Committee of Supply – Head O (Ministry of Health)

The Chairman: Head O, Ministry of Health. Dr Chia Shi-Lu.

A United Healthcare System for All

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".

This year's Budget aside from the understandable focus on the evolving COVID-19 situation, has emphasised the importance of staying united and advancing forward as one people, to meet the challenges of the next decade and beyond. This is a strategy that should be applied to healthcare planning as well. And we have to come together as one people to think, to talk, to act and to prepare our country for the health challenges we face as we move towards 2030 and beyond.

The human body works well if all of its various component parts – the cells, the tissues and the organs – work together. Disease and illness occur if one or more of these parts lose their close cooperation and their balance with other parts. The traditional model for the practice of medicine involves a close but often exclusive doctor-patient relationship, although not always with the same unity of purpose.

Health and healthcare policies in the past have also often proceeded on a typically prescriptive and directive approach, presumably because there is often a fair degree of information asymmetry, and also because admittedly, many of us could not always be relied on to make the right choices for our personal health.

The Healthcare 2020 Masterplan that was enunciated by MOH in 2012 outlined clear goals in terms of healthcare quality, affordability and accessibility, and put forward concrete, quantitative objectives in terms of manpower, infrastructure and financial targets.

12.30 pm

But health is not simply a numbers game and I was very supportive of more recent announcements by MOH that encouraged a mindset and strategic shifts. Just as whole-of-Government actions are needed to tackle complex issues confronting our country, a whole-of-society approach would be needed to cover that last hundred yards in our healthcare journey. And in order to do this, we really need the unity of purpose amongst all Singaporeans. This is certainly something that is not easy to achieve and certainly very difficult to budget for.

Singapore's response to the COVID-19 situation is a timely illustration of the importance of societal unity to meet medical shocks. Many commentators have commented favourably on the quality of our disease preparedness planning, healthcare facilities, medical manpower, contact tracing, border controls and so on, and allow me to join my Parliamentary colleagues to put on record my sincere appreciation for the sacrifices that all frontline personnel, whether medical or otherwise, have made since the situation unfolded from the start of the year.

But one of the key elements to the success of the strategy is community involvement and how the whole of Singaporean society has come together to face this challenge. This is one critical element that Prof Dale Fisher, who was part of the WHO-China mission to Wuhan, noted as one key reason why China seems to be succeeding in controlling this outbreak and why Singapore is likewise having some success in managing the outbreak thus far. And such community involvement would likewise be critical if we are to succeed in winning other wars we have, for example, the war on diabetes, on controlling dengue, bringing smoking rates down and getting everyone to eat better, sleep better and exercise more.

At this juncture, I would like to ask the Minister for an update of whether it is "mission accomplished" for Healthcare 2020. Further to this, I would like to ask the Ministry what updates have been made to our national vision for healthcare in the coming decade and beyond? How can we work together to encourage each and every one of us to work together towards common health objectives?

Some of the major shifts that the Ministry had announced were to shift care from hospital to the community and to move from healthcare to health. I believe that this can be facilitated by rethinking some of our basic models of healthcare delivery and I hope that the planning of future healthcare facilities like polyclinics and hospitals will consider new models of care, with better integration and interaction between healthcare and community stakeholders.

The newly established Alexandra Hospital, which serves many of my residents from Queenstown, has piloted new care delivery models where patients are looked after by a team of healthcare professionals grouped functionally rather than by medical specialty. The hospital also provides novel community outreach programs, for example, we have a free, regular bus shuttle services from the nearby neighbourhoods which they serve to the hospital. The hospital itself may be old and some parts are even heritage properties, but the way it functions is very much at the cutting edge of healthcare service provision.

I foresee that there will be increasing disruptions to the way healthcare is delivered and consumed. Hopefully, these disruptions would mostly be beneficial by improving efficiency and improving quality and accessibility and in this way, reducing costs as well as manpower requirements.

I have previously asked about progress on integrating data analytics and perhaps even personalised medicine into our healthcare ecosystem and would like to ask if the Ministry has any updates on this front.

I believe that fostering a united, whole-of-society approach to health, would require better health information accessibility and integration. The excellent system of information dissemination during the COVID-19 crisis by battling disinformation and misinformation has certainly contributed much to controlling the outbreak and maintaining societal confidence in the measures the Government is taking.

Does the Minister have any updates on the roll-out of the National Electronic Health Records system?

Next, an ageing population portends that a greater proportion of the health seeking population may have physical or cognitive impairments that makes it difficult for them to physically access health services. If you are old, your eyesight is not so good, you have trouble moving, it may be more difficult for you to go to your nearby polyclinic or hospital. Outbreaks like COVID-19 also bring into stark relief the benefits that telemedicine or remote medicine and remote consultation can bring.

I would like to ask whether there any updates on how telemedicine or remote medicine can be promoted and facilitated in Singapore?

Finally, as a nation, we have made great strides in our healthcare system and indeed, in our health, over the past decade. Our excellent performance by most measures, paradoxically means that it becomes harder and harder to make meaningful improvements in the future, as quality of our health is a more nuanced assessment than looking at crude rates like life expectancy or disease burden.

Nonetheless, I believe that a united society will be a key piece to this puzzle, and I look forward to the Ministry of Health's stewardship in this regard. May we all live long, live well and grow old together as one people. Thank you, and I beg to move.

Question proposed.

Healthcare 2020, Quality and Affordability

Mr Christopher de Souza (Holland-Bukit Timah): The Healthcare 2020 Masterplan aimed for improvements in accessibility, affordability and quality of healthcare. These included plans to build new, general and community hospitals, increase the number of subsidised drugs and to make primary healthcare more affordable and accessible through the Community Healthcare Assist Scheme (CHAS) and also the building of new polyclinics.

Indeed, the COVID-19 outbreak has put into focus the high quality of healthcare system. Our healthcare workforce has truly shown courage and determination. Would there be further investment needed in the healthcare system, over and above the 2020 goals so as to have the extra capacity needed to deal with a future outbreak, if one was to occur?

Healthcare 2030

Ms Tin Pei Ling (MacPherson): MOH has achieved progress in many aspects of our public healthcare in the past decade. During my nine years in Parliament so far, I have witnessed many measures introduced to enhance senior care capacity and capability, improve public healthcare affordability, increase healthcare manpower, enhance healthcare accessibility, war on diabetes and many other schemes to promote healthy living.

And of course, in most recent times, a very successful campaign against COVID-19. And I hope that we can continue in this aspect.

With so much done and taking stock, I would like to ask the Minister if we have achieved what we set out to achieve at the beginning of the Healthcare 2020 masterplan? Now that we are in 2020, what is the Ministry's vision for the next decade? How hopeful can we be in moving from "curative" healthcare to "preventive" healthcare?

Progress of War on Diabetes

Mr Chen Show Mao (Aljunied): Sir, a year before the Minister of Health declared War on Diabetes, four years ago, the International Diabetes Foundation reported that Singapore had the second highest proportion of diabetics among developed nations. Our children and young people were increasingly overweight. One in three Singaporeans had a lifetime risk of developing diabetes, with serious and costly consequences.

Following the declaration of War on Diabetes, the Prime Minister spoke of diabetes as one of the three key long-term issues for Singapore.

Sir, the importance to Singapore of the War on Diabetes cannot be overstated. Could the Minister give us a report of progress from the front? What are the results and lessons? What are our new and continuing efforts and plans; strategies and tactics?

Living with COVID-19

Dr Chia Shi-Lu: Sir, our efforts in tackling the COVID-19 outbreak have shown good results and won plaudits from around the world. WHO had shared that it was "very impressed" with our measures. Dr Zhang Wenhong (张文宏), Director of the Infectious Diseases Department at China's Fudan University, even drew parallels between our healthcare strategies with the famed Wudang (武当) martial art fighting techniques.

Would the Ministry provide an update on the COVID-19 situation? What are our contingency preparations in readiness for possible scenarios ahead? Specifically, what are our plans should community transmission within Singapore become more widespread or the evolving pandemic worsen, increasing the risk or reported infections once again. Have we considered the scenarios in which the virus becomes endemic? How then can we learn to leave with the virus?

Globally, many healthcare workers at the frontline have been infected while caring for patients and some have even lost their lives though fortunately, not to the same extent as was seen with SARS. What actions are being taken to enhance protection for our frontline healthcare workers.

Finally, I note that contact tracing is a key pillar in our containment strategy and recent studies have also suggested that early detection improves survival from the disease. I know recent cases in Singapore where individuals have been charged for being evasive about the movements.

Is the Ministry considering expanded powers to access location and other related data from mobile devices of patients and close contacts for contact tracing? South Korea for instance has enacted laws after the MERS crisis in 2015 on managing the information of patients in an infectious disease outbreak.

COVID-19

Ms Sylvia Lim (Aljunied): Sir, I have several residents who are COVID-19 patients and our thoughts are with all patients for strength and a speedy recovery.

On the treatment front, a resident who was a SARS patient told me that a medical team visited her recently to obtain some blood samples to aid the COVID-19 cases. Some medical experts overseas have opined that using convalescent blood plasma from former SARS patients could assist very sick COVID-19 patients but was unlikely to be deployable on a larger scale. Could Ministry elaborate on the thinking and efforts on this front?

As for containment, the World Health Organization has opined that it would take 18 months to develop a safe vaccine. As the virus is assessed to be spread by droplets at close range, containing the spread via separation measures like quarantine appears to be appropriate. What are the preliminary assessments of the effectiveness of the Government's strategy so far?

COVID-19 - Planning for Future Threats

Mr Christopher de Souza: Singapore has a formidable healthcare force – the manner in which the COVID-19 outbreak is being dealt with reflects the dedication and professionalism of our healthcare workers. How is a precedent – a standard operating procedure of sorts – being presently developed by the Ministry such that the current operational experiences can be referenced by future healthcare workers in the event of a future outbreak of similar or different magnitude? This will bolster our fight in any future outbreak.

Healthcare Financing

Dr Chia Shi-Lu: Chairman, our healthcare spending is expected to jump 16.2% this year. The increase of $1.9 billion will go to fund higher subsidies and contingency measures for the COVID-19 outbreak. With our ageing population and the increasing burden of chronic diseases, will Government subsidies be able to keep pace with ever rising medical expenditures? At $13.4 billion this year, healthcare is the second highest expenditure after defence. How will MOH ensure that our healthcare expenditure remains sustainable?

MediSave, which is one of the central pillars of our healthcare financing system, is meant to provide for bigger medical expenses such as hospitalisation, day surgery and also outpatient expenses. However, very often, surgeries and hospital stays could be averted with early detection and intervention. If we could encourage more Singaporeans to work closely with their primary care providers, take preventive measures and actively monitor their medical conditions to arrest or slow their progress, we would be able to cut our healthcare expenditure significantly.

Hence, would the Ministry consider implementing measures to further reduce out-of-pocket expenses for primary care costs, including liberalising MediSave for more categories of outpatient expenses or fine-tuning, tweaking some of the existing Flexi-MediSave systems?

The principle of co-payment underpins our healthcare financing system. It was meant to encourage prudent and responsible use of healthcare resources to motivate Singaporeans to stay healthy. However, for the elderly, it is more challenging for them to keep illnesses at bay. Many of them worry that even with Government subsidies, they might have difficulty affording the co-payment component of some of the medical expenses. How does MOH plan to keep healthcare affordable for Singaporeans, particularly for senior citizens? Thank you.

Enhanced Flexi-MediSave for Seniors

Mr Pritam Singh (Aljunied): Out-of-pocket expenses for medical care when our seniors enter their 60s can be a source of significant insecurity. Sir, I have previously called for the Ministry to consider a differentiated ceiling for MediSave withdrawals.

In 2018, about 16% of individuals fully utilised their Flexi-Medisave limits. Sir, this percentage appears small but it translates to about 136,000 Singaporeans who have fully utilised their yearly $200 limit. We also know from previous Parliamentary replies over the years that elderly patients above 60 years of age with chronic conditions visited polyclinics and CHAS clinics an average of six times a year, with an average annual bill of $200 after subsidies.

Those without chronic illnesses visited these healthcare facilities on average about three times a year, with an average annual bill of about $60 after subsidies. I believe there is scope to increase the Flexi-MediSave limits, particularly those who have larger outpatient bills.

12.45 pm

Sir, calls for greater liberalisation of MediSave withdrawals have been made by my colleagues including Mr Faisal Manap. The Workers' Party acknowledges that higher withdrawal limits based on MediSave balances must be carefully considered as it may result in some Singaporeans having less MediSave savings through retirement. However, each senior Singaporean's situation is different, particularly in view of differing MediSave balances across seniors in the population.

In addition, Sir, a differentiated ceiling for seniors has been replicated for other MediSave schemes. For example, from this year, a differentiated MediSave withdrawal scheme has been introduced for Singaporeans with long-term care needs. Individuals with $20,000 or more in their MediSave account will be allowed to use $200 each month or $2,400 per year from MediSave for long-term care. Singaporeans with balances of between $15,000 and above are allowed to $150 per month, and so forth.

Apart from increasing the Flexi-MediSave limits for outpatient treatment, the additional flexibility in the form of a differentiated ceiling should also be considered to allow for inpatient co-payments that have to be paid in cash after MediSave deductions, particularly as our seniors grow older.

While MediShield Life and existing MediSave withdrawals can be utilised for inpatient bills, many patients are still required to make out-of-pocket payments in cash because of existing MediSave limits.

Sir, seniors should not be prevented from relying on their MediSave again to settle the cash component of their bills provided their MediSave amounts are healthy.

Just this Monday at my Meet-the-People Session (MPS), I saw a resident who asked me to write to the authorities to allow his 75-year-old brother – unemployed and living alone – to utilise around $1,400 from his MediSave to settle his hospitalisation bills. He showed me his brother's CPF statement and the amount stood in excess of $51,000. Sir, this is a man in his mid-70s and unemployed. Surely, there is further scope to further assist our seniors and reduce their out-of-pocket expenses for healthcare-related expenditure.

This is not a call for additional subsidies that impact the healthcare budget but a better calibrated MediSave regime that allows our seniors to better manage their cost of living concerns and give them a greater peace of mind.

MediFund for Transportation Fee

Mr Muhamad Faisal Bin Abdul Manap (Aljunied): Sir, MediFund Scheme is meant to financially assist Singaporeans who have difficulties with their medical expenses for both inpatient and outpatient treatments. It is made available at polyclinics islandwide as well as the restructured hospitals.

I would like to call upon MOH to allow the use of MediFund for reimbursement of transport fare for needy Singaporeans, who need to travel by taxi or private hire car to and fro their medical appointments due to their poor health conditions. A good example is stroke patients.

I have encountered residents who defaulted their medical appointments especially those who have multiple appointments in a month, as they are too weak to travel by bus or train, and they do not have the financial means to take a taxi or private hire car to ferry them.

Sir, this segment of our fellow Singaporeans are usually those who are unemployed due to their medical conditions and they depend heavily or solely on financial assistance, such as ComCare, and handouts from relatives and friends, which amount they received is only sufficient, and in some cases, not even enough for their monthly sustenance.

I do know of Voluntary Welfare Organisations (VWOs) that offer subsidies for private ambulance fee to needy individuals. However, this subsidised fee is still too high and unaffordable for some.

Sir, MediFund Scheme is to ensure that needy Singaporeans are not being deprived of their rights to medical treatments due to their financial standings. Allowing MediFund Scheme to be used for reimbursement of transport fare will surely ease the financial struggles and, more importantly, will enhance the accessibility of medical treatments for this group.

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

MediSave and Healthcare Financing

Ms Tin Pei Ling: In my cut earlier, I mentioned that public healthcare affordability has improved over the years that I have seen in this House. It has. But in the course of my constituency work, I still meet many middle-age and senior residents who continue to worry about healthcare costs.

One of the issues they face is not being able to use more of their MediSave to pay for their medical bills, forcing them to make out-of-pocket payments. This poses a cashflow challenge to them. A common argument I have heard from affected residents is that they still have savings in their MediSave, so why can they not use more of their own money for their own treatments? Attempts to explain how CPF works cannot be the same as how a private bank account works were futile as they have immediate needs to solve.

