, encourage adoption of smart technology and empower different groups of healthcare workers to maximise their contributions.

MOH introduced the Healthcare Productivity Fund (HPF) in 2012. More than 250 projects have been implemented so far, benefiting over 70 public healthcare and community care organisations.

Our productivity movement is achieving good progress. To encourage more to participate and seize opportunities to improve productivity, we will add another $80 million in productivity funding to HPF over the next three years to support our institutions and healthcare workers.

Use of smart technologies will be integrated in existing and upcoming public healthcare facilities to increase system-level productivity, improve patient care and prepare our healthcare facilities for the future.

The productivity efforts extend beyond hospitals to the community. AIC will collaborate with providers to redesign traditionally manpower-intensive processes, such as rehabilitation and showering. AIC will also help providers to adopt assistive equipment, such as ceiling hoists, to ease the physical strain on our healthcare workers.

I will now speak on the next P: Partnerships.

Besides working closely with public healthcare institutions, we collaborate with private sector providers to tap on their expertise and resources. For example, a local startup, Kronikare, developed a smartphone application using AI to analyse wounds. It can do so within seconds to detect early stages of infection, a task that previously required two or more nurses up to 30 minutes to perform.

In the ILTC sector, MOH invites VWOs and private operators to tender for operating rights at our Build-Own-Lease (BOL) facilities, and we partner private operators to provide subsidised nursing home care through the Portable Subsidy Scheme (PSS).

BOL and PSS operators are appointed via competitive requests-for-proposal, where operators propose and commit to their fees and charges for subsidised residents. As Miss Cheng Li Hui said, this can help to ensure prices for quality care remain reasonable. MOH supports providers, including private nursing homes, with manpower development and productivity initiatives.

Mr Chairman, partnerships also mean all stakeholders – patients and caregivers, healthcare providers and professionals, insurers and employers, and the Government – working together on a common goal to keep healthcare costs sustainable and affordable for everyone over the longer term. At the most fundamental level, it is in the philosophy and design of our healthcare financing system.

During the Budget Debate, Ms Sylvia Lim asked if the higher MediShield Life deductible for older policyholders was a form of "reverse discrimination". This is not the case. We should look at the complete picture rather than focus on a single observation in isolation. Allow me to clarify.

The MediShield Life Review Committee wanted MediShield Life to be a basic health insurance plan for all Singaporeans. The objective was to provide coverage for large hospital bills based on inpatient treatment at subsidised wards, as well as costly outpatient treatments like dialysis and chemotherapy. For the scheme to remain sustainable, premiums are computed to be actuarially sound. The Government then provides means-tested subsidies and additional premium support to ensure that premiums remain affordable for lower- and middle-income Singaporeans. This is a progressive and inclusive scheme.

On MediShield Life deductibles, the amount is set for each policy year and not for each treatment. The deductible amount can be paid using MediSave and Singaporeans who require further financial support can approach our medical social workers for assistance. As older policyholders incur higher medical bills in each policy year compared to younger cohorts, their premiums are higher to reflect the larger and more frequent claims. There is a trade-off between the deductible amount and premiums, with lower deductible amounts resulting in higher premiums. On balance, the Committee recommended a higher deductible for those aged 81 and above to reduce their premiums.

The Government accepted the Committee's recommendations. Recognising that policyholders will pay higher premiums as they age, the Government has provided higher MediShield Life premium subsidies for older Singaporeans. This is in line with the progressive design of our healthcare financing system, with more Government subsidies going to older Singaporeans and those from lower- and middle-income families.

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On average, an elderly Singaporean aged 65 and above obtains more than six times the amount of Government subsidies per year, compared to younger Singaporeans below 65. Besides higher MediShield Life premium subsidies, they also receive 50% more subsidies in polyclinics. For PG, they enjoy further benefits, such as special CHAS subsidies at GP clinics, additional MediShield Life premium subsidies and MediSave top-ups every year.

So, rather than having "reverse discrimination" against older Singaporeans, our healthcare system is, in fact, providing them with more financial subsidies. We do the same for the lower- and middle-income Singaporeans. Singaporeans support this financing approach because it is consistent with our values to build a fair and just society.

Mr Chairman, beyond healthcare financing, partnership amongst all stakeholders is also needed to ensure that quality care is delivered at sustainable and affordable cost for Singaporeans.

Since May 2017, MOH has issued Appropriate Care Guidelines on medical treatment and drugs to guide healthcare providers making decisions that are based on clinical and cost effectiveness. Last year, the Singapore Medical Council revised their ethical guidelines for doctors indicating that fees paid to Third-Party Administrators must not be based on a proportion of the doctor's fees, or what is commonly known as "fee splitting". This is to prevent unnecessary inflation of healthcare costs.

In January this year, MOH set up a Fees Benchmarks Advisory Committee to recommend and develop fee benchmarks for medical procedures and services. The purpose is to encourage appropriate charging by healthcare providers and enable patients and payers to make better informed decisions.

As I have said in this House at a previous Sitting, most of our doctors do charge appropriately, as they have their patients' well-being at heart. But for the ones who charge excessive fees, please know that MOH is monitoring and will take action against doctors who overcharge.

During the Budget Debate, Ms Sylvia Lim suggested reviewing medical insurance schemes to include deductibles and co-payments, to discourage over-consumption and inefficient use of resources. This was similar to the earlier recommendations from HITF which Dr Chia Shi-Lu has asked for an update. Let me explain why these are important issues and what MOH intends to do.

Every Singaporean Citizen and Permanent Resident (PR) is covered by MediShield Life. Today, about two in three Singapore residents have also bought IPs, and these are private insurance products that offer added coverage.

Both MediShield Life and IPs have co-payment features in the form of deductibles and co-insurance, and their premiums can be paid using MediSave. Among those who have bought IPs, some have paid additional cash, for what is known as "full riders". These cover the entire co-payment under the IP plan so that the policyholder ends up paying nothing, regardless of the bill size.

Currently, about 29% of Singapore Residents have these full riders. As highlighted in the HITF's report, the zero co-payment feature of these full riders has resulted in the buffet syndrome, leading to over-consumption, over-servicing and over-charging of healthcare services.

In 2016, the average medical bill size for full rider policyholders was about 60% higher than the average bill size for those without riders, even though rider policyholders are younger and generally in better health. Some of the examples of over-consumption and over-servicing are, to put it plainly, disturbing.

In one case, a full rider policyholder made claims for 12 nose scopes in a year without clear medical need. We also have patients who are admitted for gastritis or piles and then referred to many other specialties ranging from dermatology, ophthalmology, ear, nose and throat, and orthopaedics, for additional scans and tests. The final bill? Up to $25,000 for a hospital stay that was less than 24 hours.

There was also a full rider policyholder who underwent an expensive surgery for a small breast lump removal that cost $70,000 in doctor's fees alone, when there was an equally effective alternative procedure which costs only $5,000.

To be fair, not all doctors prescribed such expensive treatments, and not all full rider policyholders submit such large claims. But it is clear that full riders have a detrimental impact on overall healthcare cost in Singapore. This is a key reason why rider premiums have increased by up to 225% over the past two years.

The negative impact of the zero co-payment feature extends beyond full rider policyholders. Over the last two years, IP premiums have also risen by up to 80%, with older policyholders and those on private hospital plans experiencing higher increases. If this trend continues, I am worried that IP and rider policyholders will find their insurance premiums increasingly unaffordable as they age.

The zero co-payment feature of riders also pushes up healthcare costs in Singapore. Over-consumption, over-servicing, over-charging of healthcare services will lead to faster and larger increases in overall healthcare expenditure. These increases will ultimately be borne by all Singaporeans through higher medical fees, insurance premiums and taxes, which all of us will pay directly or indirectly.

So, I am glad there is support from both sides of the House on the need for co-payment to keep healthcare expenditures sustainable and affordable for all Singaporeans over the longer term. Ms Salma Khalik has also written an insightful piece in today's Straits Times. We have to make a change now to prevent the problem from becoming worse in future.

In line with the HITF’s recommendation, MOH will issue the following requirements for all new rider plans with immediate effect. New IP riders must incorporate co-payment of 5% or more. To address concerns from some policyholders that they may face high co-payment amounts due to the unlikely event of very large bills, the new riders will have a cap on the co-payment amount each year. Most insurers are planning to launch their new riders with an annual cap of $3,000, though they are allowed to set higher thresholds. This places an upper limit on the risk exposure of policyholders, to protect them against very large bills.

New riders will be available within a year. In the meantime, insurers can continue selling their existing rider plans but must inform new policyholders that they will transit to the new riders with co-payment from 1 April 2021. Once the new riders are ready, these policyholders can choose to switch to the new riders earlier if they wish to do so, and any pre-existing conditions that are covered prior the switch will not be excluded. We expect the new riders to have lower premiums than full riders, so the switch will result in premium savings for policyholders.

Let me be clear that MOH is not issuing these requirements to bail out the insurers. Our objective is to address the concerns with overconsumption, over-servicing and overcharging as these will lead to patients and policyholders paying rapidly escalating fees and premiums over time. It will be an unsustainable and undesirable outcome for Singapore, especially when we are ageing as a society.

Policyholders can continue to tap on MediSave to pay for their co-payment amounts under the new riders. At 5% co-payment, half of the inpatient bills in 2016 would have a co-payment amount of $100 or less. Three quarters of inpatient bills would have co-payment of $250 or less. Nine in 10 inpatient bills would have a co-payment of $550 or less. The 5% co-payment can be covered within the current MediSave withdrawal limits for 99% of all inpatient bills.

For private hospital inpatient bills, in 2016, one in two would have a co-payment of $380 or less. Three in four would have a co-payment of $670 or less, and nine in 10 would have a co-payment of $1,270 or less.

The above requirements will apply to new rider policies. We recognise that existing rider policies are commercial contracts between insurers and their policyholders. If insurers intend to make changes to their existing policies, they should consider the interest and well-being of all policyholders as they seek to keep premiums affordable for everyone in the longer term.

The requirements for new riders will not affect MediShield Life and IPs which already have co-payment features. For patients who face financial difficulties with their bills, MediFund remains available as a safety net to ensure they continue to have access to quality subsidised healthcare in our public hospitals.

Let me now move to the third P – Prevention.

An important aspect of Prevention focuses on early screening and intervention. Last year, I announced the enhancements to the Screen for Life programme where eligible Singaporeans can have access to subsidised health screenings at a cost of $5, which includes the first post-screening consultation with a doctor. CHAS cardholders ‒ both orange and blue ‒ will pay $2, while the package is free for Pioneers.

Dr Chia Shi-Lu asked whether the Ministry is considering further enhancements to CDMP as well as the Flexi-MediSave Scheme. I recalled Ms Thanaletchimi had raised a similar query during a previous COS debate.

From June this year, MOH will make the following enhancements to CDMP. These will also broaden the coverage of our CHAS chronic subsidies.

First, we will extend the scope of diabetes to cover pre-diabetes. Based on current trends, one in three people with pre-diabetes could develop Type-2 diabetes within eight years. Through early detection and intervention, we hope more patients with pre-diabetes can improve their condition and avoid developing diabetes.

Second, we will expand the list of CDMP conditions to cover ischaemic heart disease (IHD), bringing the total number of covered conditions to 20. This will benefit all our patients with IHD, even if their condition is not linked to diabetes or hypertension.

Third, we will enhance the support for diabetics who require insulin injections, as they require lancets and test strips to regularly monitor their blood glucose levels. To support these patients, MOH will extend CDMP to lancets and test strips.

In addition, we will raise the withdrawal limit for MediSave400 scheme by 25%, from $400 per year to $500 per year. This will take effect from June this year.

We will also lower the eligible age for Flexi-MediSave, which is currently set at 65. From June this year, Singaporeans aged 60 and above can use up to $200 of their MediSave per year, for outpatient medical treatments at public sector Specialist Outpatient Clinics (SOCs), polyclinics and CHAS GPs. This expansion of Flexi-MediSave will benefit an additional 260,000 Singaporeans between the ages of 60 and 64.

To conclude, Mr Chairman, we need to transform our healthcare system so that it remains sustainable and affordable for all Singaporeans. Productivity, Partnerships and Prevention are key enablers. Everyone needs to play our part to stay healthy and prevent healthcare costs from rising too rapidly. Together, we can achieve better health and a better life for our people.

The Chairman: Ms K Thanaletchimi, can you take your second cut now.

Preparing Our Workforce in Intermediate and Long-term Care sector

Ms K Thanaletchimi: Sir, one of MOH's key thrusts, that is, "Beyond hospital to community" will give rise to more job opportunities in the community sector. As such, will there be current jobs at risks and new jobs created across the healthcare sector? With the expansion of the ILTC sector, how can we better attract locals for the jobs when, at present, 80% to 90% of these jobs are filled by foreigners?

Singaporean healthcare professionals are less inclined to join the ILTC sector due to the perceived prestige, progression as well as the varying remuneration offered, which is less favourable than that provided by public healthcare institutions.

I applaud MOH for the efforts and training programmes it has introduced to attract Singaporeans into this sector in recent years, though more can be done.

To further drive the success brought about by the existing MOH and AIC initiatives to bring locals into ILTC, I would like to suggest a holistic review of jobs, skills training, career progression and remuneration across this sector. Jobs can be redesigned to create higher value jobs that provide areas of growth for the individuals.

Sir, let me declare my interest as the President of the Healthcare Services Employees' Union (HSEU).

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For example, in the public healthcare sector, HSEU had worked closely with the healthcare institutions to redesign the career pathway for Patient Service Associates (PSAs). The process included multiple consultation sessions with our members to tailor the job role as they were the key stakeholders. It is essential for them to take ownership of their own future. The union helped to convince our members with the advantages of taking on larger specialised job roles to meet the changing needs of this sector so as to energise them with possible career progression and enhanced remuneration.

With strong union-management collaboration, the redesigned career pathway for PSAs greatly enhanced the attractiveness of the job. Concurrently, it has mitigated the possible redundancy for this group of employees whose jobs are increasingly at risk with the advent of technology.

We should also look at other initiatives to attract back-to-work women, to encourage non-practising nurses to return to nursing and workers from other sectors to join through the Professional Conversion Programme (PCP). Retiring healthcare workers in the mainstream of public healthcare institutions should also be given the option. On this, I urge those who are in their early 50s and 40s to be engaged in the conversation as early as possible for second career options in ILTC.

The union can act as a conduit to refer more local workers into this sector for upskilling and reskilling. I urge MOH to implement a national skills framework for ILTC sector jobs and remunerate based on the skills and job worth.

Lastly, I would again urge MOH to act as a catalyst to help navigate the formation of an association for the ILTC sector so that the national skills framework and all relevant best practices can be uniformly adopted by the players in this sector which will be a win-win-win for all, that is, the organisations, staff and patients at the heart.

Empowering Nurses for Future Healthcare

Ms Tin Pei Ling: Sir, nurses play a crucial role in healthcare. They are on the frontline every day, tending to the sick, counselling patients on their health, improving processes throughout the healthcare system, and the list goes on.

With the push towards delivering greater quality and value in healthcare, the role of nurses is undoubtedly even more important. We must, therefore, equip our nurses with adequate skills and knowledge to meet the increasing demands on them and also empower them to tackle the many difficult situations that they are faced with on a day-to-day basis.

Therefore, I would like to ask the Ministry for an update on the development and career pathways for our nurses. As our public healthcare transforms, how will the role of nurses change and how will their training and career development transform along with it as well?

Healthcare Manpower

Ms Joan Pereira: Chairman, one of the challenges facing the Ministry is that of getting sufficient healthcare workers, both frontline and backroom. This is especially so with the adding on of more healthcare facilities and the rising demands on our medical services. With tight manpower against high demand, it will mean longer queues and much inconvenience for the patients.

The Ministry has succeeded in getting some retired nurses to come back. This is very good. Can I ask if the Minister would draw on the pool of retirees in Singapore and offer them a career path in the healthcare sector so that it is a mutually beneficial exercise?

(In Mandarin): [Please refer to Vernacular Speech.] Apart from welcoming retired nurses to come back to work, we can also encourage retirees or mid-career switchers to join the nursing industry. Some women quit their job in order to look after the children or the elderly in the family. After their children have grown up, they may want to come back to the workforce. We should encourage these women to join the nursing industry. If these mid-career switchers and retirees can undergo relevant nursing training, they will be able to help to alleviate the manpower shortage issue in the healthcare sector.

Allied Heath Force – Recognition and Role

Mr Christopher de Souza (Holland-Bukit Timah): Sir, allied healthcare workers provide a strong human resource infrastructure in our healthcare system. Facilitating career advancement and training of allied healthcare workers will benefit many Singaporeans.

First of all, the patients who will receive quicker and more targeted care; second, the doctors' workload will be alleviated; the third to benefit are the allied healthcare workers themselves as they can look forward to career opportunities; and fourth to benefit would be the next generation of Singaporeans who will have the option of entering meaningful healthcare-related vocations.

Therefore, would the Minister for Health consider a central body which studies and charts career opportunities of the allied healthcare workers in each of the integrated healthcare clusters?

Skillset for Taking Care of Seniors

Mr Kwek Hian Chuan Henry (Nee Soon): Sir, in my recent Private Member's Motion on senior policy, I noted that MOH has embarked on arguably one of the fastest expansions in healthcare spending among developed countries. In a few short years, we have ramped up considerable infrastructure.

However, effective healthcare, especially to meet our ageing population, requires a well-trained healthcare workforce. This proper training is especially important, given that we are also transforming the way we deliver healthcare services, from a hospital-centric to a people-centric model, and through an aggressive adoption of technology.

As such, can MOH provide an update on our preparations to ensure that our healthcare workforce have both the necessary hard skills and soft skills to care for the aged?

Lastly, I would like to note my appreciation for our healthcare workers – nurses, doctors and medical social workers – for their hard work and dedication.

Pipeline of Doctors and Medical Faculties

Mr Christopher de Souza: Sir, it is good that concerted effort in policymaking has been undertaken to meet the healthcare needs of Singaporeans.

However, is MOH also tracking the supply and number of doctors needed to meet the vast cross-section of healthcare demands in Singapore? For example, are the sizes of the cohorts in the medical faculties in our universities calibrated such that the rate of supply of doctors in the profession would meet the needs of our population over the next 10, 20, 30 years?

Additionally, can MOH, in collaboration with the integrated healthcare clusters, provide guidance and regulations to prevent a disproportionately high number of qualified doctors from specialising in niche specialties? This is because disproportionate over-specialisation may leave other specialties less well-staffed which will, in turn, lead to multiple healthcare needs not being met.

The Chairman: Assoc Prof Fatimah Lateef. Not here. Dr Lily Neo.

Breast Cancer

Dr Lily Neo: Sir, breast cancer was the top killer of women cancer sufferers in Singapore from 2011 to 2015. The Breast Cancer Foundation conducted a nationwide survey last year and found that more than half of the 1,005 women aged 15 and above who were surveyed had limited knowledge of breast cancer. Only 45% of the women did self-examination as well as went for medical check-ups.

Early detection of breast cancer in the early stages of the disease offers a higher chance of survival. This is because breast cancer is one of the easiest cancers to beat, if found early.

May I ask MOH if there is an improvement in the early detection of breast cancer since the start of national screening in 2002, and have we achieved better outcomes on the prognosis of breast cancer in the past 10 years with better treatment? In order to further improve the early diagnosis of breast cancer, could MOH please enhance our national screening programme? And how can MOH raise public awareness of breast cancer further?

Giving Babies a Chance at Life

Mr Alex Yam (Marsiling-Yew Tee): Chairman, I am heartened to note that the number of unwanted pregnancies is decreasing in Singapore.

According to figures by MOH, the number of abortions between 2007 and 2017 has dropped nearly 40% to 7,217 last year. Medical advances, the easing of stigma over unwed mothers, the availability of contraception, and the support available for unwed parents could be contributing factors for the decline in the numbers.

But let us put things in context. In the same time period in 2017, there was 39,605 life-births in Singapore. Therefore, it is a proportion that means at least 15% of pregnancies were terminated.

Under the 1974 Termination of Pregnancy (Amendment) Bill, abortions are currently allowed up to 24 weeks of pregnancy without restriction. This was based on the scientific norms of the time where 24 weeks were considered the justification age by which babies have a chance of survival. The same Act of 1974 removed the previous stipulations of parental consent rallied round abortion and approval by the Termination of Pregnancy (ToP) Authorisation Board.

As we look at the basis of the 1974 Termination of Pregnancy Act, we have progressed on many fronts since then. We no longer have a population explosion. We have access to proper and high-quality healthcare. Gone, too, are backstreet quack doctors.

Science and medical care have advanced greatly, too, and evidence shows that survival rates for extremely early pre-term babies have improved dramatically in the last 15 years. In 1995, practically no children survived when born at 22 weeks of gestation age, while in 2008, 21% survived. A 2015 report in a New England Journal of Medicine also found that infants born at 22 weeks could have a good chance of survival without severe health problems if hospitals treated them.

Termination of pregnancy is not an easy decision. I remember still the words of a 68-year-old lady who told me, "The procedure itself did not hurt much but my heart has been aching for the last 47 years."

Gestational Diabetes

Ms Tin Pei Ling: Sir, gestational diabetes can lead to birth complications and a higher risk of diabetes in the children born to mothers who suffer this condition. In Singapore, one in five pregnancies are affected by gestational diabetes and two in three mothers who have gestational diabetes go on to develop diabetes later in life.