I have a resident, Mr Tay, who has a strong sense of self-pride and self-reliance. He needs to seek heart treatments regularly. While his wife and children are financially independent and he has a good relationship with them, he is highly reluctant to ask them to support his medical expenses. He argues for more use of his MediSave beyond the current annual cap so that he can pay for his own needs.

While I personally believe that children who can afford it, should support parents, I respect his fierce sense of self-reliance. Therefore, can the MOH consider increasing the flexibility of and annual cap on the use of MediSave?

Can we also conscientiously target our publicity and social outreach to encourage children with means to take the initiative to top up parents’ Medisave and Ordinary savings so that their parents need not feel the burden of having to ask their children for money? There is no guarantee that the children will comply but it is a social signal that we should actively send.

Also, the community can play a role in raising resources to support seniors who need help with their medical expenses. Would MOH consider a matching fund to boost the funds raised for this purpose?

Finally, I urge the Ministry to consider expanding the list of chronic diseases that are eligible for use of MediSave.

I once met a relatively young resident during my block visit, about my age or younger. He suffers from severe eczema, highly uncomfortable, and has difficulties finding or holding down jobs. His parents are working but they are just typical 3-roomers and they worry about how they could continue to finance his skin treatments as they age. It is a struggle for them and certainly tormenting for the young man himself. Statistically, an estimated 13% of Asians suffer from eczema.

Therefore, could the Ministry review the list of chronic diseases under the Chronic Disease Management Programme and consider including chronic conditions such as eczema?

Healthcare Capacity

I serve in the MacPherson SMC, a 52-year-old community. Together with the Marine Parade GRC and Mountbatten SMC, the Marine Parade Cluster has seen an average increase of 11% in our senior population from 2016 to 2019. This is a significant rise.

As such, healthcare demand will also rise. Studies have shown that the elderly are four times more likely to be hospitalised than younger Singaporeans. Therefore, what is MOH’s plan to expand capacity in eastern Singapore to cope with the anticipated increase and demand for healthcare? With a rapidly ageing population across Singapore, what are MOH’s plans beyond 2020 to keep care accessible for all Singaporeans?

The Chairman: Dr Chia Shi-Lu, you can take both cuts.

Raising Capacity for an Ageing Population

Dr Chia Shi-Lu: Thank you, Chairman. One-third of the patients admitted into hospital here in Singapore were aged 65 and above and this ratio is set to rise year on year. By 2050, almost half of our population will be in this age group. As the elderly are four times more likely than younger Singaporeans to be hospitalised, there will be much greater demand for hospital beds.

Would the Ministry share an update on how it will ensure that we have enough capacity in our hospitals, the corresponding number of healthcare professionals and other necessary medical resources?

I would also like to ask the Minister if he has the capacity projections for our various healthcare institutions in the next 10, 20 and 30 years. These include general hospitals, community hospitals, nursing homes, hospices, day care and eldercare centres and, very importantly, day rehabilitation and dementia day care centres. What are MOH's plans to keep this care accessible?

Another one of my concerns is how we can better regulate and balance the capacity growth in public versus private healthcare institutions. Is there room for closer collaboration and greater permeability between our public and private sectors to optimise healthcare resources, particularly in times of emergency and crisis?

Presently, the Ministry already has such a partnership with Raffles Hospital for patients with non-critical medical conditions sent there by the Singapore Civil Defence Force emergency ambulances. These patients will benefit from subsidised care at rates similar to those at our public hospitals. What is the progress on the areas of cooperation with the private sector to expand our national capacity?

Primary Care

Next cut. It has been demonstrated that health systems with a strong primary care sector produce better health outcomes by improving access to comprehensive care services. They also keep medical expenditures lower in the long run. Our primary care professionals are indeed the bedrock of our healthcare system here in Singapore.

MOH had earlier announced that it would be building 10 to 12 new polyclinics by 2030, thereby expanding the total number to be between 30 and 32. Ten of the polyclinics' locations have been confirmed, with at least three scheduled to be opened by 2025. Are the other seven clinics on track to be ready by 2030? Would the Minister share details of the types of services each polyclinic will offer?

Besides expanding our public sector primary care capacity, we should continue to strengthen our private sector as well. Our vast network of private General Practitioner (GP) clinics has the benefit of delivering the personal "one patient, one doctor" service. How will MOH support GPs in providing better holistic care? How close are we to the ideal of "one patient, one doctor" in Singapore?

Under the Primary Care Networks (PCN) scheme, GP clinics can organise themselves into networks to provide team-based care. Would the Ministry provide an update on the progress of the PCN scheme? Are there any new models for primary care delivery that the Ministry is considering?

The Public Health Preparedness Clinics (PHPCs) system has also proven its value during this recent COVID-19 outbreak. Are there plans to expand and strengthen this very useful initiative?

Polyclinic for Bishan

Mr Chong Kee Hiong (Bishan-Toa Payoh): Chairman, MOH announced that it would expand the number of polyclinics from the current 20 to about 30 to 32 by 2030. Three will be located in Serangoon, Kaki Bukit and Tengah and are slated to be ready by 2025. The other seven will be located in Bukit Panjang, Eunos, Kallang, Sembawang, Khatib, Tampines North and Yew Tee. Is MOH on track to reach the target of opening these seven clinics by 2030?

With the locations of these 10 polyclinics confirmed, there remains two more possible sites. I strongly urge the Ministry to build one of these in Bishan.

Over the last few years, a few condominiums were built in Bishan. In the next few years, HDB will be adding many blocks too. The profile of Bishan will be changed significantly with many more households and an increasing population of older residents. As of today, the proportion of senior citizens in Bishan is already higher than the national average.

Presently, due to the lack of a polyclinic in Bishan, my residents have to travel to the polyclinics in Toa Payoh and Ang Mo Kio. As part of the journey, some of the elderly need to cross a pedestrian overhead bridge not served by elevators.

A polyclinic is a facility many residents are looking forward to. It is also a necessity, so that the new households moving into Bishan will not overwhelm the polyclinics in Toa Payoh and Ang Mo Kio.

Besides expanding public sector capacity, what are MOH's measures to support private GPs in providing better and holistic primary care for Singaporeans?

Mental Healthcare

Dr Lily Neo (Jalan Besar): Sir, WHO once reported that depression was poised to become the second largest cause of disability worldwide after heart disease by 2020.

According to the Singapore Mental Health Study conducted in 2010, 5.8% of our adult population in Singapore suffered from Major Depressive Disorder some time in life. There is a stigma attached to mental conditions that stops people acknowledging them and seeking medical help. It is important to note these afflicted persons need medical care and treatment that can relieve them from their predicaments and bring them back to normality and happiness.

May I ask MOH what plans are available in detecting and treating mental illnesses and especially for depressive disorders? As good community mental health provision will enable us to have better outreach to those afflicted, may I ask how MOH is ensuring this adequacy?

Raising awareness and educating more people about depression, especially on the symptoms of depression, such as suicidal thought, sleep disorder, feeling of hopelessness and loss of interest in daily activities, will prompt family members or friends to intervene earlier. Seniors especially those living alone or those with no family support are more prone to having depression. May I ask MOH whether there can be a targeted approach to reach out to these vulnerable seniors.

Depression occurs in the young too. Last year, IMH said that stress-related anxiety and depressive disorders are common conditions seen at its Child Guidance Clinics which treat children aged six to 18. Our youths have long precious journeys in their lives. May I ask MOH whether there can be a holistic support for youths-at-risk to detect, to prevent and to provide early medical assistance, when necessary, to ensure their mental well-being?

1.00 pm

A majority of those with mental disorders do live at home. Even those with major disorders are usually not hospitalised. It is always a drain on the care-givers to look after those afflicted family members, especially those with major disorders. May I ask whether there is any scheme to better support such care-givers?

Mental Health

Assoc Prof Daniel Goh Pei Siong (Non-Constituency Member): Chairman, Sir, the 2016 Singapore Mental Health Study found that one in seven Singaporeans have experienced a mental disorder in their lifetime. Depression is the most common disorder, with around 6.3% of adults suffering from major depressive disorder at some point in their lives.

The good news is that people are now more aware and more willing to seek treatment. Thus, the years of delay in seeking treatment for major depressive disorders have dropped from four in the 2010 study to one in the 2016 study.

The Government's efforts to ramp up mental wellness promotion are starting to bear fruit. Indeed, the increased prevalence rates in the 2016 study could be attributed to greater awareness and willingness to seek treatment. But this also means that we are really only catching up to the true extent of mental health disorder and there are a lot more Singaporeans who remain undiagnosed.

Sir, the Government and many community initiatives have been doing well in generating awareness about mental well-being. I want to focus instead on three other As – availability, accessibility and affordability.

On availability, MOH announced in Budget 2017 that one in two polyclinics will have a mental wellness clinic, or a dementia clinic, or both, by 2021. There were already such clinics in seven of the 18 polyclinics in 2017. I believe the Government should aim higher now and make mental wellness clinics available to Singaporeans in all 18 polyclinics. The other issue is the availability of psychiatrists and psychologists, especially in the public health sector, as the 2016 study noted the low rate per 100,000 residents here compared to higher income countries. Are there plans to improve on this front?

On accessibility, five of the seven wellness clinics in the polyclinics only see referred patients and the two Community Wellness Clinics run by IMH allow for consultation by appointments. Persons suffering from mental disorders are already finding it hard to come forward for treatment due to social stigma, thus we need to make the clinics as accessible as possible. Would the Ministry make all mental wellness clinics at polyclinic open to consultation by appointment?

Lastly, on affordability, patients can withdraw from MediSave up to $500 a year for outpatient mental health treatments, but estimates for subsidised treatments ranged from $220 to $380 a month. I believe there is a need for the limit to be raised to at least $1,000 a year to make mental health treatments more affordable.

Mr Chairman: Ms Anthea Ong, you can take your four cuts together.

Improving Quality of Mental Healthcare

Ms Anthea Ong (Nominated Member): Chairman, how do we ensure that the quality of mental healthcare is on par with what Singapore is known for in healthcare? Implementing a measurement feedback system (MFS), adopted in countries such as England, could is one way.

In the public consultation on mental health that my team and I conducted, 26 responses indicated feedback on treatment could improve their health outcomes. Could the Ministry clarify what measures are in place to ensure that there is regular feedback given by clients to their mental healthcare professionals?

[Deputy Speaker (Mr Lim Biow Chuan) in the Chair]

It is recommended by WHO and National Health Service (NHS) England that treatment for mental health conditions should be supported by talking therapies including counselling. From the consultation, 29 respondents described the importance of psychological support alongside medication in treating mental health conditions. One elaborated that her husband did not fare well on medication alone, as "no trust was established (and) he did not open up". Would the Ministry consider measures to ensure that individuals requiring mental healthcare be supported not only by psychiatrists and medications, but paired with psychotherapy and counselling?

WHO encourages engaging stakeholders in the evaluation of mental health initiatives. In a similar vein, could the Ministry share what measures have been undertaken to involve stakeholders, including people with lived experiences of mental health conditions, in evaluating initiatives launched under the Community Mental Health Masterplan?

In expanding mental healthcare into community settings, personnel including social workers and community counsellors now interact with issues of mental health, and steps should be taken to ensure they are appropriately qualified and competent. In continuity with a whole-of-Government approach, would the Ministry consider instituting a code of practice for non-medical personnel involved in mental healthcare, including psychologists, therapists and those within community settings such as social workers and community counsellors?

Double Stigma of Mental Health and LGBTQ+

Next cut, which was initially directed to MSF. WHO suggests that the LGBTQ+ community should be considered as a vulnerable group in mental healthcare, with the double stigma of homophobia and seeking help for mental health issues. In a recent public consultation on mental health that we conducted, 13 responses referenced such a double stigma. One lamented that "it doesn't help too with social stigma against mental health and LGBTQ+ that push more away from the care they need, like me."

For the LGBTQ+ community, specific issues include discrimination by mental healthcare professionals as well as disclosing one's sexual and gender identities to family without consent. Given the Government's commitment to mental healthcare in community settings, we now have social workers and counsellors who support mental health, in addition to mental healthcare professionals such as psychiatrists and psychologists. Would the Ministry consider adopting a whole-of-Government approach in ensuring that personnel working in mental healthcare, including those within community settings, are trained and competent in LGBTQ-related issues?

Diversity officers supporting minorities is a common practice in the business sector. Would the Ministry consider appointing diversity officers, sited within respective agencies, across the healthcare and social services sectors? They can serve as a resource for professionals to tap on to better understand LGBTQ-related issues, help to develop competencies in serving LGBTQ individuals and ensure dissemination of LGBTQ-specific resources.

Mental Healthcare Access for All

We have come a long way in recognising mental health as an integral part of our total health, but still a long way to go in giving this priority and parity to physical health in our policies. Barriers to mental healthcare are significant issues facing many Singaporeans.

First, affordability. Through the public consultation, more than 65% of the respondents felt that costs for mental healthcare was high, prompting some to stop treatment. One shared, "I stopped my therapy at the hospital because I just couldn't afford it even at $17 twice a month. It caused me to be more depressed instead."

There exists a significant disparity between claim and withdrawal limits under MediShield and Medisave for physical and mental health conditions, which is incongruent with the increasing prevalence of mental illness. I am sure the Ministry wants to assure Singaporeans that there is no discrimination against those with mental health conditions. Could the Ministry please clarify when this overdue parity in MediShield and MediSave limits for physical and mental health treatments will be rectified?

Obsessive Compulsive Disorder (OCD) and substance abuse are currently excluded from the list of mental health conditions covered under the Chronic Disease Management Programme (CDMP) for MediSave withdrawals despite the increasing and high prevalence of these two conditions according to the Singapore Mental Health Study 2016. Will the Ministry consider including these conditions?

Given the high co-morbidity between those suffering from chronic physical health conditions and those with mental health conditions, how does the Ministry ensure this group of patients benefit from sufficient Medisave withdrawal limits for outpatient treatments?

In line with the spirit of the Community Mental Health Masterplan to shift mental healthcare from medical institutions into the community, would the Ministry consider allowing patients to tap on their MediSave for mental healthcare provided by community mental health services such Shan You Counselling Centre, Clarity, and Counselling and Care Centre?

Lastly, to remove the first cost hurdle and encourage help-seeking behaviour, would the Ministry consider piloting programmes that provide free initial mental health consultations with a psychiatrist or psychologist?

Second, accessibility. We have 4.4 psychiatrists and 8.3 psychologists per 100,000 population. Overall, the median waiting time for new subsidised appointments is 27 and 28 days to see a psychiatrist or a psychologist respectively. Can the Ministry clarify on what plans are in store to improve these numbers so as to increase accessibility?

Seventy-one respondents shared that lack of clear, trusted and consolidated information on how to seek help limited their help-seeking behaviour. There are more than 10 helplines available under NCSS' Mental Health Resource Directory. Would the Ministry consider setting up a centralised helpline – maybe 991 or something – to make it easier for a person in distress to call for help? These helplines could even be manned by peer supporters, given the many community efforts to promote peer support training.

Would the Ministry also consider a centralised platform for mental health services to include information about service providers and treatment options available, estimated costs of treatment and available subsidies for treatment?

Building on the Ministry's community outreach efforts, would the Ministry consider expanding the modes of referral for community mental healthcare, including text or web-chats, phone calls, walk-ins, referral by friends and family, and also self-referral? As subsidised referrals for public healthcare can only be made through public healthcare institutions, would the Ministry consider allowing professionals in community mental healthcare to make these subsidised referrals?

PDPA and Mental Health Information

Last cut. This was initially directed to MCI. The Tripartite Alliance for Fair and Progressive Employment Practices' (TAFEP) recent declaration that stating one's mental health history on job application forms is discriminatory is very welcomed, especially as 48 respondents or 12%, from this public consultation cited confidentiality issues as a prohibitive factor against seeking help.