So, may I ask what is the Ministry doing to control gestational diabetes among women in Singapore?

The Chairman: Senior Minister of State Amy Khor.

The Senior Minister of State for Health (Dr Amy Khor Lean Suan): Chairman, with your permission, may I display some slides?

The Chairman: Yes, please. [Some slides were shown to hon Members.]

Dr Amy Khor Lean Suan: Thank you. Singapore needs to prepare for a rapidly ageing population in the next one to two decades. By 2030, the number of seniors aged 65 and above will almost double to over 900,000. The largest increase will occur between 2020 and 2025, with about 179,000 Baby Boomers entering 65 years and above.

Our vision is a Nation for All Ages, where all our citizens can age healthily, purposefully and gracefully in place. Hence, we are investing efforts at three levels.

First, at the individual level, we will create new options for ageing in place and empowering self-care. Second, at the community level, we will build a strong community care system for seniors. And third, at the national level, we will develop enablers to better deliver care services for seniors.

Our models of care will need to evolve, as there is no one-size-fits-all option for seniors. Mr Leon Perera spoke about Silver Towns. MOH is working closely with MND, HDB and the Urban Redevelopment Authority (URA) to pilot new forms of housing developments that are twinned with care services and integrated within public housing estates. This will be our Singapore model for assisted living.

Both Ministries are already studying potential sites for such "assisted living" developments within public housing as well as in the private residential market. Basic domestic services, such as housekeeping and 24/7 monitoring and response, could be offered to support independent living. Home care could be layered on, as needed, for frail seniors. We are collaborating with the Singapore University of Technology and Design (SUTD) and various agencies to explore how design interventions can help make our neighbourhoods age-friendly, as suggested by Ms Tin Pei Ling. The Standards, Productivity and Innovation Board (SPRING) Singapore also works with public agencies and private organisations to develop national standards to support active ageing and senior-friendly infrastructure design.

Beyond new "housing plus" models that combine housing with care, we also need to enhance current services to support the majority of seniors who are already staying in existing residential estates to age in place.

For seniors in ageing rental precincts who are unable to afford domestic help, for example, we had piloted the Care Close to Home (C2H) programme in 2014 where care services are provided out of SACs. To date, over 2,500 seniors have benefited from the C2H programme. This year, we will expand the programme from the current 11 to another four sites in the Beach Road, Chai Chee, Chin Swee and Lengkok Bahru areas, so that more seniors can benefit.

Today, our Active Ageing Hubs (AAHs) provide a suite of care services for seniors as their needs evolve over time. We have started two AAHs at McNair and Kampung Admiralty, and will be opening three more in the Toa Payoh, Queenstown and Bukit Merah planning areas.

Overall, I am encouraged to know that home and community care services have gained traction among seniors in Singapore. Around 14,000 clients have benefited from subsidised home and community care services as of late 2017, more than the 10,000 clients who had taken up subsidised nursing home places. In fact, this has been the trend for the last three years.

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MOH will do more to support ageing in place in the coming months. Today, seniors with complex medical conditions may be taking multiple medications prescribed by various doctors. There is also the risk of non-compliance or medication errors.

We will launch a new community-based Pharmaceutical Care Services pilot so that, in the future, seniors can get help with their medications at community touchpoints, such as senior care centres, where community pharmacists will be stationed, saving them multiple trips to the doctor or hospital. We will start with a pool of some 20 pharmacists from our polyclinics and retail pharmacies, such as Guardian, Unity Pharmacy and Watsons.

This year, we will enhance the Seniors’ Mobility and Enabling Fund (SMF) to enable seniors with frailty to age confidently. To date, we have disbursed close to $100 million since the launch of the scheme in 2011, with over 49,000 beneficiaries. As earlier announced at Budget, we will top up another $100 million over the next five years to further extend SMF subsidies to benefit more seniors.

To lend more support to end-of-life care, we are extending SMF subsidies to clients on home palliative care services in the coming months. MOH will also review the SMF means-testing tiers for devices so that our subsidies remain effective and targeted at those who need help.

Ms Tin Pei Ling asked for an update on Our National Innovation Challenge on Active and Confident Ageing. I am pleased to report that we have launched six grant calls to date, with around $33 million awarded across 23 projects. These include projects in areas, such as home monitoring solutions and assistive devices.

To improve care navigation, we are leveraging technology, which Miss Cheryl Chan spoke about, to develop a Health Marketplace.

Many consumers are already using e-platforms, such as "Amazon" and "Redmart". We hope to create an equivalent platform to make it easy for seniors and their caregivers to find, customise and order community-based eldercare services, such as home care, medical escorts and transport and meals on wheels. They can do so via a mobile app and will also have the opportunity to give ratings on services and providers. We plan to collaborate with the industry to start a Health Marketplace over the next year or so.

We believe that it is also important to integrate seniors within supportive communities so that they do not feel isolated, as mentioned by Dr Lily Neo. Our goal is to build an inclusive “Kampong for All Ages” through the Community Networks for Seniors (CNS) programme.

As announced at Budget 2018, we will be expanding CNS island-wide by 2020. The Silver Generation Office (SGO) placed within AIC, also puts us in good stead through our SG Ambassadors to proactively reach out to new cohorts of Singaporeans aged 65 and above, bringing health and healthcare to them. And where help is needed, various Government agencies and partners will come together to deliver coordinated care to the senior, closing the “social last mile” for our seniors.

Ms K Thanaletchimi and Dr Lily Neo asked about the benefits of our integration efforts. The transfer of functions from MSF to MOH, including services under the SCNs, will be accompanied by a transfer of staff and resources. No jobs will be lost. This will allow MOH to plan and develop health and social support services for seniors more holistically. The staging of SCN services already takes into account the demographics of each planning zone and will continue to do so.

The consolidation allows us to make the delivery of services more citizen-centric, increases productivity by minimising duplication and ensures that no needy senior falls between the cracks. MOH will take the opportunity to review and inject more programming to enhance the SACs, such as conducting preventive health and wellness programmes, to keep seniors active and well in the community.

Ms Thanaletchimi also asked about a one-stop centre for all relevant senior services. AIC currently provides a one-stop service to help seniors and their caregivers navigate services and schemes in the community, with several touchpoints to facilitate this. Many of our VWOs are also go-to points for seniors and caregivers.

In parallel with our nationwide rollout of CNS, MOH will also invest in community nursing. Our healthcare clusters are doing more to support this shift to community care. In the past year, they have piloted eight geographically-based community nursing teams, to anchor population health and care for residents and, in fact, these teams have actually reached out to more than 10,000 patients. Our nurses are familiar with the services in hospitals and the community and can bridge patient care needs across both settings.

We currently have a pool of about 130 community nurses from our three clusters providing care for residents with different needs across care settings, and we hope to increase this to 200 by end 2019. In the area of preventive health, for instance, community nurses can reach out to residents in the community and coach them to manage their health better. For residents who have been discharged from hospital and may have complex medical issues, the community nurse can provide direct care in their homes, for example, in wound care management. And for those in need of end-of-life care, they can be supported by community nurses trained in palliative care.

Senior Staff Nurse Noormala Hamid from the National Healthcare Group is one example. Noormala is experienced in managing palliative care patients, and works closely with other healthcare professionals to coordinate care plans, administer medication and monitor patients at home. She serves as a bridge between her patients and their doctors, and also provides support to families and caregivers who experience the psychological and emotional challenges that come with end-of-life care.

A strong community care system also includes community mental health. Ms Joan Pereira asked how we are making mental health services more accessible, while Assoc Prof Daniel Goh suggested a national dementia plan. Dementia support has been a central component of our community mental health plan which I announced last year. We have strengthened measures to provide care for persons with mental health conditions and dementia, including making services more accessible for them. We have made good progress to date. Over 6,000 frontline staff from various Government agencies and community partners have been trained to identify and respond to persons with mental health conditions. AIC is the key agency that coordinates care and support of persons with mental health needs in the community across health and social care sectors, including SSOs. More than 1,900 individuals have benefited to date.

In addition, AIC has worked with social service partners to establish a network of 33 community outreach teams to reach out to persons at risk of depression or dementia. They also educate the public on mental health and dementia conditions as part of our outreach efforts.

In the area of Primary Care, we have rolled out a combination of mental health and dementia services in eight polyclinics. We are on track to meeting our target for one in two polyclinics to implement mental health clinics by 2021. More than 140 GP partners have been trained to diagnose and support persons with mental health conditions in the community, supported by allied health-led community intervention teams. To date, 16 of such teams have been established to support the GPs, community and grassroots organisations in caring for persons with mental health conditions.

To date, some 8,800 patients have also benefited from the Institute of Mental Health’s (IMH’s) post-discharge "after-care" support, transiting smoothly from hospital to home. MOH will continue to work closely with IMH to enhance its capability to monitor these patients post-discharge.

As mentioned by Miss Cheng Li Hui, we have established six dementia friendly communities (DFCs) to create a culture of awareness of dementia and inclusivity so that persons with dementia and their families feel at home and supported in the community. We plan to expand to 15 DFCs in the next three years or so. To date, we have reached out to over 23,000 people to support persons with dementia and their caregivers and will continue to do more.

Similar to the Singapore Civil Defence Force Community First Responder app, AIC is developing a Dementia Friends mobile app to support seniors with dementia and their caregivers. We had initially considered building a national database of persons with dementia which Assoc Prof Daniel Goh spoke about. However, families we consulted preferred a voluntary approach where caregivers can register their loved ones. Going forward, caregivers can do so by using the AIC's mobile app and also access useful resources. Members of the public can also register as Dementia Friends to learn about the signs and symptoms of dementia and to help keep a look-out for persons with dementia who are lost or wandering. We plan to launch this app later this year.

Mr Murali Pillai asked about how we will work with MSF to implement a change for Persons with Disabilities (PWDs) who need to apply for the FDW schemes. MOH will accept the Client Assessment Form which is already administered by disability care services, such as day activity centres, so that the PWDs need not have to go through an additional assessment.

Next, let me touch on our healthcare workforce, a critical enabler in achieving our vision for community care. Given the twin challenges of rising demand for healthcare and slowing local labour force growth, we need to ensure the sustainability of the healthcare workforce over the long term. Our approach, as reflected in our Healthcare Manpower Plan 2020, must be to equip our healthcare workforce with future skills to provide better care, achieve higher productivity in healthcare and grow a strong local core.

The growing healthcare industry offers good jobs, and we are stepping up efforts to attract more locals into the sector, from school leavers to mid-career professionals as well as older workers.

Our local medical intake has grown from 350 to 480 students over the past five years, and we are on track to reach our target of 500 in 2018. The total nursing intake has also increased by 30% from 1,500 in 2012 to around 2,000 students in 2017. To attract more mid-career Singaporeans into the nursing profession, I announced last month that NUS Nursing will launch a two-year Bachelor of Science (Nursing) Programme later this year under the PCP for Registered Nurses (PCP-RN) and will complement the existing PCP-RN at Nanyang Polytechnic.