Although we have robust laws governing confidentiality in the Personal Data Protection Act (PDPA), there continues to be worries about access to one's mental health history within the public healthcare system, especially by employers. A respondent from the consultation shared that within the Public Service, a colleague's mental health condition was accessed through the public healthcare system and was shared as office gossip by supervisors.

Additionally, respondents have shared with me their worries on the sharing of their personal information by mental healthcare professionals, including one who was threatened by her school counsellor that her parents will be informed of her same-sex relationship.

There are also instances of unnecessary declarations of mental health information, with a respondent indicating that she was unable to donate blood due to her mental health history.

In light of these issues, would the Ministry consider establishing a framework on rightful instances requiring mental health information declaration, accessibility of patient's mental health information within the public healthcare system and better processes for breaking of confidentiality, for example, professionals to discuss with individuals on which information continues to be kept confidential?

Mental Health Rehabilitation for Persons with Disabilities

Ms Yip Pin Xiu (Nominated Member): Chairman, for persons with disabilities (PWDs), medical rehabilitation is always available. What is neither routinely recommended nor provided is any kind of mental health rehabilitation and support. Discrimination and abuse add their own weight to the already present guilt and shame many PWDs experience. It prevents the PWD from speaking out against it or seeking external help to cope with it. Can there be more information on where PWDs can seek access to mental healthcare if necessary?

The idea persists that PWDs are disabled, not mentally challenged, and therefore do not require mental health support. This view serves only to perpetuate the stigma around mental health concerns and makes it extremely challenging for PWDs to access mental healthcare.

Access to mental healthcare for deaf persons is one such example. Given that mental health support is typically given through oral consultation, whether in counseling or therapy, can the Ministry share what measures are in place to ensure that those who are hard of hearing or deaf are adequately supported by our mental healthcare professionals, both in public hospitals and community settings?

Community Mental Health

Mr Melvin Yong Yik Chye (Tanjong Pagar): Chairman, in addition to providing better support for mental health issues at our workplaces, we also need to do our part to provide better mental health services at the community level, particularly for our youths and young adults.

According to a 2018 study by the Institute of Mental Health (IMH), young adults are most at risk of suffering from mental health issues in Singapore. If left unaddressed, this could significantly affect the mental well-being of the next generation of our workforce.

I am therefore glad that the Government has announced that it will create the Youth Mental Well-being Network, which will bring young Singaporeans together and look at ways to promote mental wellness for their generation. I would like to ask if the Ministry has any further plans to make mental health more accessible at the community level, particularly for our youths.

The Labour Movement will also do our part to foster better mental wellness among youths through our Young NTUC arm. Young NTUC has since begun engaging with youths and young working adults to better understand the mental wellness issues that affect them as they transition from school to working life.

A recent study that Young NTUC conducted with over 120 youths found that close to 60% ranked mental well-being as their top workplace concern. Young NTUC is working to put together peer-to-peer support systems for our youths and I hope that the Government can partner with the Labour Movement to make mental wellness services more readily accessible to our young adults and youths.

Access to Mental Health Services

Mr Murali Pillai (Bukit Batok): Sir, it seems to me that there are still challenges on the ground in ensuring that people suffering from mental health issues get timely access to appropriate treatment. I wish to illustrate some of these challenges through three cases I dealt with in the recent past.

1.15 pm

The first challenge is difficulty in detecting these cases.

Recently, I met a lady who sought some assistance to repair a water pipe in her kitchen. I arranged for a community volunteer to visit her. When he attended at her home, he observed, to his shock, that the entire hall of her home was filled with rubbish by the lady, who appears to be suffering from Obsessive Compulsive Disorder (OCD). No one, even her immediate neighbour, knew of hoarding. Not only that, the lady was staying with her daughter who was later identified as suffering from depression. She used to receive from IMH but defaulted.

Quite clearly, the lady and her daughter are unable to seek help on their own. If not for the chance meeting between the mother and I, this case would not have been detected.

The second challenge we see on the ground is lack of cooperation on the part of care-givers, mostly because of lack of trust.

A few months back, I received a complaint from a resident of noise disturbance from his neighbour. I asked my community volunteer to help mediate.

The family residing at the unit in question consists of three persons: father, mother and their young son. My volunteer could immediately tell that the son was mentally unwell. He was not able to look at my volunteer in the eye. He was muttering to himself and pacing to and fro. The parents related that he has a habit of shouting and banging on the walls, too.

My volunteer tried to convince the boy’s parents to admit him to IMH. The father was, unfortunately, dead set against sending his son to IMH because of some unrelated incident that happened in the past.

In the meantime, the poor neighbours continue to put up with the disturbance which happens in the wee hours of the night.

Without the parents’ consent, there was no way even for the IMH Crisis Team to attend at the scene to intervene to help the boy. In addition, because the boy's actions were not deemed to be a danger to himself or others, he cannot be arrested under the Mental Capacities Act and brought to IMH, too.

The third challenge is ignorance on the part of care-givers.

I recently met a couple at their home. Their daughter, now in her 20s, has been holed up in her bedroom for years. She simply refused to come out from her room since she was in Secondary 3. When I asked them why they decided not to ask for help earlier, they told me that they were worried that her daughter may end her life. Hence, they kept quiet.

They were plainly anguished by their daughter's condition but simply did not know what to do for years. Not only that, they were undergoing serious stress themselves and would have suffered mental meltdown, if not for subsequent intervention.

Sir, as can be seen from these cases, mental health cases are sometimes presented as social issues that have arisen in the community. Hence, it may be useful to consider engaging the representatives of organisations involved such as the grassroots organisation, Police, SSO, FSCs and so on in an integrated way so that a plan may be drawn up for each patient who has been identified as needing help.

In particular, we should keep an eye and follow up on patients who are suffering from serious mental illnesses who have defaulted in their treatment. This is because treatment for such cases is focused on containing the situation, not to cure the patients. So, if they are not receiving treatment, one can reasonably expect these patients to be in trouble.

Alternative Medicine Practitioner

Mr Muhamad Faisal Bin Abdul Manap: Sir, the use of complementary and alternative medicine (CAM) is widespread in Singapore, with a study showing that as high as 76% of Singaporeans are utilising at least one form of CAM. This is not only includes traditional medicine practices, such as Traditional Chinese Medicine, Jammu and Ayurvedic medicine, but also includes practices such as Chiropractic and Homoeopathy. However, not all types of CAMs are treated the same under our existing laws and regulations.

Currently, only Traditional Chinese Medicine practitioners are regulated under separate legislation and Chinese proprietary medicines are regulated by HSA. However, regulations do not cover the Jammu or Ayurvedic practitioners or the product they sell.

Chiropractic practices popular amongst office worker has also seen an increasing number of complaints against practitioners in the field as reported by The Straits Times in 2016. This has led to a call by the Chiropractic Association for Government regulation. The lack of regulation, particularly concerning the unregulated use of CAM practices, may lead to detrimental outcomes of patients who simultaneously see western-trained doctors alongside CAM practitioners.

A 2017 Straits Times article reported that CAM is widely used by patients doing chemotherapy which sometimes increases the side effects of chemotherapy. The same article also reported that the use of CAM also delayed a patient seeking western treatment by an extra six weeks as compared to non-CAM users, exacerbating their conditions.

With the pitfalls that patients could suffer from CAM being left unregulated, I propose that MOH considers studying the possibility of a regime that can regulate CAM practitioners in the same way TCM practitioners are being regulated now, which can fall under the ambit of a potential Complementary and Alternative Medicine Act. The Act can help to set regulations that imposes a minimum standard of protection against consumers.

Such a regime should consider requiring mandatory registration for all CAM practitioners and mandatory information given to the patient about the underlying risks of using CAM. This also should include the mandatory disclosure of usage of CAM treatment to healthcare medical practitioners when patients seek medical treatment. Such a regime should ensure regulation is in place for both CAM practitioners and patient that otherwise need to seek recourse elsewhere.

The Chairman: Minister Gan.

The Minister for Health (Mr Gan Kim Yong): Mr Chairman, several Members of Parliament have asked about COVID-19. Let me provide an update on the situation.

As of 4 March 2020, yesterday, we have 112 confirmed cases, 79 have been discharged while 33 patients remain in hospital. Of these seven are in critical condition. Contact tracing is on-going. Dr Chia asked about contact tracing, we are indeed strengthening our capability on contact tracing efforts. I want to thank Singaporeans for their cooperation and support for the various measures we have implemented, without which, our efforts will not be effective.

Globally, the number of cases outside mainland China continues to grow at an alarming rate across continents and regions. This is worrying as they pose a high risk of importation of cases into Singapore. Therefore, we must expect to see significantly higher numbers of new cases in time to come.

In line with our risk assessment of the situation, we have implemented precautionary measures, including travel advisories and restrictions, temperature screening, contact tracing, quarantine, among others.

Ms Sylvia Lim and Mr Christopher de Souza asked about the effectiveness of our current strategy and how we can better prepare for the future. We have to appreciate that every outbreak is different. COVID-19 is different from SARS and different from H1N1. Even as we do our best to learn from each outbreak and prepare for the next, we must always expect the unexpected.

To mount a swift and effective response, we have to adopt a whole-of-Government approach and mobilise the resources of all the relevant agencies. This will allow us to assess, decide and execute our response quickly.

It is important to be transparent, too and share the information we know as soon as possible. This will help to preserve the trust between the people and the Government so that we can have the support of the public as we work together to fight COVID-19. It is also crucial to counter and respond decisively to fake news to avoid diversion of our resources and prevent disruption to our efforts.

The international scientific community has been working hard to study the virus, share new findings and develop solutions. We are sharing our best practices, research and knowledge on COVID-19 with other countries. For example, scientists from China published the genetic sequence of the COVID-19 virus quite early on, on 12 January 2020. Within just over a week, Singapore’s National Public Health Laboratory (NHPL) developed a specific PCR diagnostic test. Shortly after, A*STAR produced a PCR test kit, which has been used locally and shared with international partners to help identify patients and contain the disease. Our scientists are also participating in international clinical trials for treatment and vaccines.

Ms Sylvia Lim asked about using blood plasma for treatment. We are indeed planning to do so and NCID is collecting blood plasma from patients but there are limitations and constraints.

It may take some time before effective treatments and vaccines become available. As the global situation evolves, many countries may become infected. It will become increasingly difficult to stop the virus at our borders as we cannot ban visitors from every country and shut ourselves out from the world.

Even amongst our closest neighbours, the situation is also evolving. Therefore, it is likely that we will continue to see more cases and this disease will stay with us for quite a long time. We will have to continuously adjust, fine-tune our measures to deal with the disease so that life can go on while appropriate precautions are put in place.

I am glad to see the SG Clean campaign picking up momentum and I would like to thank Minister Masagos for leading this important effort. More initiatives will be announced later. All of us have a role to play and we must continue the good practices that have proven effective in reducing the spread of infectious diseases – such as staying home when unwell, practising good personal hygiene. I am beginning to sound like a broken record, but sometimes broken records are good.

We should also maintain high public hygiene standards in our food centres and public toilets. This will strengthen our collective resilience against COVID-19 as well as other infectious diseases, while allowing us to go about our daily lives as normally as possible.

Our healthcare workers are critical in our efforts in managing and containing this outbreak. I want to assure Dr Chia Shi-Lu that they are well-trained on infection control and prevention, and are provided with the appropriate personal protective equipment (PPE) for their safety. I would like to take this opportunity to thank them for their contributions and their dedication.

As Deputy Prime Minister announced, we will be giving them a token of appreciation through a Special Bonus for healthcare workers in our public hospitals and institutions, who are directly involved with treating COVID-19 patients. The senior management of our three healthcare clusters have informed me that as a gesture of solidarity with our healthcare workers, they will donate their own Special Bonuses to the staff welfare fund of their respective clusters.

The details of the Special Bonus for our healthcare workers will be released in due course, but for now our focus is to keep up our fight to contain the spread of COVID-19.

Mr Chairman, even as we tackle the COVID-19 outbreak, we need to continue to plan forward and build our healthcare system. MOH first introduced Healthcare 2020 in 2012 to increase accessibility, raise quality and enhance the affordability of healthcare services.

We are now in 2020, Dr Chia Shi-Lu, Mr Christopher de Souza and Ms Tin Pei Ling have all asked how we have fared with regard to Healthcare 2020. Mr Chairman, I must say I did not expect to still be Minister for Health in 2020. But I am still Minister for Health and I am happy to share that MOH has delivered on what we promised. [Applause.]

We have invested significantly in infrastructure to add capacity. In 2019 alone, we opened the National University Centre for Oral Health Singapore and Outram Community Hospital. The Sengkang General and Community Hospitals, which first began seeing patients in 2018, were also officially opened in 2019. Of course, we also opened the National Centre for Infectious Diseases (NCID) in time for this COVID-19 outbreak.

We stepped up building of long-term care facilities too like nursing homes and daycare centres to meet the needs of our ageing population.

We continued to improve the quality of care, with significant expansion in medical school and nursing intakes to ensure sufficient healthcare manpower. We expanded our polyclinic and GP networks, and further integrated patient care through the introduction of team-based care, and strengthened referral pathways to our Specialists Outpatient Clinics (SOCs).

We have made healthcare more affordable for all. Over the years, we have progressively enhanced and expanded the Community Health Assist Scheme (CHAS) to make primary care more affordable and for all Singaporeans. We also introduced the Pioneer and Merdeka Generation Packages in 2014 and 2019 to help our senior generations. Since then, almost one million Pioneers and Merdeka Generation seniors have received over $2.5 billion in benefits.

We rolled out the MediShield Life and will be launching CareShield Life (CSHL) later this year together with other changes to make MediSave usage more flexible which many Members of Parliament have asked about. Senior Minister of State Tong will go into greater details later on.

Most importantly, our overall healthcare outcomes have improved, with longer life expectancy and Health Adjusted Life Expectancy (HALE). This means that Singaporeans are not only living longer but living longer in good health.

1.30 pm

However, this is the bad news. There is still room for improvement. Singaporeans are still living about 10 years in ill health. Several factors have contributed to this. Based on National Population Health Survey 2017, for example, approximately one in three of residents aged 40-69 has hypertension, one in seven has diabetes and two in five have hyperlipidaemia. To combat chronic diseases, we declared War on Diabetes in 2016. Let me give an update on the War on Diabetes that Mr Chen Show Mao has asked for.

To overcome this fearsome adversary, we have to start at the ground level, to build a strong foundation by shaping an eco-system that encourages healthier choices like living healthy lives and staying physically active. While healthier lives for Singaporeans will take many years of effort to realise, some of our efforts have yielded early progress.

For example, we have created more options for healthier meals. As of 2019, one in two stalls across hawker centres and coffeeshops listed at least one healthier option on their menu, as part of the Healthier Dining Programme (HDP). The number of healthier meals sold also grew to 205 million in 2019, up from 158 million in 2018. The prevalence of regular leisure-time exercise has also increased by about six percentage points from 29% to 35% between 2017 and 2019.

We will be launching a public campaign later this year to increase awareness on regular diabetic foot and eye screening. With greater awareness, we hope to reduce the incidence of lower limb amputation and give our patients better quality of life. These are just some of the many efforts we are taking on preventive healthcare that Ms Tin Pei Ling has asked about. Senior Parliamentary Secretary Amrin will be sharing more on our efforts later.

Besides prevention, we are also providing greater support for individuals living with diabetes. Under our Patient Empowerment for Self-care Framework, we have developed the National Diabetes Reference Materials on HealthHub, as a comprehensive resource for patients and their care-givers. This is helpful for patients and families as they can "self-help" themselves to information about their condition and what they can do for better disease management. For example, patients who wish to start exercising can learn simple, safe and practical ways to do so. These materials can also be customised by healthcare professionals for their own patients.

Our healthcare clusters will also be commencing pilot programmes from the second half of 2020 to increase patients' ownership of their care journeys. For example, one of the programmes will empower newly diagnosed patients with diabetes to initiate and sustain lifestyle changes through group health coaching and greater peer support.

To win the war on diabetes we will need concerted, multi-year efforts and many of these efforts will only bear fruit in the long-term. However, we will continue to monitor the intermediate outcomes, like physical activity and dietary practices to better track the progress of our various initiatives.

Going forward, I would like to assure Dr Chia Shi-Lu and Mr Christopher de Souza that we will continue to invest in new healthcare infrastructure and facilities to ensure care continues to be accessible to meet the needs of the ageing population.

We will be opening four more new polyclinics in over the next two years. Senior Minister of State Lam will share more about the expansion plans for our polyclinics later on. Woodlands Health Campus is scheduled to open progressively from 2022. We had experienced some challenges during the construction due to soil conditions, but we have mostly caught up. Now, with COVID-19, we are discussing with our contractors and suppliers to assess the impact and we hope to minimise delays.

Other upcoming facilities include a new community hospital in Novena and the redevelopment of two national specialist centres, that is, the new National Cancer Centre and the National Skin Centre.

MOH had previously announced that National University Health Systems (NUHS) would design new and innovative care models and test them at the Alexandra Hospital (AH) as part of AH's future development. The master planning exercise of AH was completed in 2019 and we will be calling tender soon for Medical Planners for this project. The first phase of redevelopment is scheduled to be completed by 2030.

Ms Tin Pei Ling has asked about healthcare capacity in the east. Changi General Hospital (CGH) is currently the only hospital in the east. While we have added significant capacity in CGH through expansion over the years, the healthcare demand has grown substantially as a result of population growth and ageing. Ms Tin will be pleased to know that we have commenced the planning of a new integrated acute and community hospital in the east, targeted to be ready around 2030. While the hospital will include the normal range of hospital services, we also want to hear what the community would like to see in this new hospital. As such, SingHealth, which will be operating this new hospital, will be engaging the community to co-create ideas to better meet the needs of the residents there. SingHealth will reach out to the community leaders when they are ready to do so.

Expanding our healthcare system will also mean that expenditure on healthcare will grow, both in the development cost of building new facilities, and later on, as the cost of operating these facilities.

Overall, our national health expenditure increased from $13 billion in 2012 to $22 billion in 2017, or about 11% per annum.

Of this 11%, about five percentage points of this 11% increase was due to increased utilisation. Let me explain.

As our population ages and grows, demand for healthcare services also increases, as some Members of Parliament observed earlier.

We are also utilising more healthcare than in the past, even after accounting for ageing and population growth. This is partly the result of making care more accessible and affordable to all, and partly due to earlier diagnosis, closer monitoring and follow-ups for medical conditions, that means, more frequent consultations and treatment. The range of treatment options has also expanded as the frontiers of medicine advance, increasing utilisation, but at the same time, improving lifespans and the quality of life.

That is five percentage points of the 11%. Approximately, another four percentage points of the growth in national health expenditure can be attributed to higher manpower costs. On the one hand, our healthcare workforce expanded significantly between 2012 and 2017. On the other hand, our healthcare workers' salaries also increased as we implemented pay adjustments to attract and retain our healthcare workers. So, that is four and five, that, is nine percentage points out of 11%. The remaining two percentage points have largely been due to increases in the costs of drugs, medical devices and other overheads.

And as Deputy Prime Minister highlighted in his Budget 2020 round-up speech, we can expect that the overall national health expenditure will continue to increase as our population ages and we step up our investments in facilities and services. But we must continue to be prudent in our healthcare expenditure to ensure that it is directed towards where it gives us the best outcomes.

Therefore, to answer Dr Chia and Ms Tin Pei Ling's questions on what our strategy is going forward, we must continue on our transformation journey for healthcare to ensure we have a good and sustainable system. We must press on with our efforts to go beyond healthcare to health, beyond hospital to community and beyond quality to value.

Patients too can play a role. We can make wise decisions and choices and have a trusted family physician to turn to for advice. Only then can we ensure that our healthcare system is sustainable and remains affordable for our patients.

Information technology (IT) will continue to be an essential enabler for our healthcare system, and we will continue to strengthen our governance and safeguards on our data. This will be essential to maintain the public's trust.

Over the past year, we have been taking concrete steps to implement the recommendations of the Committee of Inquiry (COI) on the SingHealth cyber attack. These steps will help to raise the cybersecurity posture of the public healthcare system. Close to 80% of the control measures recommended have been implemented or mitigated. The more complex measures require careful implementation to avoid disrupting essential healthcare services and impacting patient safety. These will be progressively completed by 2022.

Various enhancements have also been made to strengthen the security of the National Electronic Health Records (NEHR). Work is still on-going and the enhancements are being implemented. Mandatory contribution to NEHR will be deferred until all enhancements are completed and we are satisfied that the system is assessed to be sufficiently robust. We will further updates at the appropriate juncture.

[Mr Speaker in the Chair]

While we secure our systems, we continue to explore new technologies, such as telemedicine, how they can improve care. To-date, 25 public healthcare institutions and 39 community care partners have started video consultation pilot services. We will also leverage technologies, such as Artificial Intelligence, machine learning and robotics to support the work in public healthcare, which Dr Chia has asked about in his cut.

One example we are already deploying is the Singapore Eye Lesion Analyser Plus (SELENA+). This is a deep-learning artificial intelligence software system which can detect three major eye conditions: diabetic eye disease, glaucoma and age-related macular degeneration. SELENA+ highlights areas with potential vision threatening eye disease and refers abnormal cases to human graders, allowing them to focus on the more complex cases. SELENA+ has proven to be more efficient in delivering fast and accurate results. Building on SELENA+'s capabilities, a predictive risk assessment model for cardiovascular disease will be developed to help doctors accurately identify high-risk patients and conduct more timely interventions to save lives and achieve better outcomes.

To conclude, shaping better healthcare in Singapore is not something that MOH and our healthcare providers can do alone. Everyone will have a role to play in this.

We can start by taking care of our own health – by taking responsibility to keep ourselves healthy, we can live better, longer and healthier lives. Mr Chairman, if I may, let me speak in Mandarin.

(In Mandarin): [Please refer to Vernacular Speech.] To battle COVID-19, we must be calm and not panic. As long as we take the right precautions, pay attention to personal hygiene, we can carry on with our day-to-day activities. I would like to take this opportunity to urge Singaporeans to exercise more and stay healthy. I am happy to see that many of our exercise programmes have resumed, after putting in place the appropriate safety measures.

Last Sunday, together with Minister Masagos and a few colleagues, I went to the Teck Whye Garden in Choa Chu Kang to take part in their community morning exercise that was just resumed. I am heartened to see that so many of our residents are committed to staying healthy and actively participate in activities.

(In English): Sir, keeping everyone healthy is a team effort and we are all part of that team. So, let us all play our part to keep Singapore and Singaporeans in good health. [Applause.]

The Chairman: Mr Melvin Yong.

Healthcare Manpower

Mr Melvin Yong Yik Chye: Chairman, our healthcare workers have been working tirelessly since the onset of the COVID-19 outbreak to combat the spread of the virus. Many have suspended vacations and put in extra hours. I commend all healthcare workers – nurses, doctors, medics, and more – for putting your lives on the line to serve Singapore.

Indeed, healthcare workers are a special group of professionals and I urge our tripartite partners to come together to do more for them.

One, let us recognise them not only when we have a crisis. Two, let us ramp up recruitment efforts and bring in more local talents. And three, let us reduce attrition and address the reasons why some leave service.

Sir, with our ageing population, our healthcare system will require more workers, especially nurses. While I commend the Ministry's "Care To Go Beyond" campaign, which profiles the work of nurses to attract locals into the industry, more needs to be done. I would like to ask what are MOH's plans to meet the increasing demand for healthcare workers, particularly in community care.

1.45 pm

Perhaps the Ministry can consider recruiting more mid-career nurses in their 50s and place them in wards that are less intense. Mdm Wan Sok Meng, a staff nurse at the National University Hospital, is one such example. At 59 years old, Mdm Wan finally achieved her childhood ambition of becoming a nurse. More details of her story and other inspiring stories of those who have found nursing to be their calling in life can be found on my blog post today – because I only have limited time here!

Sir, in addition to recruitment, we also need to retain more healthcare workers and encourage more to return to nursing. About 850 local nurses leave our public healthcare sector yearly for a variety of reasons. Despite best efforts to attract them to return to nursing, only around 400 return to practice annually.

Some do not return because they feel that their skills are out of touch. To address this, our Healthcare Services Employees' Union (HSEU) is in partnership talks with Homage, a technology platform that matches trained and qualified care professionals to those in need of care, to explore providing nurses and care-givers who resign with opportunities to freelance as a care professional and keep their skills relevant. The union is also discussing how to provide training to these nurses through its Healthcare Academy – training that are relevant and timely.

I hope that the Ministry can work with the Labour Movement to improve retention of nurses and to encourage those who have left service to return to nursing.

Healthcare Workers

Assoc Prof Daniel Goh Pei Siong: Chairman, Sir, even as we honour our frontline healthcare workers in this COVID-19 situation, we should make sure that we protect them in three ways: physical health and safety, mental wellness and social well-being.

On physical health and safety, the most heartbreaking COVID-19 news are those on doctors and nurses getting infected and succumbing to the disease. The SARS outbreak saw about one-fifth of the cases occurring among healthcare workers. A recent article by Dr Gan Wee Hoe and Dr Chia Kee Seng published in The Straits Times gave details on some measures taken to protect the health and safety of our healthcare workers. Would the Minister share the key measures implemented to protect our healthcare workers' own health and safety?

On mental wellness, again, based on the SARS experience, frontline healthcare workers suffer from high levels of burn-out and post-traumatic stress. Would the Minister please share whether any mental health resources are made available to our healthcare workers in this crisis, and whether free counselling and mental health resources can be made available to our frontline healthcare workers for the years after this crisis has blown over?

On social well-being, reports of healthcare workers in uniform being ostracised in public bring back ugly memories from the SARS epidemic, where about half of local healthcare workers experienced some form of social stigmatisation. I think it is amazing to see how many Singaporeans are fighting back to show appreciation to our frontline workers in concrete ways.

Nevertheless, I want to raise two points here. First, are healthcare workers afforded any legal protection from being abused when they are in uniform, whether at work or in public? Second, in a recent Straits Times report on the ostracisation of nurses in uniform, healthcare leaders reassured the public that the uniforms do not pose any risk of infection.

After this crisis has blown over, it may be timely to rethink whether uniforms are important for nurses or they should, like doctors, go to work in office attire and change to professional scrubs at work.

I am ambivalent about this as I grew up watching my mum go to work in her nurse uniform and I am still immensely proud of her. She related to me some of the obstracisation she experienced during SARS and how it forced her to change out of uniform to return home. Thus, I would rather see a change in public attitude. Nevertheless, a public conversation on the uniform will be useful, if anything, to see whether the public attitude can be changed.

Community Nursing

Ms Joan Pereira (Tanjong Pagar): It has been three years since Community Nursing (CN) teams were set up as part of the Ministry's nationwide plan to bring healthcare closer to communities and homes, especially for the more vulnerable elderly residents. These personalised, coordinated and fully-subsidised care services play a crucial role in preventive care for the less privileged seniors.

As the nurses visit their patients in their homes, they are better able to detect the environment, social and other factors affecting their health. This enables them to have a more holistic understanding of their patients' needs. Over time, patients build trust in their nurses and this makes it easier for them to open up and accept their nurses' advice.

With our rapidly ageing population, more Community Nursing Posts (CNPs) will be required in our neighbourhoods all over Singapore. Would the Minister share an update on the number of such Community Nursing Posts to date and how many more does it intend to set up in the next 10 years? The posts are currently located at Senior Activity Centres. Will MOH partner with other organisations such as other Voluntary Welfare Organisations (VWOs) to expand the location options for future posts, as this will bring care closer to home for seniors.

How many nurses are working under this scheme and how many more will MOH recruit to cope with the increasing number of elderly persons in the coming years? What is the ratio of community nurses to residents under their charge? How has the retention rate of the nurses been so far?

Allied Healthcare – Career and Support

Mr Christopher de Souza: Allied healthcare workers such as physiotherapists, speech therapists, nurses, medical support staff all play a significant role in the overall care for the patient. Methods to increase opportunities and training for their career and wage advancements are also key. This will ensure that a strong, core body of well-trained allied healthcare workers can pass down their experiences and knowledge to successive cohorts. How has the MOH prioritised their career and wage advancement and training?

The Chairman: Ms Irene Quay, you can take your two cuts together.

Medical Certificates by Allied Health Professionals

Ms Irene Quay Siew Ching (Nominated Member): Mr Chairman, I declare my interest as the President of the Pharmaceutical Society of Singapore and the Assistant Director of Allied Health Office at KK Women's and Children's Hospital.

I would like to speak on how MOH can empower our allied health practitioners, AHPs in short, and collaborative prescribing practitioners, or CPPs in short, to combat chronic diseases in Singapore by giving them the right tools through specific policy changes.

I spoke during the Employment (Amendment) Bill debate in 2018 on allowing AHPs and CPPs to issue recognised medical certificates (MCs). Currently under the Medical Registration Act, only qualified medical practitioners are able to issue medical certificates.

As our ageing population increases along with the surge in chronic diseases, we need to change our approach towards long-term follow-up for chronic patients to ensure healthcare and financial sustainability. AHPs and CPPs need to have the right tools to step up in their roles to care for these patients. At the moment, it is reassuring to see more of them taking over follow-up appointments for chronic cases as well as being equipped to manage them.

However, they are handicapped for reasons pertaining to regulatory restrictions. Patients often require MCs after consultation and they will have to be directed to medical doctors for issuances of MCs. This results in unnecessary delays to patients and is disruptive to the AHPs and CPPs as well as the doctor who might be seeing another patient.

I request that MOH consider permitting this group of healthcare professionals to issue MCs which are limited to two days per patient visit, starting with restructured healthcare institutions where AHPs and CPPs are taking on more in the management of chronic disease patients. This can be piloted through a regulatory sandbox approach. Perhaps, Public services can also take the lead to recognise time sheets and reimbursement for minor ailments and medication from retail pharmacies to relieve our polyclinics from their heavy workload.

In a similar vein, I understand that MOH has been attempting to right-site chronic disease patients to be cared for in the community by AHPs. Can the Minister provide an update on the success of this shift so far and the projected targets for the next five years?

I am concerned that the current financial gradient may not be steep enough to facilitate this shift from acute to the community. May I ask if MOH is looking at porting more subsidies for AHPs in the community settings to facilitate this transition? If done right, I see potential to effect an even more efficient and financially sustainable healthcare system for our citizens.

Combat Medication Adherence

Mr Chairman, in this COS speech, I would like to address the need to direct support towards pharmacists in tackling medication-related issues within the community.

One such issue is polypharmacy, which is the concurrent use of multiple medication. It is a growing and persistent issue in Singapore as our population rapidly ages alongside with an increase in the number of patients with chronic diseases.

In the previous committee hearing, I talked about the different types of medication waste. Some examples include expired drugs, drug hoarding, drugs prescribed without indication, or duplication of drug therapy. I quoted a study from a local hospital on the estimated drug wastage cost detected during hospital pharmacist visits, at any time point, to be a staggering figure of $663 per patient.

For this year's committee hearing, I would like to highlight another grave medication-related problem in our healthcare system – medication non-adherence or compliance. This issue is especially prevalent among the elderly.

In late 2017, researchers from the National Healthcare Group Health Services and Outcomes Research department reported that seven in 20 newly diagnosed diabetic patients do not adhere to prescribed medication. This makes up about 35% of newly diagnosed diabetes patients in Singapore. There are many reasons for medication non-adherence, which include a lack of understanding or knowledge of diabetic medicine, difficulty in managing their complex medication regimen, concerns about medication side-effects and cultural beliefs.

Another study by the Saw Swee Hock School of Public Health and the Department of Pharmacy in NUS shows that pharmacists play an important role in educating patients on how their medication work. This can help to prevent long-term complications by explaining to patients the potential side-effects and how to manage them.