I agree with Ms Joan Pereira and Ms Thanaletchimi that the silver workforce is an important resource and can be an engine for national development. Today, more than nine in 10 public sector healthcare professionals who reach the age of 62 are re-employed, and we will do more to attract seniors without prior healthcare experience into the sector.

In going beyond hospital to community, we have also accelerated recruitment efforts over the past year to place more than 1,000 Singaporeans with some 29 aged care service providers in the community. This includes over 40 professionals who made a career switch to the community care sector in 2017 under the Senior Management Associate Scheme.

Mr Henry Kwek and Ms Thanaletchimi asked about our plans to develop the healthcare workforce as we grow the sector. Ms Tin Pei Ling also asked for an update on the training and career pathways for nurses.

MOH has been working closely with SkillsFuture Singapore (SSG) to develop a Skills Framework for nurses, allied health professionals as well as support care staff to facilitate a national recognition of skills in the healthcare industry and development of career progression pathways as well as remuneration frameworks. This is targeted to be developed by the end of this year, and we will be engaging employers and the healthcare union on its adoption. I note that Ms Thanaletchimi has also called for the formation of an Association for the ILTC sector. As Senior Minister of State Lam Pin Min mentioned in Parliament on 1 March, we already have existing structures in place to promote collaboration among sectoral bodies, AIC and MOH, and will continue to strengthen existing partnerships as well as build new ones.

MOH will be investing in developing a more robust Continuing Education and Training (CET) system, which is skills-based and industry-focused, for our nursing profession to complement pre-employment training in a few ways.

First, we want to develop a more comprehensive and coordinated system of upgrading to higher qualifications. We will collaborate with our Institutes of Higher Learning (IHLs) and healthcare institutions to design skills-based, modularised and stackable courses for our nurses that can add up, over time, to higher qualifications. Both the Nanyang Polytechnic and Ngee Ann Polytechnic have introduced part-time skills deepening programmes, such as the Specialist Diplomas in nursing gerontology, community gerontology and clinical education. As of end 2017, about 90 nurses have enrolled in the three specialist diploma courses.

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Later this year, NUS Nursing will introduce a new part-time and modular graduate diploma in Community Health Nursing to equip nurses with the clinical skills to manage population health needs in the community, including clinical decision-making and chronic disease management. The new programme will allow nurses greater flexibility in pursuing part-time study while continuing to work. They can obtain a graduate certificate upon completion of each module that will "stack up" towards a graduate diploma.

Second, we want to build a more robust system of in-employment training across the acute as well as ILTC sectors. Given the dynamic healthcare landscape, our nurses will have to continue to learn and deepen their skills on the job. MOH, together with the Singapore Nursing Board, will engage the nursing leadership to look into a stronger system of skills recognition so that nurses who are trained by any accredited healthcare institution, can have their skills recognised for portability across the healthcare sector. This may mean that a stronger national skills credentialing capability will have to be built.

Third, we want to nurture and build up stronger institutions for nursing education. As a start, we will be working with NUS Nursing to strengthen the nexus of its curriculum with practice, by forming a new advisory council comprising key nursing leaders from both the acute and community care sectors. In the future, we envisage new national centres of excellence in specific areas of specialised nursing education that will train practising nurses across the various healthcare clusters in specific skills, such as geriatric care.

Taken together, we hope to build a first-class nursing education system that can empower our nurses with deep skills and give them the confidence to be at the forefront of driving care transformation.

During last week's Budget Debate, Assoc Prof Daniel Goh Pei Siong called for an increase in the salaries of our local nurses, citing a lag when benchmarked against the pay ratios in other countries. Let me highlight that the basis of the health local income statistics he quoted are not comparable. The median monthly income for full-time employed residents had included employer's Central Provident Fund (CPF) contributions, but the amount cited for registered nurses had not. If we exclude employer's CPF contributions for both, the local ratio is, in fact, not 1.06 but 1.2, which is actually comparable to the pay ratio in Australia, as quoted by Assoc Prof Daniel Goh Pei Siong. However, as workforce demographics and income profiles vary across countries, benchmarking purely based on pay ratios is not meaningful.

Over the years, we have reviewed the salaries of nurses, which have increased in tandem with their expanding roles and responsibilities.

Beyond pay, we have also enhanced professional development and career advancement opportunities for our nurses. Through these efforts, we are encouraged that our nursing intakes have increased by 30% over the past five years and the proportion of males in nursing has also risen from 8% to 10% during the same period.

I am personally inspired by the experience of Dr Pauline Tan. Currently CEO of Yishun Community Hospital, Pauline started out as an enrolled nurse at the age of 18, and actively pursued training opportunities to upgrade her skills and knowledge. Over the years, she has made invaluable contributions in various roles within the healthcare sector. Pauline is testament to the capabilities and potential of our nurses and the many career progression pathways available.

As we deepen the skills and capabilities of our nurses and other healthcare professionals, we can also enhance their scope of practice to support the implementation of more person-centred care models. Today, all prescriptions drafted by nurses and pharmacists require a doctor's counter-signature. Moving forward, we will revise our rules and put in safeguards to allow experienced and qualified nurses and pharmacists in the public healthcare sector to legally prescribe medicines through collaborative prescribing, under the supervision of doctors, so as to increase patients' access to quality care.

Let me illustrate with an example of 77-year-old Mr Tan. Diagnosed with prostate cancer in July last year, he was referred to a home palliative care team upon discharge. With the introduction of collaborative prescribing rights, Mr Tan’s palliative care nurse can assess his condition and issue the prescription for antibiotics, for example, saving his caregiver an additional trip just to collect the prescription.

We recognise the need to also upskill our allied health workforce, as highlighted by Mr Christopher de Souza. MOH and our public healthcare institutions have established various initiatives and grants to support the training and development of our allied health professionals (AHPs). These include skills attachments, postgraduate qualifications, and fellowships in clinical, education and management-related areas. We have been supporting the development of close to 250 AHPs annually.

Our therapy support staff are an equally important group who work alongside therapists to provide rehabilitation care to patients. As a further boost to their training and development, the Institute of Technical Education (ITE) will be rolling out a new Work-Learn Technical Diploma in Rehabilitation Care in April 2018. The new apprenticeship-based diploma, where a majority of the training is conducted in partnership with the employers, allows newly hired and in-service therapy assistants to take on larger roles to provide rehabilitation care to seniors, and progression in their careers as senior therapy assistants.

Mr Alex Yam asked whether MOH will be reviewing the abortion time limit. This upper gestational limit of 24 weeks for abortions is based on scientific evidence of foetal viability outside the womb. Medical experts from our healthcare institutions note that foetal viability below 24 weeks remains low, while neurodevelopmental disabilities are very high among premature babies who survive.

This is also supported by international studies and professional bodies. Only 1% of all abortions in 2017 were performed between 22 and 24 gestational weeks, of which, more than half of these were due to foetal anomalies and other medical reasons. MOH will continue to monitor and review this issue as new evidence emerges.

Chairman, to conclude, let me affirm MOH's commitment to build communities of care for seniors across Singapore so that they benefit from preventive health and affordable, quality healthcare that is person-centric. Together with a capable workforce, we can meet the needs of our ageing population in a sustainable way, enabling our seniors to age gracefully in place and with peace of mind.

The Chairman: Mr Baey Yam Keng.

War on Diabetes

Mr Baey Yam Keng (Tampines): Mr Chairman, when the Prime Minister spoke about the War on Diabetes during his National Day Rally last year, there were some questions why this topic warranted such a high level of attention.

As the saying goes, "health is wealth". It does not matter how much money one makes or receives in the SG Bonus. Without good health, it is useless having lots of money. Wealth cannot always buy good health. That is why, during Chinese New Year, I always wish my residents and friends good health, "身体健康" and people always respond that that is the best and most important blessing they desire.

However, I am glad to note that people do not just wish for good health blessings. Many have taken heed of the call to fight and prevent diabetes. People are mindful of what they eat. There are now healthier food options available at buffet spreads and I have seen many taking the effort to exercise more regularly, with quite a few looking reasonably slimmer, fitter and better.

Diabetes is a chronic disease. It is a lifelong condition and takes a dedicated effort to keep it under control. The beautiful part of it is that regular exercise and controlled diet can also help fight other chronic conditions like high blood pressure and high cholesterol levels.

I would like to ask MOH for an update on the War on Diabetes. What are the challenges faced and what is the plan to sustain awareness and translation into action over the long term?

Mr Chen Show Mao (Aljunied): Sir, in 2015, the International Diabetes Foundation reported that Singapore has the second highest proportion of diabetics among developed nations. In 2016, the Minister for Health declared War on Diabetes. In 2017, the Prime Minister spoke of diabetes as one of the three key long-term issues for Singapore.

Sir, the importance to Singapore in the War on Diabetes cannot be overstated. Our children and young people are increasingly overweight. One in three Singaporeans has a lifetime risk of developing diabetes with serious and costly consequences. Could the Minister give us a report of progress from the front? What are our new and continuing efforts, plans, strategies and tactics?

In this connection, could the Ministry explore avenues for working with the food manufacturing industry and the Ministry of Trade and Industry (MTI) to apply existing incentives and support local food manufacturers to release low-sugar snacks and drinks? The Industry Transformation Map (ITM) for food manufacturing is more advanced than most other ITMs and seems well-placed to develop and promote low-sugar products on an industry basis.

Primary Care Transformation

Dr Chia Shi-Lu: Sir, MOH has previously stated its support for the principle of "One patient, One doctor", and I am heartened by its commitment towards strengthening our primary care services through many programmes, such as the Primary Care Network, for example.

Our family doctors, I am sure everyone will agree, are at the frontlines of healthcare in our community. Often, they are the first point of contact for medical intervention by patients and their families, and patients and their families have also built a relationship with them. Family doctors are thus usually in the best position to provide patient-centric care as they have a comprehensive overview of their patients' physical and mental health conditions and, to varying degrees, the context as well. They play an important role in complex care needs, such as case management and preventive care. These will help lower our escalating healthcare expenditure due to our ageing population.

Can MOH provide an update on the progress of and future plans for primary care transformation in Singapore?

Healthcare Delivery System

Dr Lily Neo (Jalan Besar): Sir, I wish to declare that I am a general practitioner. MOH has previously indicated its intention to repeal the Private Hospitals Medical Clinics Act (PHMCA) enacted in 1980. In view of the fast-changing medical and IT development, the intention on repealing it is timely, to align MOH's priority and better safeguard patients' interests.

Embracing IT is necessary for the provision of medical care at a higher level of proficiency and efficiency. Having this new Bill will also improve governance of healthcare providers and ensure continuity of care and accountability.

I hope MOH will be thorough and will not leave out any inadequacy of governance to tackle unfavourable healthcare practices that have no recourse with the present Act. This will ensure that the new Bill will be relevant and encompassing.