However, to address the many concerns that patients may have is very time-consuming. Currently, pharmacists working in healthcare institutions are beset by high patient load on a daily basis. They are unable to tailor individualised care for the needs of each patient and to follow-up to ensure that their concerns are addressed.

For instance, according to the Well-being of the Singapore Elderly (WiSE) study led by the Institute of Mental Health (IMH) in 2015, one in 10 persons aged 60 and above may have dementia. This translates to almost 82,000 people in 2018, and the number is expected to exceed 100,000 in a few years' time. These patients requiring multiple medications will most certainly be at high risk of polypharmacy and non-compliance.

I would therefore like to propose to MOH to set aside and expedite funding to support pharmaceutical services, particularly in the areas of medication review and reconciliation, de-prescribing efforts and related health literacy education, medication delivery services to facilitate instalment collections to avoid medication hoarding and waste, subsidies for adherence toolkits such as pill boxes and medication packaging instructions to fill these pillboxes, and multi-dose drug sachet dispensaries to improve drug compliance.

A recent report from the MOH Health Manpower Development Plan (HMDP) visiting expert, Dr Catriona Bradley, pointed out that the resources of the current community pharmacists are not optimised, and that there is an uneven spread of work leveraging on the capabilities that exist within primary care. She recommends increasing the deployment of community pharmacists in the areas of medication management and pharmaceutical care, which is in line with directives from the World Health Organization's (WHO) Patient Safety Challenge of "Medication Without Harm".

I quote verbatim, "Where multiple prescribers treat the same patients across primary and secondary care, there is a need for a central point of review for medications".

I understand that MOH is currently piloting studies to explore the benefits and cost effectiveness of such pharmaceutical services, but in view of the ageing tsunami, expedited efforts are necessary to galvanise our healthcare professionals to oversee this urgently.

Regardless of how much funding our Government pours in to subsidise drug treatments and improve access to medication, a patient's treatment cannot be optimised if he or she does not swallow a pill that is tailored to their needs.

Mr Chairman, I would like the Committee to consider my proposal to increase funding towards pharmacists with regard to the above-mentioned points. This will enable them to provide more individualised care for patients and at the same time, reduce medication-related problems and long-term healthcare cost in the community.

Eldercare

Dr Lily Neo: Sir, may I ask MOH what further plans are in place to enhance the care of our seniors? Many seniors express the desire to age in place for as long as possible. What are the measures provided to facilitate them to achieve this aim? It is a known fact that keeping seniors socially, physically and mentally active early on when they are mobile will assist them to have healthier and happier lives as they age. This will enable them to lead independent lives, ageing in place in their own homes and in the community for as long as possible.

Will MOH implement a baseline service model for all our eldercare centres to have programmes that will help achieve the above targets?

2.00 pm

Preventive healthcare, such as preventing premature mobility difficulty or disability, will enable our seniors to live independent lives for as long as possible. Thus, the aim is to limit and delay the onset of disabilities in old age which more often than not are due to diseases. The most common causes of disability among older adults are chronic diseases, injuries, mental impairment and visual impairment. Early detection and having good control on chronic diseases can prevent disabilities such as strokes and heart diseases. Physical activities and keeping active can make our seniors stronger and lower their chances of falling, reduce their fracture rates and prevent injuries. Regular eye checks to diagnose cataracts and other visual impairments for early treatment can also prevent disability in seniors.

Our eldercare centres can support our seniors in this area by paying attention to their health, by checking their hypertension, monitoring their diabetes, arranging yearly eyes check and when necessary, referring them for medical help.

As seniors live till ripe old age, frailty may inevitably set in. But even so, with the right measures of social and medical assistance in place to assist them with their daily living, they can still age gracefully in the comfort of their own homes.

The Agency for Integrated Care (AIC) of MOH has in place such a program that presently looks after about 500 frail seniors living alone at HDB rental flats in the Chin Swee and Kreta Ayer precincts. It is an excellent scheme that should be extended to other constituencies. AIC has a team of two nurses and eight healthcare aides, who attend to the seniors; supervising their medical conditions and daily living essentials. This team also arranges for the grassroots volunteers and various voluntary care groups on assisting the social needs of these seniors in a coordinated effort. This has enabled residents to have lesser frequency of hospital visits and has enabled them to stay in their own homes despite their illnesses and immobility.

Supporting Seniors Age in Place and Grace

Ms Tin Pei Ling: In Singapore, we see a rapid rise in elderly population and smaller families. On the ground, it is not uncommon to meet elderly parents who shared that they wish not to burden their children or who are struggling to get by because their children simply have too many life priorities but they are sadly not one of them. This shift in demographics, family structure and individual attitudes has a profound impact on our society and how we organise ourselves in time to come.

At present, we see a network of community partners offering a range of services to our seniors. There are also efforts to better coordinate efforts across the different partners. Could the MOH share how effective has this approach been in engaging and serving the needs of our seniors? We have about 3,000 Silver Ambassadors now, how successful are we in reaching out to the different corners of our community? It is important that we reach the frail and lonely, every senior counts. How else can we better engage our seniors to avoid social isolation and better support them to age in place and with grace?

How can we leverage technology to coordinate our community networks and resources better and to engage our seniors better?

With so much done and will be done, I wonder when and how will we know if we have succeeded in achieving our vision of ageing in place and with grace. Could MOH articulate how Singapore has progressed in terms of caring for our seniors over the past decade? What is the state of physical and mental health of our seniors in Singapore and how has this changed over the years? Are there indicators that MOH uses to monitor our seniors' social well-being and how engaged they are in Singapore?

Long-term Care

Assoc Prof Daniel Goh Pei Siong: Chairman, Sir, the Government has been preparing for the ageing society that is already upon us. Intermediate and long-term care, or ILTC as it is known, will become a critical sector in our healthcare system. This year Singaporeans will see the introduction of CareShield Life and MediSave withdrawals for long-term care.

A severely disabled Singaporean, who is unable to perform three or more activities of daily living, will receive a payout of $600 for life, and if the Singaporean's Medisave balance is $20,000 and above, he or she can withdraw another $200 a month. If we add in the Home Caregiving Grant, there is another $200 in cash assistance to receive. This adds up to a potential $1,000 in cash withdrawals to support the financing of the long-term care needs of a severely disabled Singaporean. If the affected person is from the Pioneer Generation, there is another $100 in cash assistance.

Sir, my concern is with the financing needs of middle-income households, especially those whose wage earners are from the sandwich generation facing the cost of raising school-going children and supporting ageing parents. The latest figure for 2019 from the Department of Statistics for median monthly household income from work per household member is $2,925. This suggests that about half of Singaporean households will not get any subsidies for their elderly household member accessing ILTC non-residential services, since cut off for subsidies is $2,800.

A Long-term Care study by Aviva in 2018 suggests that one would need around $2,300 a month on average for care, medical and everyday expenses. Sandwiched middle income wage earners could be facing the additional financing burden of around $1,300 a month to support an elderly parent needing long-term care.

I believe this burden will become widely felt in the near future, if it is not already being felt. Already, for the Home Caregiving Grant, there is a note on the AIC website that says it will take about three months to process applications due to the high volume of applications received. Has the Ministry done any study to ascertain the long-term care financing needs of middle-income households in the next five to 10 years? What more can be done to support the long-term care financing needs of middle-income households who fall outside of the Government subsidy threshold? Would opening CareShield Life to additional private insurance enhancements regulated by MOH like the Integrated Shield Plans of MediShield Life, with premiums payable by MediSave within limits be a possible answer?

Foreign Domestic Workers and Eldercare

Ms Yip Pin Xiu (Nominated Member): Chairman, Sir, in the last few years, the number of households with at least one member aged 65 years and above who hired a foreign domestic worker has been increasing. It seems that more families are relying on the help of a domestic worker to care for their elderly family member. Does the Ministry expect a growth in this number over the next few years?

Overall, does the Ministry view foreign domestic workers as a long-term measure in supporting our aging population? What is the Government's overall strategy to the role of foreign domestic workers in providing eldercare? Will this extend to the government's management of foreign domestic worker employment agencies?

Emerging data from AWARE's research on foreign domestic workers' role in eldercare suggest that domestic workers experience the lack of training in providing eldercare as a source of work stress. Would the Ministry consider mandating training for domestic workers who are hired to care for older persons or persons who need assistance with a certain number of Activities of Daily Living?

Respite for Care-givers

Mr Christopher de Souza: A lot of strain and pressure is felt by care-givers,especially those who are caring for an elder in the family while working. These responsibilities sometimes fall on a sibling who is single and staying with a parent or both parents. They need to work at the workplace, come home to care for their elderly and make significant decisions for the person they care for. As such, what measures have we put in place to provide respite care and how effective have these measures been?

Assisted Living

Ms Joan Pereira: Sir, the Ministry announced last year that it was working with MND and HDB to pilot an assisted living development in public housing for the elderly. Seniors would be able to select a HDB flat with senior-friendly features and choose from a menu of care packages with optional add-on services to suit their needs and preferences. Examples of these choices include health screening, exercise classes, personal care, housekeeping and round-the clock emergency support. The development would even come with communal facilities and programmes to encourage social interaction.

It is an exciting development and I am glad to note that Singapore's first Assisted Living Public Housing for seniors will be launched in Bukit Batok in May. I strongly believe that this will help our seniors age in place. May I ask the following: how has the progress been thus far? Which service providers have been shortlisted as partners? How much will such a unit and the care packages cost? Will there be enough assisted living flats for all seniors especially with our ageing population. What other initiatives is the Ministry considering to support active ageing and to help our seniors age in place?

The Chairman: Senior Minister of State Dr Amy Khor.

The Senior Minister of State for Health (Dr Amy Khor Lean Suan): Chairman, ageing should not be regarded as a Silver Tsunami to be feared but rather as Silver Equity to be drawn upon. Longevity is also not a disease! It is a gift to celebrate, so long as we stay healthy. With the gift of time and health, we can pursue the things we enjoy.

Minister Gan shared that Singaporeans have a life expectancy of 84.8 years, of which 74.2 years are lived in full health. How would we seize the opportunities of at least 74 good years?

Since we launched the Action Plan for Successful Ageing in 2015, we have made significant strides in building a caring and inclusive home, centred on 3Cs – care, contribution, and connectedness. From scaling up the Community Networks of Seniors nationwide, to promoting learning and volunteering opportunities, we have sought to enable seniors to age in a caring environment, pursue the activities they enjoy and contribute to others in the way they wish.

We are also helping our seniors stay connected by capitalising on man's best friend. No, I do not mean a dog or cat – Member Mr Louis Ng is not here – but, you might have guessed it. I mean the smart phone.

Together with Smart Nation and Digital Government Office and Public Service Division, we have developed the Active Ageing module in the Moments of Life (MOL) app. As one of the 250,000 Merdeka Generation members that the Silver Generation Ambassadors have reached out to to-date, I found it really easy to access information about the various active ageing programmes via the MOL app and pick the one nearest home.

From next month, not only can I browse information on the MOL app, I can also sign up and "chope" a spot for active ageing programmes by the Health Promotion Board (HPB), such as health talks, cooking demonstrations and more!

This January, we launched the Healthy Longevity Catalyst Awards in partnership with the United States National Academy of Medicine, to spur bold, innovative ideas and technology to extend healthy longevity. This could include assistive devices, smart-enabled homes or job redesign solutions. We received more than 100 applications and I look forward to leveraging these innovations to help seniors stay active and engaged.

With all our efforts, I am glad to inform Ms Tin Pei Ling that the 2019 Ageing Survey showed that Singaporeans generally had a positive outlook towards ageing. Across all age groups, those who were still working or volunteering were also less likely to describe themselves as old. However, 96% of Singaporeans cited health as the top concern in old age and three in four retirees wished they could have worked longer.

As we plan for both seniors of today and tomorrow, we must respond to changing needs and aspirations. As part of the SG Together movement, the Government will engage Singaporeans across all ages to refresh the Action Plan for Successful Ageing, so as to co-create a future where generations of seniors may thrive in. Health and employment will be key focus areas in the Action Plan, to address our seniors' top concerns.

Of course, while we strive to make the best of our golden years, most of us will eventually come face to face with creaky knees and back pain. But if we prepare ourselves and plan ahead early, we can better cope with the uncertainty and lengthen the good years of our lives.

To that end, we have partnered the Centre for Seniors (CFS) to pilot bite-sized life-stage conversations, with the aim to reach out to some 5,000 mature workers, especially those in their early 50s, through collaborations with companies, union leaders and community organisations over the next two years. The conversations will touch on a wide range of topics such as employment, health and family, to help mature workers prepare themselves early for the transitions in their senior years. As of December, CFS had organised some 63 lunch-time talks for over 2,000 participants.

Chairman, speaking from experience, I will now like to urge all younger Singaporeans in their 20s and even younger to prepare early for their golden years, which could so easily come upon us in the blink of an eye. Just like me – Members of this House on the right side of 50, I think would surely understand.

Bone health, in particular, deserves our careful attention. With an ageing population, the number of hip fractures has nearly doubled, from 1,500 cases in year 2000 to nearly 3,000 in 2017. About 14% of those with hip fractures pass away within a year of fracture – a sobering statistic. Of the patients who survive, 20% require assistance with activities of daily living. Fractures can have a debilitating effect on our quality of life.

2.15 pm

To reduce the risk of fracture when we age, we must start "saving up" calcium from young, before we reach maximum bone density at around 30 years old, after which, we can only maintain the density at best. To inculcate the importance of proper nutrition and a healthy lifestyle, HPB will be conducting a pilot outreach to 10 schools on bone health. Besides "saving up" calcium in our youth, we must also continually upkeep and prevent depreciation of our assets. In this case, depreciation refers to bone loss.

HPB will be working with Osteoporosis Society Singapore to train 300 Bone Health Ambassadors to reach out to more Singaporeans on the importance of a healthy lifestyle and diet, starting in the second half of this year. These ambassadors will help to run public educational sessions, particularly in the area of fall prevention.

Dr Lily Neo, Ms Tin Pei Ling and Ms Joan Pereira asked about our progress in supporting seniors to age-in-place. Since 2015, MOH has expanded the number of home and day care places by 70% to support seniors to age-in-place. For nursing homes, we have expanded bed capacity by 30%, we now have sufficient capacity nationwide.

Besides expanding capacity, we are also enhancing the scope of services to better address the spectrum of care needs. I announced last year that we will enhance the scope of eldercare centres, to go beyond aged care to social support and preventive health. Currently, MOH funds 82 Senior Activity Centres to provide wellness programmes and social support to residents in rental flats. In the next four years, we will progressively level up and fund at least double the number of eldercare centres to provide an expanded suite of baseline support services for all seniors nationwide and not just those living in rental blocks.

Services include active ageing programmes for the well, befriending services for the lonely, and information and referral for care services for our frail seniors.

In addition, about half of the eldercare centres will also provide higher level care services, such as day care and community rehabilitation services, to cater to those who are more frail.

We also echo Ms Irene Quay’s view that community pharmacists play an important role in ensuring medication adherence in the community. In 2017, of some 517,000 seniors, more than 43% were prescribed five or more regular medications and seen by three or more healthcare providers. Seniors who have multiple co-morbidities often struggle with making sense of many medications from many clinics and the risk of medication error then increases.

Thus, MOH conducted a small proof-of-concept for a pharmaceutical care service for 150 seniors at eight eldercare centres last year. Community pharmacists from both private and public healthcare institutions worked with the centres’ care teams to optimise seniors' medications. Through one-to-one sessions with their pharmacists, seniors and their care-givers received tips on managing their medications, including medication packing and management of side effects, so that they may take their medications safely and independently at home. Feedback from participants of the pilot has been positive. Hence, over the next three years, we will be extending the pharmaceutical care service to another 2,500 seniors at more eldercare centres. This will allow us to establish scalable solutions to help seniors manage their medications safely.

Besides pharmacists, community nurses pounding the ground complement the role of eldercare partners. To Ms Joan Pereira's question, we have expanded the number of community nursing posts from about 70 a year ago to about 120 community nursing posts today. These are sited at senior activity centres, community centres and religious sites, just to name a few. We now have a pool of 245 community nurses, exceeding our target to recruit 200 community nurses by end 2019. As feedback has been positive, we target to expand our pool to 300 community nurses by 2021. Kudos to our nurses from the Regional Health Clusters, who have attended to 86,000 residents in the community, up from just 33,000 just a year ago. I am glad that not only do our residents cherish our community nurses but nurses, likewise, found their job meaningful, and nearly all of them have stayed on the team since the pilot started. In fact, only one left.

This year, as earlier announced by Minister Lawrence Wong, we will also be rolling out another HDB housing type – assisted living flats – to expand the housing options for seniors. The first one will be launched in Bukit Batok. These new assisted living flats are meant to provide seniors with a housing option for independent living, with care available if needed, and a gotong royong spirit amongst neighbours.

We co-designed the flats with Singaporeans. In the past year, MOH and MND conducted 14 Focus Group Discussions (FGDs) with seniors, service providers and healthcare professionals.

Chairman, may I display a few slides, please?

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

Dr Amy Khor Lean Suan: The FGDs were conducted at these specially constructed mock-up flats and communal living room to help participants better imagine the assisted living experience. It was helpful as participants could give us very specific feedback: a moveable partition between kitchen and sleeping areas, room for a full-sized fridge, and more. We took in all the feedback and improved the design of the housing units, communal living room and basic service package. We are also exploring additional care service options to support frail seniors, such as after-hours care.

So, what is the difference between assisted living flats and the range of senior housing options today, such as 2-room flexi-flats? Unlike 2-room flexi-flats, these assisted living flats will be sold, twinned with a service package. Elderly residents will benefit from 24/7 emergency response, as well as the assistance of an on-site community manager.

The community manager will monitor the health status of residents and link them up with relevant care services according to their needs. The community manager will also curate programmes to foster a strong sense of neighbourliness, and residents can look forward to mingling at the communal space on every floor – much like the good old kampong days.

The first Assisted Living flats in Bukit Batok will be reserved for seniors aged 65 and above. In addition, we will set aside some units where priority will be given to seniors with care needs. More details will be shared in the coming weeks. Planning for a private Assisted Living pilot is also underway. MND and MOH have consulted developers and care operators on this and will announce details later.

MOH continuously seeks to wrap care and support around Singaporeans. Dr Lily Neo, Ms Anthea Ong, Mr Daniel Goh and Mr Murali Pillai highlighted the importance of taking this approach for not just physical health but also mental health. I agree and we are embracing this approach. For instance, the HPB promotes both physical and mental health in its preventive health programmes organised in the community and at workplaces.

Like a migraine or backache, we should seek help for mental health issues early, so as to avoid problems that are more challenging to address later on. To that end, we have set up 43 community outreach teams and trained over 24,000 frontline staff from Government agencies and community partners across Singapore to identify persons with mental health needs in the community and refer them for appropriate support. As of December 2019, we have reached out to over 300,000 persons and provided assistance to more than 23,000 persons who were at risk of developing mental health conditions or dementia.

IMH and the National Council of Social Service (NCSS) have also been driving the “Beyond the Label” national campaign to facilitate more conversations about mental health. This way, we hope to chip away at the stigma associated with mental health and encourage those with mental health issues to seek help promptly.

Ms Anthea Ong should also be assured that physicians are bound by duty and ethics to protect patient confidentiality and to ensure data sharing and use for patient care purposes only – for all medical conditions, not just mental health. Healthcare institutions are also required by licensing conditions to safeguard confidentiality of medical records. Specifically, our public healthcare institutions have implemented safeguards to ensure access by authorised users on a need-to-know basis. Severe disciplinary and enforcement actions are taken against users who wilfully breach patient confidentiality. Organisations must also comply with the Personal Data Protection Act.

Chairman, over the years, we have expanded our network of partners to ensure that persons with mental health issues can access the support they need. For example, the Institute of Mental Health operates a 24-hour Mental Health Helpline. NCSS has also recently launched a Helpbot named "Belle" to provide 24/7 access to consolidated information about helplines and mental health resources, according to what users are looking for. To date, Belle has supported 1,000 users.

Community intervention teams have also been established to support partner General Practitioners (GPs) and service providers with allied health services, such as psychotherapy and counselling. Over 26,000 persons have been supported by these teams. In addition, persons with mental health issues who face social and family issues may approach Family Service Centres for counselling support.

To date, more than half of our polyclinics provide mental health and dementia services. In addition, over 210 GP partners have been trained to diagnose and support persons with mental health conditions.

These services are available to all Singaporeans, irrespective of their specific risk factors, such as disability or gender identity. However, we agree with Ms Yip Pin Xiu and Ms Anthea Ong that care providers need to take into account specific care needs and risk factors.

For example, for persons with hearing loss, sign language translators will provide counsellors with the necessary support. The Singapore Association for the Deaf also provides counselling services.

Over the next year or so, MOH and the Agency for Integrated Care will be engaging our stakeholders, including disability associations, to identify ways to improve mental health support.

As highlighted by Ms Anthea Ong and Mr Daniel Goh, Singaporeans can tap multi-layers of financial support, such as Government subsidies and CHAS, MediShield Life, MediSave and Medifund, for treatment of mental health conditions.

MOH reviews the amount of financial support regularly to ensure that they are adequate. For example, the MediSave and MediShield Life claim limits differ across inpatient treatments to reflect different bill sizes. As the bill sizes of inpatient psychiatric treatments are comparatively lower than other inpatient treatments, the MediShield Life and MediSave limits are also correspondingly lower, to cater to different treatment types.

Based on the latest available data, fewer than one in 10 subsidised patients exceeded the MediSave yearly withdrawal limit for inpatient psychiatric stays, while fewer than three in 10 subsidised bills exceeded the MediSave daily withdrawal limit. As for MediShield Life, we have been reviewing the claim limits and more details will be announced later this year.

For outpatient treatment of mental health conditions under the Chronic Disease Management Programme (CDMP), which includes depression, anxiety, including Obsessive Compulsive Disorder (OCD) – so, that is included in CDMP – bipolar disorder and schizophrenia – CHAS cardholders may tap on subsidies of up to $500 per year for treatment at CHAS GPs, and more for our Pioneer and Merdeka Generation cardholders. Patients can also withdraw up to $500 per year from their MediSave for outpatient treatment for conditions under the CDMP. In 2018, only about two in 10 patients who withdrew MediSave for their outpatient mental health treatment reached the yearly withdrawal limit. To further defray the costs for patients with complex chronic conditions, say, a patient with OCD and osteoporosis, we will be raising their MediSave withdrawal limit. Further details on this will be shared by Senior Minister of State Mr Edwin Tong. Singaporeans who still require financial support after tapping these schemes can apply for MediFund from our public healthcare institutions.

2.30 pm

We must also not forget that the well-being of persons with mental health conditions often rests on the care-givers, and they are at risk of burnout.

Hence, we will be piloting a structured system of support for care-givers of persons with mental health conditions. Under this system, upon first diagnosis of their loved ones, hospitals and community partners will provide care-givers with information, such as disease progression and expected care needs and link them up with the necessary health, financial and social support services. With this, we hope that care-givers will know upfront that they are not alone, that there is an entire network of support for them.

Even as we expand our suite of care services for persons with mental health, we must strengthen our multi-pronged strategy to better address mental health and this extends beyond medical care. Hence, in the coming months, we will be undertaking a whole-of-Government review of our mental health strategy, to identify gaps and strengthen existing inter-agency efforts. Besides enhancing support for the mental well-being of seniors, we will also focus on youth mental well-being, which Senior Minister of State Lam will elaborate on.

Chairman, in recent months, our healthcare workers are at the frontline, battling against the spread of COVID-19.

I will also like to take this opportunity to thank all our healthcare workers who have gone above and beyond their duty to keep us safe. We are grateful, and we will do our utmost to support all of them.

I share Assoc Prof Daniel Goh's pride in our nurses. It is unfortunate that some of our nurses were shunned and even berated for wearing their uniforms in public recently. Our nurses wear their uniforms with pride, and I hope members of the public can appreciate and trust their professionalism and affirm their efforts

The work of our healthcare workers is not any easier in "peacetime". Healthcare workers sometimes, inadvertently, bear the brunt of patients' and their families' emotions. Under the Protection from Harassment Act, the Government adopts a zero-tolerance policy against the harassment of public healthcare workers performing their official duties. The same Act also protects them as private citizens if they are harassed when off duty. All our public healthcare clusters also have counselling services and hotlines for our healthcare workers if they need help.

But the best way to support our healthcare workers is not to react after harm is done but to refrain from taking out our stress on them. I urge Singaporeans to take a moment to recognise their efforts, and I am heartened by those who have rallied behind them.

Chairman, our healthcare workers are truly the backbone of our healthcare system. Battling COVID-19 is but the latest example. Their role will only continue to grow in importance. As care needs increase in our ageing population, we will need a steady pipeline of dedicated healthcare workers. Manpower is a perennial challenge, but on the flipside, it is also an opportunity for Singaporeans who seek a meaningful career.

We have made some headway in growing the number of healthcare workers. For instance, the number of practising nurses has grown by 3.3% per annum in the past five years. In comparison, Singapore's total employment grew by 1.1% per annum over the same period.

With the expansion of services, we could see up to around 6,000 additional jobs in the healthcare sector in the next two years. This is on top of hiring to replace attrition. We will continue our efforts to attract and recruit Singaporeans to build a strong local core in our workforce.

However, with shrinking birth cohorts, the labour market will become much tighter in the decade beyond 2020. To meet our growing manpower needs, we must rethink our current approach and find creative ways to attract and retain people in the sector, particularly in the growing community care sector.

First, we need to diversify our hiring sources. Besides attracting fresh graduates, we will continue our efforts to bring mid-careerists into healthcare. Mid-careerists play a valuable role as they bring with them unique expertise and fresh perspectives from their previous careers. In the last two years, about 2,000 local mid-career PMETs transited into the healthcare sector, and about one-third of them are mature workers aged 40 and above.

Besides healthcare staff, there are many administrative positions available in the healthcare sector too. Take, for example, Ms Noraini, who joined Ren Ci Hospital after spending more than 20 years as a special needs educator and then as a business executive. Ms Noraini's experience placed her in good stead for her role as a resident care manager in Ren Ci Hospital.

Nevertheless, to support her transition into the community care sector, Ren Ci Hospital placed Ms Noraini under the Senior Management Associate Scheme (SMAS). When she completes her induction programme this year, Ms Noraini can continue to attend leadership programmes to support her development.

Second, we must invest in our people, especially in the community care sector, to enable the shift of care beyond hospital to community.

To support the attraction and retention of manpower in this sector, MOH previously funded a total of $350 million between 2012 and 2017 to community care institutions to raise salaries for their staff. Around 90% of MOH-funded institutions participated in this exercise.

Over the next three years, MOH will set aside another $150 million to support community care institutions to further improve the competitiveness of salaries. We project that this will benefit up to 4,000 local nurses and support care staff, if it is fully taken up. After these three years, MOH will factor in the higher salary levels in our funding to community care providers.

We strongly encourage employers to take the opportunity to enhance salaries of nurses and support care staff and continue to improve career prospects of our care staff in the community.

We are also eager to bring non-practising nurses back to our healthcare family. Over the past four years, about 500 local nurses have returned to practice annually. Returning nurses may undergo a refresher course under the Return to Nursing scheme, and those who return to the community care sector are eligible for a retention bonus of up to $5,000. In response to Mr Melvin Yong, MOH has been actively working with the union and employers on the retention and development of our healthcare workforce.

I also echo Ms Joan Pereira and Mr Christopher de Souza's call to continue supporting professional growth and development for nurses and allied health professionals.

Last year, we launched the Skills Frameworks for allied health workers and medical social workers, just to name a few. This year, I am pleased to launch the Community Nursing Competency Framework, which can be used by community nurses and employers as a guide to identify skills gaps and pursue development opportunities.

From this year onwards, fresh school leavers and in-service staff may apply for the new Community Care Scholarship to take up programmes relevant for the community care sector, such as in the disciplines of Occupational Therapy and Social Work.

Besides training, we must also create opportunities for our healthcare workers to take on leadership positions in the sector.

Nurses, in particular, play a leading role in care delivery in the community care sector and we must nurture those with strong clinical skills and leadership potential.

Let me share the story of Assoc Prof Edward Poon. He started as a staff nurse at Singapore General Hospital (SGH) before joining the community care sector early in his career. Over time, he took on various leadership positions and he is now Director of Nursing at St Luke's Eldercare (SLEC).

Assoc Prof Poon's impact extends beyond SLEC. In addition to upholding and maintaining the quality of care at SLEC, he also conducts training for the sector and collaborates with public hospitals on geriatric research.

We hope there will be more budding professionals who will go on to take on nursing leadership roles in the community care sector, just like Assoc Prof Poon. Hence, we will be introducing a new Community Care Nursing Leadership Programme this year, to groom the next generation of nursing leaders for the sector. Regardless of their current place of practice, all experienced Registered Nurses who want to take on leadership roles in the community care sector are welcome to apply.

The programme will provide nurses with opportunities in clinical training, leadership development, attachments and mentorship.

Lastly, all of us must find ways to eliminate unnecessary workload and adopt best practices to work smarter. This would include process and role redesign as pointed out by Ms Irene Quay.

Collaborative prescribing is one example. Since 2019, 34 advanced practice nurses and 31 clinical pharmacists in 11 healthcare institutions have been trained and empowered to prescribe drugs to their patients. We hope more institutions and professionals will come on board in the near future.

In response to Ms Irene Quay, employers may already choose to go beyond the minimum provisions in the Employment Act to accept medical certificates or time chits issued by allied health professionals.

In respond to Mr Faisal Manap, the regulatory scope of the new Healthcare Services Act (HCSA) includes traditional and complementary medicine services. MOH will monitor the prevalence of use and risks to patient safety, before considering whether to license these services under HCSA. Nonetheless, traditional and complementary medicine practitioners are already subject to relevant provisions under the Medicines Act and the Sales of Drugs Act, just to name a few.

Chairman, even as we face shrinking birth cohorts, we are also presented with the gift of longer health-adjusted life expectancy, which we can capitalise. Singaporeans are living longer and healthier and we should allow them to continue contributing, if they wish to.

This is a win-win scenario for both employers and employees. In 2019, around 99% of public healthcare workers aged 62 and beyond were offered re-employment and 95% of them accepted the offer.

To support our mature healthcare workers who are able and willing to continue working, MOH has worked with the Healthcare Services Employees' Union and public healthcare institutions to raise the retirement age to 63, and re-employment age to 68 from July 2021 onwards – one year ahead of the national schedule. Those who wish to retire or stop working at 62 may still do so whilst those who want to keep working now have the choice to work even longer.

In closing, it is our unending pursuit to find ways for each of us to age healthier, happier and in a fulfilling manner. I want to urge all Singaporeans – young and old – to help us achieve this.

The Chairman: Ms Irene Quay.

Antimicrobial Resistance

Ms Irene Quay Siew Ching: Mr Chairman, I refer to the nationwide curbing of antimicrobial resistance (AMR), an issue which I have also spoken on before on the need for us to curb AMR through legislative changes.

AMR is a major global threat that persists and will continue to worsen if left unchecked. I do not speak this lightly, but the potential fatal consequences of AMR will surpass that of SARS, H1N1, Ebola, MERs-CoV and COVID-19 combined.

A quote from England Chief Medical Officer, Dr Dame Sally Davies, "The threat of antibiotic resistance is as great as that from climate change." This imminent danger is a result of antibiotic overuse, misuse and the lack of regulation.

A local study reporting a 10-year review of AMR in Singapore noted a marked difference in the community rectal carriage of ESBL-producing Enterobacteriaceae, that is, 6.3% in 2006 versus 26% in 2016 between two dissimilar surveys, appearing to signify an increasing trend despite the differences in methodology.