MOH has sought public feedback on the draft Healthcare Services Bill earlier this year. I would like to seek an update from the Ministry on the feedback given, and the progress of the Bill, including the provisions to contribute to the National Electronic Health Records (NEHR).

I favour the NEHR system because health records follow the patients. This means convenience for patients and accuracy of medical information, without them having to repeat their medical histories and medications at every visit to a clinic. This is especially important in emergency settings when patients cannot relate.

I want to share the challenges I face when I adopted a clinic IT system that contributes to NEHR in my clinic last year. My very first concern was what happens if the IT system should suddenly fail, a possibility from any computer or IT glitches? I stand to lose all the medical records of my patients. The system did fail; true enough. It was just as well that I continued manually writing and recording on the usual hard copies whilst I entered electronically entailing double work. There is also another concern of late, that of cyber security. NEHR also needs getting accustomed to, even if the staff and nurses are IT-savvy, thus they have to be retrained, entailing expenses on the adoption of NEHR.

When MOH rolls out NEHR more widely, I hope the above challenges can be addressed to ease its adoption. There will be patients who prefer to opt-out from NEHR record sharing for various personal reasons. I hope MOH will give flexibility of choice that includes opt-out options to those who request.

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Tobacco Control

Dr Chia Shi-Lu: Sir, sadly, the proportion of smokers in Singapore has stayed around 13% for the last few years. The recently announced 10% increase in excise duty on all tobacco products may help to reduce the demand for cigarettes but we must also continue with other measures, such as public education, to highlight the negative effects of smoking and perhaps also increasing the number of smoke-free zones.

The Government will also need to step up its surveillance in this regard. Smugglers are increasingly creative due to the attractive profits. Beyond raising the minimum legal age for smoking and purchase of tobacco to 21 years by the year 2021, what other measures is MOH taking or considering to reduce tobacco use in our population? In addition, what measures does the Ministry have to reduce the impact of second- and third-hand smoke?

The Chairman: Senior Minister of State Lam Pin Min.

The Senior Minister of State for Health (Dr Lam Pin Min): Mr Chairman, may I have your permission to display some slides during my speech?

The Chairman: Yes, please. [Some slides were shown to hon Members.]

Dr Lam Pin Min: Minister Gan has highlighted efforts to ensure healthcare remains accessible, affordable and is of good quality. I will now elaborate on how we are developing capabilities and capacity for the future, ensuring that Singaporeans have access to good care close to their homes.

The cornerstone of a sustainable healthcare system is strong primary care, where patients with chronic conditions are managed well in the community, with better health outcomes. In addition to our newly opened polyclinics in Punggol and Pioneer, there are ongoing polyclinic developments in Eunos, Kallang, Sembawang and Bukit Panjang scheduled to open by 2020.

The Minister has announced plans to develop a further six to eight new polyclinics which will enlarge our network to 30-32 polyclinics by 2030. I am pleased to inform Members that two of the new polyclinics are expected to be operational by 2023 and will be developed in the northern region in Nee Soon Central, and the eastern region in Tampines North. Residents in the West and Central regions can also look forward to new polyclinics.

We are also renewing our existing facilities. Redeveloped Bedok and Ang Mo Kio polyclinics opened in July 2017 and January 2018 respectively. The redeveloped Yishun Polyclinic will open in mid-2018.

Dr Chia Shi-Lu has asked for updates on our primary care transformation efforts. We are investing more resources to support our GP partners, through the PCN scheme. PCNs are networks of GPs delivering care via multidisciplinary teams comprising doctors, nurses and primary care coordinators, who provide holistic care. The PCN scheme commenced in January this year with 10 PCNs on board, involving more than 300 GP clinics. We hope to eventually see 50% of CHAS GP clinics on board the scheme.

I have shared MOH’s vision for primary care, which is "One Singaporean, One Family Doctor" in previous COS debates. The PCN scheme complements our efforts to encourage trusting, long-term relationships between doctors and their patients. Let me elaborate.

Mdm Siti Saujana, a diabetic patient, has seen Dr Kwong Kum Hoong for the past six years. This continuous follow-up has allowed Dr Kwong to gain a deeper understanding of her needs. For example, Mdm Siti’s high blood pressure was detected early as Dr Kwong had advised her to screen for other chronic conditions, as part of the plan in managing her diabetes.

Mdm Siti has also benefited from the team-based care offered by the NUHS PCN, which Dr Kwong's clinic is a part of. She received advice on her diet and lifestyle activities from the PCN nurse, as well as utilised diabetic eye and foot screening services provided by the PCN team. The PCN care coordinator also ensured her appointments were well-coordinated.

I am heartened by the strong rapport and trust forged among Mdm Siti, Dr Kwong and the PCN care team, and encourage all Singaporeans to have a regular family doctor today.

To augment our Primary Care sector, we are also increasing capacity across various settings to ensure appropriate and seamless care. Since 2010, we have opened or expanded five hospital facilities, namely, Ng Teng Fong General Hospital, CGH-St Andrew's Community Hospital Integrated Building, Jurong Community Hospital, Yishun Community Hospital and Khoo Teck Puat General Hospital.

The development of three more hospitals are underway. Sengkang General and Community Hospitals will open by the second half of 2018, while Outram Community Hospital will open progressively by 2020. Hospital bed capacity will increase further when the Integrated Care Hub at Novena and the Woodlands General and Community Hospitals open by 2022. In addition, the National Centre for Infectious Diseases will progressively open from end-2018.

Aged care capacity will be increased to meet the demands of an ageing population. By 2020, home care capacity will increase from the current 8,000 places to 10,000 places, while day care capacity will increase from the current 5,000 to 6,200 places. There are also plans to increase the number of nursing home beds from the current 14,900 to 17,000.

In tandem with the increase in infrastructure capacity is the need to ensure sufficient manpower. Mr Christopher de Souza asked if we are calibrating the training pipeline for specialists to meet medium- to long-term needs. We have increased the proportion of residency positions offered to specialties that are in greater need to address the demands of an ageing population. The number of residency positions taken up in Advanced Internal Medicine, Rehabilitation Medicine and Geriatric Medicine have doubled from 4% of the total residency intake in 2013 to 8% in 2017.

MOH does regular reviews to calibrate the number of residency positions for each specialty, based on our projected needs. MOH also periodically reviews the training requirements to ensure relevance to our local context. This includes instituting a mandatory Geriatric Medicine Modular Training Programme to equip residents with the skills to manage elderly patients. However, we cannot indefinitely increase capacity and manpower. We have thus embarked on efforts to improve our care delivery.

Mr Chen Show Mao and Mr Baey Yam Keng have asked for updates on the War on Diabetes (WoD). This is a whole-of-nation effort where everyone has a role to play. MOH is developing a Patient Empowerment for Self-care Framework to empower people with diabetes to initiate and sustain lifestyle changes with the support of healthcare professionals, community-based providers and other forms of social support.

Under this framework, there will be a National Curriculum developed with educational materials for patients, caregivers and the public, and resources which healthcare professionals and community-based providers can use for patient empowerment. The first tranche of the materials will be available by mid-2018.

MOH is currently enhancing our diabetes management programmes. As part of the Disease Management Workgroup, set up under the National Diabetes Prevention and Care Taskforce, we have rolled out initiatives targeted at eye and kidney complications. We will now address diabetic foot complications, as diabetes is the most common cause of non-traumatic lower extremity amputations (LEAs). In 2015, about 180 diabetes-related major LEAs were performed for every 100,000 adult Singaporeans with diabetes, compared to the Organisation for Economic Cooperation and Development (OECD) average of 60.

MOH will be setting up a workgroup to review the national organisation of diabetic foot services, make recommendations on national care guidelines, and review the roles and training needs of healthcare professionals involved in diabetic foot care to decrease the lifetime risk of amputation for diabetic patients. Mr Speaker, let me now speak in Mandarin.

(In Mandarin): [Please refer to Vernacular Speech.] If diabetes is not treated early or managed well, there may be long-term complications, such as blindness, kidney failure and LEA.

In 2015, for every 100,000 adult Singaporeans with diabetes, about 180 had an LEA, which is much higher than the OECD average. We must pay attention to this problem.

MOH will be setting up a workgroup to develop a strategy to reduce diabetes-related amputations. The workgroup will review the national landscape of the diabetic foot services provided to patients with diabetes, make recommendations for the national care guidelines, and review the roles and training needs of healthcare professionals involved in diabetic foot care. Through improving the quality of care services, we can promptly detect foot problems among patients with diabetes and start treatment immediately to avoid amputations.

(In English): Chairman, WoD is a shared responsibility. We have thus provided funding to support cluster-led, community-based diabetes prevention and management programmes.

For example, in the Central region, the National Healthcare Group (NHG) has launched a Diabetes Community Intervention Programme (CIP) pilot with Toa Payoh Polyclinic to engage patients with, or at risk of, diabetes to take ownership of their well-being. In the East, CGH has worked with the East Coast Group Representation Constituency (GRC) to train volunteers as Health Peers to motivate residents with, or at risk of, diabetes towards behavioural change.

Later this year, NUHS will launch the Patient Activation through Community Empowerment/Engagement for Diabetes Management (PACE-D) programme in the West where patients will be assigned to dedicated multidisciplinary care teams who will support them to take on proactive roles in disease management and lifestyle changes. Even as we develop new initiatives, we need to ensure the delivery of safe and quality care.

Ms Sylvia Lim has asked about how hospital complaints on patient care are handled. Hospitals have their own Hospital Quality Service/Patient Relations Office to deal with such complaints, and patients’ inputs are sought as part of the review process. Mediation is another avenue for patients and their families to resolve their disputes with hospitals.

Complaints escalated by patients to MOH are taken seriously and assessed in an independent manner for potential breach of the Private Hospitals and Medical Clinics Act. A formal investigation will be initiated by the Regulatory, Compliance and Enforcement Division against the hospital once a potential breach is identified. The independent investigation by MOH will include opinion from the relevant appointed experts, and interviewing all parties related to the case, including the patients and their next-of-kin.

Under the Private Hospitals and Medical Clinics Act (PHMCA), institutions are required to report occurrences of Serious Reportable Events (SREs) to MOH and establish quality assurance committees (QACs) to review these SREs. Investigation reports are submitted to the Clinical Quality, Performance and Technology Division under the Healthcare Performance Group of MOH. The priorities of this Division include Quality Assurance, Patient Safety systems and Quality improvement. One of the Division’s foci is to leverage the reported serious events for improvement and cross-institution learning opportunities, similar to the approach of the UK’s Healthcare Safety Investigation Branch. Anonymised information is shared amongst the healthcare institutions, and forums are organised for healthcare institutions to discuss gap closure measures.