It is therefore with all urgency that I ask if MOH has any data to share on antibiotic usage in the community?

I understand that the antimicrobial stewardship programme has been well established in our public institutions. May I ask if MOH has considered funding for such antimicrobial surveillance programme in the community, where the majority of our primary healthcare is provided by private practices?

I would also like to request for an update on the progress of the National Strategic Action Plan on AMR.

2.45 pm

Prevention and Early Detection of Diseases

Dr Lily Neo: Mr Chairman, I want to start by commending MOH as well as other Ministries in their efforts in tackling COVID-19 and limiting its spread, that has impressed WHO.

Healthcare workers' calling and dedication are at the greatest committal situation presently; knowing that while looking after the sick, there is possibility that they and their family members may also get sick as a result of COVID-19. May I also encourage all our healthcare workers in both the public and private sectors, especially those in the frontline, to keep up their good work and keep their spirits high. May I also thank all other frontline workers that help us in limiting the transmission of COVID-19.

I hope MOH will spare no effort in sharpening its future preparedness by enhancing this episode’s good practices and registering and correcting its shortfall. There may be areas that need attention, such as being self sufficient with locally manufactured preventive and protective items, for example masks, and enhancing our health scientist sector capability to fight viruses.

Adherence to a healthy lifestyle is associated with a lower risk of mortality. It reduces the risk of chronic diseases such as type-2 diabetes, hypertension, hyperlipidaemia and disability. May I ask MOH if there are new initiatives to assist more Singaporeans to achieve healthy living?

Diabetes and hypertension can cause heart disease, renal failure and so on. Compliance on diet and medication are key factors on the outcome on war on diabetes. Can MOH promote and motivate more healthcare providers and patients themselves to achieve it?

A local study found that the proportion of older adults with three or more chronic diseases nearly doubled from 2009 to 2017. If diabetes and hypertension are detected earlier, there will be lesser morbidity and disability amongst the seniors. All senior care centers can be tasked to assist detecting and maintaining good control for these two chronic conditions.

Breast cancer remains the most frequent cancer among women in Singapore, and approximately 6% of all women will be diagnosed with invasive disease in their lifetime. The underlying premise for breast cancer screening is that it allows for the detection of breast cancers before they become palpable. Small tumors are more likely to be early stage disease, having better prognosis, and are more successfully treated.

May I ask MOH on the percentage of women screened yearly and the percentage in detecting smaller treatable breast cancers? And how to improve its take-up rate?

Colorectal cancer is now the commonest cancer in Singapore. The average population risk for developing colorectal cancer in Singapore is among the highest in the world. Most colorectal cancers develop from adenomatous polyps, thus its early detection and removal reduces the risk of colorectal cancer. Pre-malignant period of the adenoma-carcinoma sequence makes it ideal to screen for colorectal cancer and such screening has been proven to save lives. Will Minister consider subsidised colonoscopy screening, as it is more accurate and is also preventive in nature by removing polyps early, compared to present occult blood testing?

Cervical cancer is the sixth most common cancer among Singapore women. The human papillomavirus (HPV) is the causative agent of essentially all cervical cancer cases. Because of this fact, and the fact that there are HPV vaccines that protect against infection with HPV, some countries like Holland and Australia are adopting a HPV DNA assays as primary screening methodology for cervical cancer prevention. Will MOH adopt the same strategy for better cervical cancer prevention?

Stomach Cancer is the seventh most common cancer in men and the ninth in women here. Every year stomach cancer takes more than 300 lives in Singapore. Chronic infection with Helicobacter Pylori (H. Pylori), a bacterium that lives in the mucous lining of the stomach, may increase the risk for stomach cancer. H Pylori infection is a common infection in Singapore affecting about 31% of the population, and infection increases to 71% in adults above 65 years. H Pylori is an important pathogen that can be treated with antibiotics and should be eradicated if detected.

A recently published report of a working group of the International Agency for Research on Cancer (IARC) of the WHO concluded that-randomised clinical trials have found that H pylori treatment is effective in preventing gastric cancer, and models indicate that H pylori screening and treatment strategies would be cost-effective. Will MOH raise the awareness on this finding and look into the feasibility of population based screening and prevention of stomach cancer?

Adult Vaccinations

Mr Leon Perera (Non-Constituency Member): Mr Chairman, Sir, based on the reply to my Parliamentary Question (PQ) last month, after the launch of the National Adult Immunisation Schedule in 2017, the take-up rate for adult vaccination rose, but is still way below that of some other developed countries. For example, for flu vaccines among seniors, our take-up rate may be around 24% versus 70% in the UK, US and Australia.

Can we do more to promote adult vaccination? For example, the Government works with employers to conduct health screenings, can those same platforms, events and working relationships be used to offer on-the-spot vaccinations to workers and companies?

Can we also do more to nudge GPs to display material in their clinics that prompts patients to ask for vaccinations. Of course, price is always a consideration, as many would want to conserve their MediSave for other future needs. I would repeat my call made in Parliament for the level of subsidy given for adult vaccines to take into consideration the downstream fiscal cost savings to the state from fewer diseases as a result of vaccines.

Finally, our child vaccination coverage for measles, for example, is high at around 95%. But in 2019 there were 152 measles cases, which was the highest number of cases since 1997. MOH figures also showed that there were several hundred cases of mumps every year since 2012.

In response to a PQ about measures to prevent measles outbreaks, the Minister for Health opined that passivity could explain most of the cases of children not being vaccinated.

However, the growth of anti-vaccination beliefs worldwide should not be under-estimated. I would like to ask for an update on what measures MOH is planning to reduce the numbers of children not receiving these essential vaccinations.

Do all childcare centres require vaccinations certificates before enrollment? Can we do more, for example, working with pre-school centres and private enrichment programme centres to flag out cases of non-vaccinated children?

Health Promotion and Preventive Health

Mr Charles Chong (Punggol East): Mr Chairman, in October last year, MOH announced new measures which would affect the marketing of high sugar drinks. Now, I applaud this move, as consumption and availability of highly sugared drinks continue to be a great impediment on our war on diabetes. In announcing the new measures, MOH said that more details about the measures affecting highly sugared drinks would be released in 2020. I would, therefore, like to ask the Minister if MOH has crystallised its policy on highly sugared drinks and if he can provide an update on this?

Sir, on smoking, I would like to ask the Minister about measures which are available to assist persons to quit smoking. Smoking's popularity has been in decline, as more people understand the health risks associated with smoking. I hope we can do more to discourage people from smoking and even more to encourage smokers to quit. Could the Minister provide us an update on the measures which have been put in place to assist smokers to quit and how successful has this been?

In 2018, the Senior Parliamentary Secretary for Health said that MOH was aiming to bring the smoking rate to below 10% by 2020 – this year. Could the Minister provide an update on how successful we have been at reducing the smoking rate?

And finally, Mr Chairman, I would like to ask the Minister about what we can do or what has been done to encourage Singaporeans to take preventive measures for the sake of their health such as getting regular health screenings done and having vaccinations performed when they are needed. Could the Minister let us know how successful MOH's "Screen for Life" programmes have been and how many Singaporeans have taken advantage of the subsidised screening under under the programme? Are there any plans to expand "Screen for Life" to beyond what they really are, just basic level tests?

Curbs on High-sugar Products

Mr Leon Perera: Sir, the Government has introduced mandatory front-of-pack nutrition labels for less healthy pre-packaged sugar-sweetened beverages (SSBs), and advertising bans for the least healthy SSBs on local mass media channels. More than 30 countries have introduced such labels. In Chile, the sales of drinks with the unhealthy labels fell by 25% after one-and-a-half years. However, with the daily sugar intake of Singaporeans more than double that of the level recommended by the World Health Organization, could we go farther?

Could MOH consider reviewing the results of these moves and if these are not effective consider adopting to some degree and in a tiered and calibrated fashion the measures that have been adopted for tobacco products, such as more graphic warning labels and packaging?

A study by researchers at Harvard in 2018 suggested that graphic warning labels on sugary drinks reduced purchases more than text-based labels.

Research funded by the UK's Department of Health also suggests that removing products from choice locations within a retail outlet – for example, at the check-out counter where impulse buying is common – can reduce sales. While product placement is negotiated in contractual agreement between the sellers and the retailers, it may be necessary to explore nudging retailers to move in this direction in time though, of course, not without industry consultation and piloting.

Industry buy-in for such moves may be facilitated by the fact that many of the firms producing high sugar food and beverage products are gradually seeking to shift revenue share to healthier products over time, as they see the writing on the wall globally.

The Chairman: Senior Minister of State Dr Lam Pin Min.

The Senior Minister of State for Health (Dr Lam Pin Min): Mr Chairman, for Singaporeans to continue to have good access to quality and affordable healthcare, we must press on to transform our healthcare system in the long-run, even as we face threats like COVID-19.

With Singaporeans living longer, primary care plays increasingly crucial roles in maintaining one’s health throughout their lives. Our Vision, “One Singaporean, One Family Doctor”, remains relevant while we provide all Singaporeans with affordable and quality care, near their homes. Mr Chairman, may I display some slides, please.

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

Dr Lam Pin Min: I announced in 2018 that our network of polyclinics will be expanded to 30-32 polyclinics by 2030, from 20 today. Since then, we have announced 10 new polyclinics, six of which will open by 2023.

In response to Mr Chong Kee Hiong's feedback for a polyclinic in Bishan, as well as Mr Sitoh Yih Pin’s suggestion to build one in Bidadari, I am glad to say that your prayers have been answered. We will be developing a polyclinic in each of these areas by 2030. With Bishan and Bidadari polyclinics, we will achieve our target of having 32 polyclinics by 2030.

To Dr Chia Shi-Liu's query, the new polyclinics will offer similar services as existing ones, including medical treatment for acute conditions, chronic disease management, women’s and children’s health services, and radiological, laboratory and pharmacy services.

Dr Chia also asked about our primary care transformation journey. This involves promoting a regular family doctor, which is important for continuity of care, especially for patients with chronic diseases who need long-term follow-up.

To work towards this goal, we shared last year that polyclinics are scaling up team-based care, where patients with chronic diseases see a regular care team.

We are not far from achieving this goal in the private primary care sector too – two-thirds of Community Health Assist Scheme (CHAS) cardholders with chronic diseases have a regular doctor. This demonstrates how integral private sector General Practitioners (GPs) are to our primary care transformation efforts, which brings me to Mr Chong’s and Dr Chia's queries about support for GPs in providing better and more holistic care.

Besides supporting them in their professional development, I will share more later, we have been partnering them to anchor and provide holistic chronic disease management through the Primary Care Networks (PCNs). Similar to polyclinics, PCNs are embracing team-based care.

Thanks to their support, we are on track to have at least half of CHAS GP clinics participating in the PCN by end 2020. More than 500 PCN GP clinic partners are caring for over 100,000 patients with chronic conditions, up from about 70,000 last year.

One of these patients is Mdm Lam. She was diagnosed to have diabetes and hypertension in 2007 and started visiting Jurong polyclinic to manage her chronic conditions. In 2015, she switched to Frontier Family Medicine Clinic (FMC) as she wanted to have one regular doctor to help manage her medical conditions holistically. She has also enjoyed having Frontier FMC closer to her home.

Since then, she has been regularly consulting Dr Thia, whom she is now very comfortable with and who is familiar with her medical conditions. With Frontier FMC joining the PCN in 2018, Mdm Lam also benefited from team-based care, including nurse counselling, and diabetic foot and eye screening. Now, Mdm Lam does not have to run around for multiple appointments as the PCN clinic coordinator ensures her screenings are done conveniently at the clinic on the same day as her consultation with Dr Thia. She is grateful her care team has helped her understand her medical conditions better, and that has helped her improve and keep her medical conditions in check

3.00 pm

With the continued expansion of the PCN, more patients like Mdm Lam will benefit from this scheme.

Like chronic diseases, early detection and management of cancer can make a world of difference in health outcomes. We would like to thank Dr Lily Neo for her suggestions to improve screening and follow-up.

The screening rate for breast cancer is about 39% and the rate of late-stage breast cancer diagnosis has remained around 28% between 2008 and 2017. There is therefore room for improvement. Oftentimes, all that is needed is a change in mindset. Misconceptions and fears are common barriers – thinking that screening is not necessary when one feels healthy, that "it is better not to know", and that mammograms are painful, are just some of the examples.

To counter these, the Health Promotion Board (HPB) holds annual breast cancer awareness campaigns, conducts on-the-ground activities and uses social media to expand their reach. They will continue to work with partners to encourage more women to go for screening regularly.

To enhance the take-up rate, breast cancer screening must also be made accessible and affordable. In this regard, the Singapore Cancer Society (SCS), Breast Cancer Foundation (BCF) and the National Healthcare Group Diagnostics (NHGD) introduced the Community Mammobus programme, where the first mammogram is free of charge and subsequent ones are $10 for Singaporeans. About 9,300 individuals have benefited from this programme since its launch in 2018.

Mr Charles Chong asked whether there are plans to expand Screen for Life to include additional tests, and Dr Lily Neo also suggested alternative screening tests for selected cancers such as colorectal cancer and also mentioned about the Helicobacter pylori (H. pylori) test for stomach cancer. MOH and HPB refer to the Screening Test Review Committee's (STRC) recommendations in deciding which screening tests to provide at a population level. These are based on robust scientific evidence to ensure that they are safe, effective, suitable and cost-effective.

On colorectal cancer, both the Faecal Immunochemical Test (FIT) and the screening colonoscopy are recommended for population-level screening. However, the screening colonoscopy has risks due to its invasive nature. Conversely, the FIT kit can be safely and conveniently administered by the individual at home.

Under Screen for Life, subsidised FIT is available at all CHAS GP clinics and those who test positive are referred for subsidised diagnostic colonoscopies. Screening colonoscopies are still available at Public sector hospitals and are MediSave-claimable should one choose to go for them instead.

On cervical cancer, HPV-DNA testing for women aged 30 to 69 was introduced in mid-2019, following STRC's recommendation due to its higher sensitivity and lower frequency required, compared to the Pap smear.

MOH and our partners will keep on striving to encourage more Singaporeans to go for early screening and follow-up, and update our strategies when new evidence arises.

Mental well-being continues to be a top concern based on recent engagements with youths, which highlights the need to do more. Mr Melvin Yong and Dr Lily Neo, amongst many others, have recognised this and have asked how we can improve youth mental health services and make them more accessible.

Minister Indranee Rajah has announced MOE's efforts to further support student well-being through mental health education and peer support cultures in schools. Complementing MOE's efforts, we announced last year that we will work with the Institute of Mental Health (IMH), the Agency for Integrated Care (AIC) and our community partner, Care Corner, to develop an Integrated Youth Service (IYS), where youths at risk can access coordinated mental health and social support services in the community.

I am glad to update that the Integrated Youth Service will be starting in Woodlands this year. Care Corner will reach out to youths at risk and raise awareness on mental well-being and resilience. They will also provide individualised emotional support, needs identification and peer support services, and refer those who require further intervention to appropriate health and social services.

Moving forward, we will continue to take a whole-of-society approach and work with other Ministries to address youth mental health needs. This includes MOE, MSF, MCCY, including their National Youth Council (NYC), on the recently announced Youth Mental Well-being Network.

As mentioned by Minister Gan, we must continue to move beyond quality to value. He shared that about 50% of the rise in healthcare costs is due to higher utilisation and another 15% partly due to increases in costs of drugs and medical devices. We are therefore employing a suite of strategies to increase value and lower costs so that all Singaporeans can access care without experiencing financial hardship. Let me elaborate.

One of these strategies is the introduction of surgeon fee benchmarks for common surgical procedures in the private sector last year. Anyone, including doctors, patients and payers, can refer to them on the MOH website. I am glad to share that since its publication, surgical fees have generally converged, with the majority falling within range and more than 80% below the upper limit. We also saw a slight reduction in the average fees.