To future-proof our healthcare system, it is important that our laws stay current and flexible. As announced earlier, MOH is enacting a new Healthcare Services Bill to replace the current PHMCA this year. The Bill will adopt a modular services-based licensing system to allow providers more flexibility in holding licences for any combination of healthcare services provided. It will also appropriately regulate non-premise-based services, particularly as we want to encourage the outreach of community healthcare services, such as home medical services.

Regulatory clarity will be enhanced to make it easier for providers to understand and, therefore, comply with the legislative requirements. New requirements and competency mandates will also be introduced, including an additional governance layer called the Clinical Governance Officer, to provide technical oversight over more complex services, such as clinical laboratories and radiological services.

Fundamentally, the new Bill will allow MOH to strengthen its legislative powers to achieve our primary regulatory objective of safeguarding patient safety and welfare, as well as continuity of care. Such powers include prescribing a list of prohibited unsafe practices that providers cannot offer, as well as mandatory participation of all healthcare service providers in the National Electronic Healthcare Records (NEHR). I will elaborate more shortly.

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We have actively consulted stakeholders on the proposed policies in the new Bill and I am heartened by the generally positive feedback received. Licensees appreciated the flexibility of the licensing approach to accommodate various care models. The public was also supportive of the enhanced powers in the Bill to have "step-in" rights, tighter publicity controls and prohibition of unsafe practices.

Specifically, on the mandatory contribution of summary clinical data to NEHR, licensees and members of the public were generally supportive, and provided feedback on aspects, such as the cost of digitisation, opt-out procedures and patient confidentiality issues.

Dr Lily Neo has asked about patients who may prefer to opt out of NEHR. I would like to reassure her that patients can choose to have their records logged, which would prevent it from being viewed and accessed. We are also studying a proposal when patient's future records will not be stored in NEHR at all. However, patients should note that this will cause a permanent gap in their medical record history.

To support licensees in this journey, MOH and the Integrated Health Information System (IHiS) have introduced financial, technical and clinical support to help licensees. For example, $20 million under the Early Contribution Incentive scheme is available to help licensees defray the cost of upgrading their IT systems to contribute data to NEHR by June 2019.

Even with the introduction of the new Bill, current regulations may not be flexible enough for the emergence of innovative care models. To address this, MOH will be rolling out the Licence Experimentation and Adaptation Programme (LEAP), which is a regulatory sandbox that will allow new services to be piloted in a controlled environment.

During the pilot, MOH will ensure that these businesses maintain essential safeguards for patient safety, while relaxing certain regulatory requirements or introducing new ones. Thereafter, successful pilots will be mainstreamed under the Healthcare Services Bill with appropriate regulatory requirements.

For a start, the sandbox will focus on piloting models in three areas, namely, telemedicine, precision medicine and models of care that support ageing. More details will be announced in the coming months.

Mr Low Thia Khiang has asked about how precision medicine can be harnessed for patients' benefit. Worldwide, we have seen how precision medicine treatments can be costly without strong evidence for improved health outcomes. Our end objective must be to support the development of precision medicine for positive health and economic outcomes.

To this end, MOH is coordinating a multi-agency effort to develop an integrated national strategy for precision medicine research and its subsequent implementation. This includes looking at enabling infrastructure, regulatory and ethical frameworks, as well as public education. We will provide a thorough update at an appropriate time.

MOH also ensures that human biomedical research is carried out ethically. Gene editing is presently used in basic research in Singapore and is governed by the Human Biomedical Research Act, and guidelines issued by the Bioethics Advisory Committee and National Medical Ethics Committee.

Mr Low Thia Khiang has also asked about the standards for the provision of clinical genetic testing. MOH conducted stakeholder consultations last September. The feedback provided will be taken into consideration when refining the standards, which are targeted to be rolled out in the second quarter of 2018. The sector will be given a sufficient ramp-up period before the standards become legally enforceable.

Part of developing a future-ready outlook is the task of preparing for anticipated healthcare challenges.

Overuse of antimicrobials, such as antibiotics, in the human, animal and agricultural sectors has exacerbated the problem of infection-causing microorganisms developing drug resistance. Antimicrobial resistance (AMR) is an international issue as drug-resistant microorganisms in other countries can easily spread across borders into Singapore.

MOH, the Agri-Food and Veterinary Authority (AVA), the National Environment Agency (NEA) and the Public Utilities Board (PUB) had jointly developed Singapore’s National Strategic Action Plan on AMR, which was launched in November last year to chart out how agencies will work together to detect and arrest AMR through increased surveillance, education, management, research and international cooperation.

As a member of the Association of Southeast Asian Nations (ASEAN), Singapore will continue to promote cooperation and innovative collaboration to strengthen ASEAN's resilience against AMR.

Besides AMR control, vaccination is important to prevent infection and reduce the risk of infectious disease outbreaks. Mr Leon Perera has asked about MOH’s approach towards subsidising vaccinations.

To ensure collective population-level protection or herd immunity and encourage vaccine uptake, childhood vaccinations against highly infectious diseases with community outbreak potential, such as measles, are fully subsidised at the polyclinics.

For diseases with low community outbreak potential, for example, Human Papillomavirus (HPV)-related diseases, vaccination is recommended for personal protection. The National Adult Immunisation Schedule was introduced on 1 November 2017 to provide guidance on the recommended vaccinations that persons 18 years and older should receive, and MediSave use is allowed for these recommended vaccinations.

Mr Chairman, my Ministry will continue to build capabilities and increase capacity in the future to ensure that we have a future-ready healthcare system.

This task cannot be achieved alone. I urge all Singaporeans and healthcare providers to partner us in these initiatives to make our healthcare system better and keep Singaporeans healthier. Thank you.

The Chairman: Next cut, Assoc Prof Fatimah Lateef. Not here. Ms Joan Pereira.

Promoting Healthy Lifestyles

Ms Joan Pereira: Chairman, the Government hospitals and clinics are one of the best sources for reliable and impartial information on healthcare. Will the Ministry review its handouts and information sheets for the elderly and their caregivers, using big fonts and graphics, where possible, on how to better manage their varied health conditions?

Can the information be printed in different languages to explain, for example, what type of exercises and diets are best suited for a diabetic patient, or what food or vegetables are good for lowering cholesterol levels?

This can empower our elderly and their caregivers with very helpful information and help them better manage their health and their lifestyle, so that they can live a good quality life for as long as possible.

The Chairman: Ms Tin Pei Ling.

Less Sugar, Better Health

Ms Tin Pei Ling: Sir, we know the ills of sugar and our Government has taken major steps to cut down on sugar intake, including setting a cap on the amount of sugar packet drinks can contain. It is also very encouraging to see how drinks manufacturers have responded in support of such a move.

Still, changing habits and combatting diabetes is a long journey. Hence, I would like to ask the Ministry how it is furthering efforts to promote healthy living through lowered consumption of sugar or sugar-sweetened beverages.

Also, habits are cultivated from young and it is important that our children start their lives with the right habits. I would like to ask the Ministry how it will ensure that preschools and childcare centres also actively cut down on the sugar intake for young children.

The Chairman: Parliamentary Secretary Amrin Amin.

The Parliamentary Secretary to the Minister for Health (Mr Amrin Amin): We are encouraging greater personal responsibility for healthy living, and community partnerships to make healthy living more accessible and sustainable for Singaporeans.

I will touch on three key areas – the War on Diabetes (WoD), health promotion efforts for all, particularly seniors and ethnic minorities, and tobacco control.

Mr Chen Show Mao and Mr Baey Yam Keng asked for updates on WoD. Miss Cheryl Chan spoke about helping Singaporeans lead a healthy lifestyle. We will continue to support all Singaporeans, regardless of economic and socioeconomic backgrounds, to eat healthily, be screened and exercise as part of our WoD.

HPB’s Healthier Dining Programme offers more affordable, delicious and nutritious food options. In addition to food courts and restaurants, we have extended the Healthier Dining Programme to coffee shops and hawker centres in December 2016. More than 3,000 stalls in coffee shops and hawker centres, as well as over 2,000 food and beverage (F&B) places are under this programme. We now have healthier mee soto, chapatti and carrot cake, just to name a few. So, yes, you can have your cake – just make sure that it is a healthier cake – and eat it, too. Eating healthy and well is possible.

Mr Chen Show Mao asked for an update on plans to develop low-sugar food and drinks locally. In July 2017, HPB launched the Healthier Ingredients Development Scheme (HIDS) to build our food sector’s capabilities to innovate and produce new healthier food products, like healthier oils, rice and noodles. As of December 2017, we now have 14 partners offering 37 healthier products, supplied to over 2,000 F&B stalls.

Let me share one success story. With support from HIDS, Mr Desmond Goh from People Bee Hoon invested in R&D, marketing and trade promotion of new wholegrain healthier bee hoon. Sales of Chili Brand wholegrain bee hoon doubled over the past months. This means that more families are buying, cooking and eating healthier bee hoon.

We will be further extending the HIDS grant to include sugar-sweetened beverages, desserts and sauces. Such food products contribute to about 90% of total sugar intake in our diet. I am happy to announce that HPB will be providing an additional $15 million on top of the current $20 million grant to support innovation in healthier food categories. This is a potential game changer, benefiting Singaporean families and could contribute to reducing sugar in Singaporeans’ diet by 25% by 2020.

We are working with MTI, through the Economic Development Board (EDB) and SPRING Singapore, to align our industry efforts, including through the ITM for food processing. Together, we will spur businesses to innovate and market new healthier food products.

Ms Tin Pei Ling asked about the efforts to promote lower consumption of sugar-sweetened beverages (SSBs) and to help young children develop healthier dietary habits.

Current efforts, such as the Healthier Choice Symbol (HCS) and the Healthy Meals in Preschools Programme, have shown encouraging results. The market share of lower sugar beverages marked with the HCS symbol has grown from 30% in 2012 to 43% in 2017.

Under the NurtureSG initiative, we have partnered the Early Childhood Development Agency (ECDA) to ensure all preschools only serve drinks with the HCS symbols from 1 January 2018.

We are studying sugar-reduction measures from other countries, such as the UK and France. The UK and France have implemented colour-coded front-of-pack labels for food and drinks. The UK uses traffic light colours to tell consumers whether a food item has high, medium or low amounts of nutrients, such as sugar and saturated fats. France has Nutri-score which scores the nutrient content of food and drinks.

Some countries have implemented a tax on SSBs to encourage manufacturers to reformulate their drinks and reduce the sugar content. In March 2016, the UK announced a 2-tiered levy on pre-packaged beverages. The purpose is not to raise revenue but to encourage product reformulation. Although the levy only takes effect in April 2018, the UK authorities have shared with us that more than 40% of affected products have been reformulated. MOH will carefully review this and other measures to encourage product reformulation and conduct a public consultation before deciding our next steps.

Moving on to screening, if discovered early, interventions, such as diet and exercise, can prevent pre-diabetes from worsening. Younger Singaporeans are advised to go for diabetes screening if they are at higher risk of having diabetes. Risk factors include a family history of Type 2 diabetes, overweight or high blood pressure.

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We are helping Singaporeans between 18 and 39 to assess their risk for diabetes through the Diabetes Risk Assessment (DRA) on HPB's HealthHub app. To date, the DRA tool has been used about 116,000 times by younger Singaporeans. Those identified as high-risk for diabetes should go for medical screening. For those above 40, they should go for regular diabetes screening once every three years and they can benefit from subsidies under the Screen for Life initiative.

Moving on to stepping up to the challenge of an active lifestyle. On active lifestyle, we have made strides in the first two seasons of the National Steps Challenge. HPB has rolled out the third season in October last year. More than 650,000 people have signed up and clocked more than 260 billion steps. This is equivalent to 200 million kilometres (km) or more than 5,000 times around the Equator!

We are working with SportSG to organise more fun social physical activities for all ages so that Singaporeans can have access to them at various community and workplace settings.

On the second area of health promotion efforts for seniors and minorities, on seniors, I agree with Miss Cheryl Chan that we need sustainable preventive health efforts to address the needs of an ageing population and we have stepped up efforts to improve healthy living in this aspect. Through the Community Network for Seniors (CNS), HPB, with support from Silver Generation Ambassadors, has implemented several active ageing programmes. Let me share some highlights.

Over 24,000 seniors have attended the Seniors' Health Curriculum, a series of workshops to improve seniors’ physical, mental and functional health. Community Health Posts, located in the neighbourhoods, offer health screenings, regular health coaching and lifestyle follow-up for seniors to help manage chronic conditions better. As of December 2017, over 3,400 senior Singaporeans have benefited from these health coaching sessions.

Thirdly, we have started senior-centric exercise programmes, such as Zumba Gold and FIT+, and mass workout sessions under the Community Physical Activity Programmes (CPAP). Over 159,000 older residents have participated.

Ms Joan Pereira suggested that the Ministry review information on diabetes management and diet for elderly patients and their caregivers. The Patient Empowerment for Self-Care Framework aims to help Singaporeans with diabetes initiate and sustain lifestyle changes. Under the Framework, we will develop a national curriculum to equip persons with diabetes with knowledge and life skills to manage their condition. We will take on the good suggestions by Ms Joan Pereira and will review the information on diabetes management and diet of our elderly patients and their caregivers.

On health promotion among ethnic minorities, we are seeing greater awareness among Malay and Indian communities on health matters but there is more to do.

Sir, allow me to share in Malay some of initiatives for the Malay community. The key thing is that "healthier choice" is decided based on whether that category of food is lower in terms of sugar or other not too healthy things. Is it healthier for that food band or for that food category?

(In Malay): [Please refer to Vernacular Speech.] Last August, I visited popular comedian Alias Kadir. Alias had to undergo a surgery to amputate his lower leg due to diabetes. He already had diabetes when he was in his 40s, but he did not seek treatment. As a result, he experienced complications. Unfortunately, it was already too late. His leg could no longer be saved.

After the surgery, however, Alias was determined to change. He also wanted all of us to learn from his experience – that we must always take care before something goes wrong with us. And if something does go wrong, we must not underestimate the importance of taking medications and watching what we eat, as well as remembering to go for follow-ups with doctors to manage diabetes.

Staying healthy is a lifelong commitment. We are working with many community partners to help the Malay community stay healthy at each stage of life. Let me share three areas of cooperation.

Step One – Towards a Healthy Diet. We have taken steps to collaborate with caterers to slowly change the way we eat at the community level. For instance, we are working with the Singapore Halal Culinary Federation (SHCF) and caterers, such as Eternally Yours and Jamil Catering, so that they can provide healthier halal food choices. Through this effort, it is hoped that the community can gradually grow to like healthy food that can still taste delicious.

Step Two – Towards Mosques as Health Movers. Taking care of our health is part of our religious obligations. We worked with the Islamic Religious Council of Singapore (MUIS) and, as a result, the Jaga Kesihatan, Jaga Ummah (Taking Care of Health, Taking Care of the Community) programme was born, whereby HPB collaborates with mosques to organise healthy lifestyle activities. And another outcome is that 15 mosques have now joined this health initiative. We hope that this initiative will grow and reach 20 mosques by the end of this year.

Hence, what will be done at these mosques? The mosques will provide services to help diabetes sufferers manage their condition, undergo health screening, and conduct physical activities. We are heartened to see more mosques joining this initiative.

For instance, Al-Mawaddah Mosque sent their canteen staff to attend culinary training organised by HPB so that healthier dishes can be served at the mosque. Our hope is that healthy yet delicious food is served at all mosques, be it for gatherings, breaking of fast, Hari Raya celebrations and so on. The mosques should be the health movers of the Muslim community.

Step Three – Towards a Community That Loves Exercising. We will add more spaces and opportunities for our Malay community to exercise or engage in physical activities. For example, I launched the "Get Fit for Umrah" initiative, which encourages pilgrims to build up their fitness before performing their umrah (minor pilgrimage). This is done with the support of TM Fouzy Travel and Tours last year.

We will scale up this programme so that more umrah and haj pilgrims can benefit from it. HPB will be working with the Association of Muslim Travel Agents Singapore (AMTAS) to include more Muslim travel agencies that can also offer this initiative. In addition to having a good reputation as disciplined pilgrims in Mecca and Medina, our Singapore pilgrims will also be known as healthy and fit pilgrims!

I am happy with the strong support from the community. They participated in the four health conversation sessions "Awak Ok?" ("Are You OK?") at Geylang, Jurong, Tampines and Woodlands; they worked out together, for example, at the Zumba sessions at Tampines Hub; and they also rolled up their sleeves – like the doctors, nurses and partners from Muslim Healthcare Professional Association (MHPA). So, let us work together to build a community that is active, fit and healthy!

(In English): Community organisations like the Hindu Endowments Board and the Singapore Indian Development Association (SINDA) are actively promoting healthy living to the Indian community. We want to complement and build on these efforts in three ways.

One, we will intensify health outreach to the Indian community through places of worship, Indian F&B outlets and Indian media to promote healthy eating, regular physical activity and regular screening and follow-up.

Two, we are partnering Sikh and Indian temples to bring health programmes, such as screening, exercise and healthy cooking programmes.

Third, we will leverage social networks to train Health Ambassadors and equip them with skills to actively reach out to and promote healthier living to their families and friends.

The final key focus area of my speech is tobacco control. Dr Chia Shi Lu asked what other measures we are considering to reduce tobacco use in our population. This year, we will be launching a new public education campaign to encourage Singaporeans to live a tobacco-free lifestyle. We will re-emphasise the harms of environmental tobacco smoke and the harms of tobacco. We will have a ground-up campaign involving youths in schools and IHLs. HPB will also work with partners, such as the Singapore Cancer Society and the Football Association of Singapore and other partners, to reach out to all and, in particular, youths on social media, in schools and other places.

We will continue to enhance our smoking cessation services to support smokers on their tobacco-free journey. HPB will engage more workplaces, such as taxi and bus transportation sectors, to help their employees to quit smoking. We hope to see more companies create a health promoting working environment for their staff.

There continues to be a debate on e-cigarettes. We debated this last November. Our position is clear. Any product that contains nicotine can cause addiction and pose risks to health, including e-cigarettes. We want a nicotine-free and tobacco-free future. We will allow e-cigarettes only if they are scientifically proven to be effective nicotine replacement therapy products, for smoking cessation.

MOH is also considering introducing standardised packaging. Singapore recently announced a public consultation to gather detailed views on a proposal for the introduction of standardised packaging, together with enlarged graphic public health warnings.

The public consultation will end on 16 March 2018, and we invite interested parties to submit their views. A final decision on whether to introduce the standardised packaging proposal will be made only after the public consultation. We will ensure that any measures, if introduced, are consistent with Singapore’s domestic laws and international obligations.

MOH will continue to invest and promote good health. We will work closely with individuals, families, industry and community partners. But personal responsibility for healthy living remains key. Each of us has to do our part. Our goal is to realise a sustainable healthcare future where all Singaporeans enjoy Better Health, Better Care, Better Life. We ask for your support.

The Chairman: We have some time for clarifications. Dr Chia Shi-Lu.

Dr Chia Shi-Lu: Chairman, just two clarifications on manpower.

Firstly, I am glad to hear that locally trained doctors would reach the target of 500 per year from local institutions. As I understand it, Singaporeans who are training abroad to be doctors, the numbers of them could reach the same number every year. I am just wondering how the Ministry is looking into these numbers and factoring them into our manpower planning plans. Also, are we still quite dependent on foreign medical manpower to meet our medical needs for the near future?

The second question is about nursing manpower. I am glad to hear about the remuneration framework. But as we have just heard from MSF, social service professionals are looking at up to a 12% rise in their remuneration package. So, I am just asking whether our nurses can also look forward to such salary increases, to attract more local nurses into the workforce.

The Chairman: Senior Minister of State Amy Khor.

Dr Amy Khor Lean Suan: Well, for nurses, under the National Nursing Taskforce, we have reviewed the salaries of nurses in 2014 and 2015, twice, between 3% and 10% increase each year and we introduced a special nurse payment bonus at the end of the year. We will continue to monitor and review their pay to make sure that they remain competitive. But in addition to that, of course, we also continue to look at their professional development and career progression to make sure that it would be an attractive profession to recruit and to retain nurses. In fact, one of the things we have also done is to have an assistant nurse clinician role added in so that there will be more of them who can get promoted at an earlier stage.

With regard to doctors, yes, indeed, we regularly monitor the demand and supply of doctors, taking into account demographics as well as disease trends. As I have noted, we will have a local training pipeline of 500 by this year. We do offer pre-employment training grants to Singaporeans who are graduates from recognised overseas universities and we will have to take the total number into account, even as we monitor demand and supply.

The Chairman: Ms Joan Pereira.

Ms Joan Pereira: Clarifications for Senior Minister of State Khor. The number of persons with dementia is increasing and the Senior Minister of State shared a lot of details on the services and support available for them. But I would like to know what about their caregivers? What are the support and services available for them?

My second clarification: may I also know what MOH is doing in enhancing palliative care services?

7.00 pm

Dr Amy Khor Lean Suan: In terms of support for caregivers, over the years, we have implemented quite a lot of support for caregivers.

For dementia, as I have said earlier in my speech, we are introducing a Dementia Friends mobile app. This is to complement the range of services that we provide to help the caregivers. The mobile app is really to help caregivers in terms of providing resources, as well as push notifications. For instance, if their loved ones get lost, Dementia Friends is just like the Singapore Civil Defence Force's (SCDF's) First Responder mobile app. You can receive push notifications and try to help to find the loved ones.

But there are other services that we provide, the Eldersit Programme, for instance. The Eldersitter can actually look after the loved one at home, whilst the caregiver takes her rest or needs to do other work. We have got Weekend Centre-based Respite Care, long-term Nursing Home Respite Care for seven to 30 days and so on; as well as Caregivers Training Grant to help caregivers get training through AIC programmes, for instance, to be better able to care for their loved ones. So, there is a range of services that we provide, including the Singapore Silver Line, Singapore Silver Pages webpage where caregivers can also access resources, services, referrals and information.

The other question is on palliative care. For palliative care, we have been expanding the number of in-patient palliative care beds, for instance, as well as home palliative care services, increasing the capacity. I have just said that there is the Seniors’ Mobility and Enabling Fund (SMF), where we are now also providing a subsidy through SMF for home palliative care, in terms of consumables.

The Chairman: Dr Lily Neo.

Dr Lily Neo: Mr Chairman, Sir, my cut on breast cancer has not been answered.

Dr Amy Khor Lean Suan: I want to thank Dr Lily Neo for her question and let me apologise that I was not able to reply to the cut due to lack of time for my other colleagues. So, let me just give a reply.

First of all, indeed, as Dr Lily Neo had said, early detection facilitates prompt treatment and, in fact, it is key to improving the health outcomes of women diagnosed with breast cancer.

I am pleased to say that the percentage of early stage breast cancer diagnosed has actually increased from 70.9% in the period 2003 to 2007, to 72.4% in the period from 2012 to 2016.

In addition, there was a significant increase in a five-year observed survival of breast cancer patients from 66% in the period 2003 to 2007, to 71% in 2012 to 2016. I think this is likely due to improvements in treatment, as Dr Lily Neo had alluded to.

As regards access to breast cancer screening, HPB's Screen for Life currently offers subsidised screening programme at participating polyclinics to women aged 50 and above, and close to 43,300 women have benefited from this programme last year.

In addition, HPB collaborates with partners like Singapore Cancer Society, as well as Breast Cancer Foundation. These partners provide full sponsorship of screening programmes for lower-income women, such as CHAS cardholders, so that they do not even have to pay $50 to get screening.

This year, to increase the number of women screened, HPB will work with the National Healthcare Group Diagnostics, as well as the community partners and healthcare institutions to bring the Mammobus, the mobile mammogram service, closer to the target population, to 12 additional sites. All of us, indeed, have a part to play in ensuring that people around us, our loved ones, do go for their mammogram screening.

The Chairman: Ms Tin Pei Ling.

Ms Tin Pei Ling: I would also like to ask that given the prevalence and complications of gestational diabetes, what is the Ministry doing to increase awareness and control the incidence of gestational diabetes amongst women in Singapore.

Dr Amy Khor Lean Suan: For gestational diabetes (GDM), MOH announced last year that we will undertake routine screening and make it available for all pregnant women under the care of the public hospitals with maternity services.

Since the introduction of this policy in March last year, over 12,000 pregnant women have been screened at our three public healthcare institutions – KK Women’s and Children’s Hospital (KKH), SGH and NUH. About one in five pregnant women screened over the past year was found to have GDM.

So, MOH has been reviewing relevant considerations pertaining to the management of GDM and longer-term post-delivery management. We will be issuing an appropriate care guide later this year to better support primary care doctors who are involved in the care of women with GDM post-delivery.

The Chairman: Ms Thanaletchimi.

Ms K Thanaletchimi: Sir, I have two clarifications for Senior Minister of State Amy Khor. One is with regard to non-practising nurses. Have we utilised all means to bring them back into the workforce, especially in the ILTC sector?

The second clarification is on emplacing graduands, that means, new entrants to nursing. Is there a difference between a diploma graduand and a degree graduand? Can we break the glass ceiling and emplace them correctly since they will be doing the same job?

Dr Amy Khor Lean Suan: For the non-practising nurses, in fact, we have enhanced our Return-to-Nursing programme. What we have done is to change this into a Place-and-Train programme, so that the nurses who are coming back will be placed first before they go for training, refresher course. So, they will be paid a salary instead of an allowance.

Over the last two years, we have been able to get about 25 non-practising nurses back into practice in the community care sector. We are doing as much as we can to encourage the non-practising nurses to come back into the sector, particularly in the community care sector.

For new entrants, staff nurses, diploma and graduate nurses, basically, our public healthcare institutions are paying our nurses or healthcare professionals on a performance basis, not just based on qualifications. But for new entrants, that is, people who have very little or no working experience, academic qualifications will be used as a basis.

For degree graduates, they have gone through at least six years of post-secondary education. When they join the profession, they are paid at the Staff Nurse Grade I level, simply because they have gone through a longer period of training and they would have attained deeper skills to kick off, as well as the fact that when they are employed, they would likely be assuming a wider breadth or scope of duties.

For diploma graduates, their post-secondary education is around three years. They will be able to start work after that and they would then have the same opportunities as the graduate nurses to progress in their career. In fact, after they join, both diploma and degree graduates will be assessed based on their performance, as well as any additional specialised skills that they would have gotten in the in-service training.

The Chairman: Mr Patrick Tay.

Mr Patrick Tay Teck Guan (West Coast): I have a clarification for Senior Minister of State Amy Khor.

Following from hon Member Dr Chia Shi-Lu's point on review of social workers' salaries, because we have a big group of medical social workers in our public healthcare institutions, I hope MOH can consider reviewing this as well. I am speaking on behalf of all my sisters and brothers from HSEU.

Dr Amy Khor Lean Suan: Sir, the answer is that we will continue to review and make sure that the pay remains competitive.

The Chairman: Mr Yee Chia Hsing. Is it for Senior Minister of State Amy Khor as well?

Mr Yee Chia Hsing (Chua Chu Kang): No. My question is not for Dr Amy Khor. I am very glad to hear from Parliamentary Secretary Amrin Amin that we are now only allowed to serve healthier choice drinks in our schools, but I believe these are limited to canned and packet drinks.

One of my friends told me his son became chubbier after going to school because he discovered this thing called "Ice Milo Dinosaur". To those of us who are not familiar, "Ice Milo Dinosaur" is ice milo with a heap of raw milo powder.

The Chairman: Mr Yee, no speech, please. Just a clarification.

Mr Yee Chia Hsing: So, I hope MOH can work with the schools to eliminate this "abnormality".

The Chairman: Mr Amrin, you know what is "Ice Milo Dinosaur"?

Mr Amrin Amin: Yes. I thank the Member for the question. The current focus is on pre-packaged drinks, but we will certainly look into freshly brewed drinks later on, especially given the Member's concern on ice Milo.

The Chairman: Mr Louis Ng.

Mr Louis Ng Kok Kwang: I think Senior Minister of State Amy would be relieved that my question is not for her.

I thank Senior Minister of State Chee Hong Tat for sharing the various improvements to CDMP, but I would like to ask for one more improvement, which is, addition of more auto-immune conditions, please.

Mr Chee Hong Tat: Mr Chairman, I thank Mr Louis Ng for his question. I apologise for not having enough time to address it earlier during my speech.

The CDMP, in deciding what conditions are covered, we have a CDMP Clinical Advisory Committee which comprises healthcare professionals from the public, as well as the private sector. They will review the various conditions based on considerations, such as the disease's prevalence and the effectiveness of earlier interventions to reduce complications.

So, certainly, we will refer the suggestion from Mr Louis Ng to the Advisory Committee for their discussion and review.

The Chairman: Mr Vikram Nair.

Mr Vikram Nair (Sembawang): This is also picking on the healthier choice point. Any progress we make towards encouraging people to take healthier choice is good. But I would like to make two suggestions.

The first suggestion is that we move from just healthier choice to actually healthy choice, because some things that are labelled "healthier choice" may not, in fact, be healthy. In fact, I understand Milo is considered "healthier choice", but people may be misled into thinking that means it is healthy.

Likewise, many breakfast cereals which have lots of sugar are also labelled as "healthier choice" even though that just means they are healthier than something else, but they are not healthier than, say, bread, even white bread. So, I think it may be good to have absolute standards.

And the second suggestion is: whether we want to take this even further and encourage or require companies to label sugar content in full, given if that is what the main focus is.

Mr Amrin Amin: I thank the Member for the observations. The Member is right that "healthier choice" symbol does not mean that you can "whack" and "take" as much as you can! So, that is the warning.

The key thing is that "healthier choice" is decided based on, for that category of food, it is lower in terms of sugar or other not too healthy things. It is healthier for that food band or for that food category.

As I mentioned in my speech just now, we are considering other measures. We are studying what the UK is doing with regard to its "traffic light system" for food and drinks, as well as France's Nutri-score. That is something we are working towards and we will update this House, as well as seek public consultations before making a decision on this.

The Chairman: I am not sure how "whack" and "take" would appear in the Hansard. Dr Chia, you want to raise a clarification?

Dr Chia Shi-Lu: Thank you, Chairman. Just one quick clarification for the Parliamentary Secretary.

I talked about the 10% increase in excise duty for tobacco. It seems that it has been an ongoing thing. We raise these taxes every few years. Could we have an idea of how useful these taxes are, in terms of reducing smoking prevalence?

Secondly, would the Parliamentary Secretary know whether there are any plans to further increase these taxes? Some people say that 10% is too little. So, perhaps I could have the Parliamentary Secretary's comment on that.

7.15 pm

Mr Amrin Amin: I thank the Member for supporting the increase in tax for tobacco. Tobacco taxes complement other measures to reduce smoking. So, price and tax on tobacco have shown to be one of the most effective methods in reducing demand as well as subsequent demand for tobacco products. There have been numerous studies that have documented that price as well as tax increases have an effect in reducing demand or affecting demand.

Taxes work in conjunction with our other control measures and if Members look at how we have reduced the smoking prevalence rate from the high of 23% in 1977 to around roughly 13% in recent years, it shows the extent of our success. It is, of course, very difficult to pinpoint specific measures, like how much have tax increases contributed to reducing this prevalence rate. Holistically, we have to see that, in toto, our measures have been effective and the Government will continue to review and to see what we can do to enhance this to achieve our vision of a tobacco-free and nicotine-free future.

The Chairman: I think we have come to the end of clarification time. Would the Member wish to withdraw the amendment?

Dr Chia Shi-Lu: Thank you, Chairman. First of all, I would like to thank all Members for their healthy participation in this debate and, of course, as usual, to thank Minister Gan Kim Yong, Senior Minister of State Chee Hong Tat, Senior Minister of State Amy Khor, Senior Minister of State Lam Pin Min and Parliamentary Secretary Amrin Amin and, of course, all the staff of MOH for their detailed clarifications. I wish them every success in their efforts to transform healthcare for Singaporeans, for now and for the future. Thus, I beg leave to withdraw my amendment.

Amendment, by leave, withdrawn.

The sum of $8,951,942,100 for Head O ordered to stand part of the Main Estimates.

The sum of $1,279,876,000 for Head O ordered to stand part of the Development Estimates.