Our work does not stop here. We will keep monitoring the charges, seek feedback from stakeholders, and review the benchmarks with the Fee Benchmarks Advisory Committee (FBAC), so that they remain relevant and effective.

Building on this, the committee is studying expansion to surgical fees for less common procedures, doctors' inpatient consultation fees and other fee components like anaesthetist's fees, and plans to submit its recommendations later this year. With these efforts, all of us will be able to make more informed decisions and benefit from greater transparency of fees.

We have also implemented measures to reduce drug costs, including switching to generic drugs where possible. Generic drugs or biosimilars are medicines which are clinically equivalent to branded or originator drugs and typically cost much less. If used appropriately, both patients and our healthcare system can benefit from enormous cost savings without compromising safety and quality of care.

To encourage Public healthcare institutions to use more of such drugs, MOH works with the National Pharmacy and Therapeutics (NPT) Committee every year to select a basket of drugs which can be switched, and reviews their utilisation annually. In 2018, the usage of generics in the basket increased to more than 90% by volume. We will continue to work with the committee and Public healthcare institutions to increase uptake and therefore cost savings.

We have also set up the Agency for Logistics Procurement and Supply (ALPS) in July 2018 to pool together supply chain functions and resources across our three healthcare clusters to achieve greater economies of scale. With ALPS, 85% of drugs used in clusters were purchased on national group contracts in 2018. Today, this proportion has increased to 95%, resulting in clusters saving at least 5% in drug costs, benefiting our patients in turn. For example, the cost of drugs for epilepsy was reduced by up to 85%.

Building on these efforts, ALPS will work with relevant agencies to encourage greater entry of generics and new sources of drugs in Singapore and launch different approaches in strategic sourcing and procurement to keep drug prices competitive.

We must not only reduce costs, but ensure that our limited resources are spent on care that is of value.

The Agency for Care Effectiveness (ACE) conducts health technology assessments (HTA) to facilitate clinically-effective and cost-effective care, and negotiates with manufacturers to attain fair prices for selected health technologies. Their work has improved access and affordability for over 50,000 patients. Of note, they managed to cut down the prices of medicines such as those for Hepatitis C by more than half.

ACE is on track to deliver savings of $75 million over five years, and will work on benefiting even more Singaporeans.

MOH also introduced the Value-Driven Care (VDC) programme to deliver good health outcomes in a value-conscious manner. We are extracting value for the 17 high-volume, high-cost and therefore, high-impact conditions under this programme.

Since May last year, we have been sharing data across providers to identify areas of improvement and facilitate sharing of best practices. As we are still at early stages, we will continue to monitor the programme's impact. At the same time, we are expanding our scope by identifying additional conditions and increasing the period of analysis.

MOH and healthcare providers will work together on these on-going efforts to contain costs and ensure that all Singaporeans can access quality care. As individuals, we can also play our part too, by discussing with our healthcare providers on appropriate treatments for our conditions, and financial support available, if needed.

MOH is committed to supporting the development of healthcare professionals. Today, ACE publishes Appropriate Care Guides (ACGs) to help healthcare professionals optimise patient outcomes. To support them further, ACE will be launching a national educational visiting service known as ACE Clinical Update Service (ACE CUES) in the second half of this year.

While educational visiting may be a new term to many of the Members here, it has been made available in a number of countries, including Australia, US, Canada and Norway, and is shown in many studies to improve patient care and outcomes. Through educational visiting, best available evidence and information materials on patient care are brought to healthcare professionals at their workplace, where one-to-one, focused and customised discussions are held at their convenience.

A range of clinical topics will be covered over time, the first being asthma, which affects many people of all ages, most of which are being managed in primary care settings by GPs. As there have been recent major developments in asthma treatment, it is timely for ACE CUES to bring these updates to GPs nationwide to benefit their patients, starting with those in the PCNs.

Dr Chia Shi-Lu asked for an update on integrated personalised medicine into our healthcare eco-system.

In Singapore, healthcare demands are changing fundamentally, driven by a rapidly ageing population and increased chronic disease prevalence. MOH is examining ways to be future-ready to ensure that healthcare delivery evolves to address these demands and adopts innovative approaches to transform healthcare while mitigating costs.

Precision medicine is one such promising area. Work on the national strategy for precision medicine research and implementation has been on-going. It aims to accelerate health research and develop peaks of research excellence for Singapore, and, ultimately, to improve health by identifying clinical applications that are cost-effective, sustainable and relevant.

The official launch of the precision medicine strategy and research programme is currently planned for the third or fourth quarter of this year, and more details will be made available later.

Let me come to antimicrobial resistance (AMR). Ms Irene Quay asked for an update on the National Strategic Action Plan (NSAP) on antimicrobial resistance and the measures MOH is taking to optimise antibiotic use and enhance surveillance.

Following the launch of the action plan in 2017, we set up the Antimicrobial Resistance Coordinating Office (AMRCO) under the National Centre for Infectious Diseases (NCID) to oversee its implementation. To enhance surveillance, AMRCO is extending AMR surveillance and tracking of antimicrobial utilisation, already in place for public hospitals, to private hospitals and primary care. Guidelines for healthcare professionals on the management of infections and antimicrobial use are also being developed.

In addition, AMRCO, together with MOH and partner agencies such as the Singapore Food Agency (SFA), National Parks Board (NParks), NEA and PUB, is examining an integrated approach to surveillance.

As a first step, the First Joint Report of Antimicrobial Utilisation and Resistance in Singapore will be published this year. Singapore also enrolled in WHO's Global AMR Surveillance System (GLASS) to contribute surveillance data and learn from other countries' experiences.

3.15 pm

All of us have a role to play in preventing antimicrobials resistance too by using antimicrobials appropriately. HPB will continue its "Use Antibiotics Right" public education campaign to address common misperceptions, increase awareness and encourage patients to discuss appropriate antibiotic use with their doctors.

We generally take a collaborative approach for public health programmes. We have benefited from close cooperation with the public and our stakeholders, and will continue to work together to improve public health for all. While much has already been done, our healthcare transformation journey does not end here.

As we continue to move beyond Healthcare to Health, beyond Hospital to Community and beyond Quality to Value, we need to keep in mind that success goes beyond having the right policies in place – the backing and invaluable cooperation and contributions of healthcare providers and citizens are paramount. With that said, let’s continue to work towards achieving our shared goal of accessible, affordable and quality care for all, so that we can remain a healthy nation for generations to come.

The Chairman: Mr Gan Thiam Poh.

Prevention of Diabetes

Mr Gan Thiam Poh (Ang Mo Kio): Chairman, while all of us are preoccupied with COVID-19, it is important for us not to forget about another health risk – diabetes. Diabetes can lead to health complications such as kidney failure, heart attack and stroke. One in nine Singaporean adults were affected by diabetes in 2010. As our population ages, the prevalence of this disease will increase as the risk increases with age. Rising obesity also contributes to the prevalence of diabetes in our population.

Unfortunately, Singaporeans face many sugary temptations in their food and beverage choices daily. We may be able to resist snacks and so on, but most people will get a couple of drinks in the course of the day which are often loaded with sugar. These include coffees, teas, soft drinks and even purportedly healthy beverages such as freshly squeezed juices and herbal drinks. Will the Ministry share an update on the measures to control sugar-sweetened beverage consumption?

Health of Low-income Singaporeans

The Senior Parliamentary Secretary for the Ministers for Culture, Community and Youth and Transport (Mr Baey Yam Keng): Mr Chairman, good health is not something we can buy, nor can it be taken away by people. One golden rule to good health is regular exercise, which can be free of charge, for example running. The other is a balanced diet. Food is not free, but the best and healthiest choice is home-cooked food. Buying fresh produce and cooking at home is generally cheaper than eating out.

I have come across low-income families who do not cook. One common reason is lack of time, because some have more than one jobs to make ends meet. I especially worry for their kids who might resort to convenience food like instant noodles, which offer little nutrition. I have also met some seniors who live by themselves in rental flats. It is too much of a hassle for them to cook for themselves or he could be a widower who does not cook.

So, I would like MOH to share if it has done some studies on this issue and how it plans to help low-income Singaporeans.

The Chairman: Assoc Prof Dr Muhammad Faishal Ibrahim. Take your two cuts together.

Prevention Better than Cure

The Senior Parliamentary Secretary to the Ministers for Education and Minister for Social and Family Development (Assoc Prof Dr Muhammad Faishal Ibrahim): The phrase "prevention is better than cure" is often used to encourage people to adopt preventive health measures in their lives. I commend the Health Promotion Board and other stakeholders who have passionately and persistently engaged Singaporeans to take on preventive health measures at the community and national levels.

As we move forward, I would like to ask how will MOH encourage Singaporeans across all ages to take on preventive health measures, such as doing timely health screening, vaccination and quit smoking?

Support to Community Providers

Healthcare is not one size-fits-all, and often community providers are best able to customise services to fit the needs of local populations or vernacular groups.

Over the years, we have seen many community providers coming forward to play a part and contribute towards a healthier Singapore. These community providers have helped to empower Singaporeans to lead a more active lifestyle and taking ownership of their health.

As good health and active lifestyle are expected to continue to be an important national agenda, I would like to know how the Ministry is supporting these community providers, especially during this COVID-19 period?

Community Care Providers

Mr Charles Chong: Mr Chairman, the speaker before has already said all the things that I wanted to say. So, I shall not repeat them, other than to say that I support what Assoc Prof Dr Faishal Ibrahim has said. [Laughter.]

The Chairman: Senior Minister of State Edwin Tong.

The Senior Minister of State for Health (Mr Edwin Tong Chun Fai): Mr Chairman, as the Minister for Health has shared, we have delivered on our Healthcare 2020 objectives, including having Minister Gan remain as the Health Minister till now.

Today, Singaporeans live longer, healthier lives than when we made these goals in 2012. We enjoy some of the best healthcare in the world, and this remains affordable and also accessible to all. But the future will bring new challenges, and we cannot afford to rest on our laurels. It will take bold steps – from Government and the community in partnership – to ensure that we can continue keeping these commitments to our citizens.

Our healthcare financing system has weathered the test of time. Each financing scheme plays a unique role in ensuring that no Singaporean will be denied appropriate care because of an inability to pay.

First, Singaporeans enjoy means-tested subsidies across public healthcare settings, covering up to 80% of the costs of treatment. Singaporeans are also covered by MediShield Life for large hospitalisation bills and costly outpatient treatments. Coverage starts from the moment one is born, and is for life. Next, MediSave helps Singaporeans set aside some income towards future healthcare needs. It can be used to offset out-of-pocket expenses and also pay for health insurance premiums. Finally, MediFund provides a safety net for those facing financial difficulty.

This framework has worked well for us. Seven in 10 subsidised hospitalisations by Singaporeans do not incur any out-of-pocket expenses or payment, while eight in 10 incur payments of less than $100. Still, we regularly review each pillar of healthcare financing to give Singaporeans peace of mind in seeking the care they need.

As our population ages, we can expect more Singaporeans to face chronic conditions. Ms Tin Pei Ling asked how we are supporting chronic disease patients, and Dr Chia Shi-Lu asked specifically about what we can do to encourage them to seek early intervention in the community.

In June 2018, we raised MediSave withdrawal limits for conditions under the Chronic Disease Management Programme or CDMP, from $400 to $500. We also expanded CDMP to cover ischaemic heart disease and pre-diabetes. Today, CDMP covers 20 conditions, including four mental health conditions: schizophrenia, major depression, bipolar disorder and anxiety. We regularly review the list of CDMP conditions in consultation with clinical experts, and will include conditions such as eczema in our review.

Last November, we introduced higher subsidies for complex chronic conditions for CHAS Blue and CHAS Orange card-holders, and also expanded CHAS Orange to cover common illnesses. We also launched the CHAS Green card – part of a wider initiative to shift healthcare beyond hospitals and into the community. All Singaporeans are now eligible for subsidised CDMP treatments at CHAS GP clinics, regardless of income levels. This represents a fundamental shift in primary care financing, with universal subsidies for GP treatment.

Ms Irene Quay asked for an update on the success of these measures. Let me just outline the broad parameters with reference to a few facts. I am happy to share that around 200,000 Singaporeans received their CHAS Green cards in 2019, entitling them to the programme that I have just outlined a moment ago. Altogether, 1.7 million Singaporeans have received their CHAS cards, seven times more than when CHAS was first launched in 2012.

With our continuing efforts to bring more clinics onto the scheme, CHAS card-holders can now receive subsidised treatment at close to 2,000 GP and dental clinics island-wide. In 2019, we disbursed more than $160 million in CHAS subsidies, significantly alleviating the cost of outpatient treatments for Singaporeans.

This year, we will be further expanding the use of MediSave for CDMP treatments in outpatient settings. Currently, Singaporeans can tap on the MediSave500 scheme for CDMP treatments, for approved vaccinations and screenings. From 2021, we will increase support for patients with complex chronic conditions by raising their annual withdrawal limit from $500 to $700. Patients with complex chronic conditions include those who have visits for two or more CDMP conditions, or one CDMP condition with complications, within a year. This is aligned with the higher CHAS subsidies we implemented for complex chronic patients in November. In effect, rather than MediSave500, these patients will in fact benefit from an extension of the scheme, or MediSave700.

Administratively, we will align MediSave500 with all other MediSave schemes, shifting from a per-account to a per-patient limit. Overall, we expect more than 176,000 patients to benefit from the enhanced MediSave700 scheme.

Ms Tin Pei Ling asked us to consider greater flexibility in the MediSave withdrawal limits, especially for seniors with significant balances. I believe Mr Pritam Singh also raised the same issue. We have been working to increase flexibility under MediSave in a few key areas. Let me outline them.

First, covering new treatments and services. We are expanding MediSave to cover severe disability under the upcoming MediSave for Long-Term Care scheme. With cash withdrawals, patients will also have greater flexibility to choose appropriate care options, relevant for themselves and their particular circumstances. Second, increasing flexibility within existing schemes. So, first we cover new schemes and new treatments, and second, we look at increasing flexibility within the scheme itself. One example is lowering the age threshold for Flexi-MediSave in 2018 from 65 to 60. Another example is the MediSave700 scheme I have just outlined. The higher withdrawal limits increase flexibility for patients with complex chronic conditions, as they are likely to incur higher costs for their CDMP treatments.

Overall, these enhancements are designed to strike a balance, as we have to continue to do, between current medical expenses and of course, future healthcare needs down the road. We will continue to take on board the suggestions, review our MediSave withdrawal limits in light of our overall financing framework, to introduce greater flexibility where possible, and to ensure that they are adequate for the majority of patients in subsidised settings.

Dr Chia Shi-Lu asked how we can plan to keep healthcare affordable for elderly Singaporeans. The three pillars of our long-term care financing framework – CareShield Life, MediSave Withdrawals for Long-Term Care, and ElderFund – mirror the "3M" schemes that we have for acute care, and that has worked well for us. They complement existing subsidies of up to 80% for long-term care services, such as day care and home care.

The first two pillars represent significant changes. CareShield Life provides better protection for severely disabled policyholders with lifetime payouts. MediSave Withdrawals for Long-Term Care, or MediSave Care for short, will allow Singaporeans to withdraw directly from their MediSave in cash, providing flexibility for long-term care expenses. Both schemes will be launched later this year.

Assoc Prof Daniel Goh asked how we are supporting families who might fall outside of the subsidy thresholds. So, we have those within the framework, that I have just outlined. What happens to those who might fall outside the subsidy thresholds? First, let me clarify that the current income criterion of $2,800 for long-term care subsidies covers close to two-thirds of resident households in Singapore. The median household income per member quoted by Assoc Prof Goh includes the employer CPF contributions, which we exclude in assessing the eligibility for subsidies.

The figure is also based on all employed households, and does not consider households with no working persons. Elderly households, or households with elderly members, tend to have a lower income per household member. Hence, a larger proportion of such households will qualify for subsidies, with many qualifying for the maximum rate of subsidies.

Together with CareShield Life and other schemes highlighted by Assoc Prof Goh, most Singaporeans will be adequately covered for basic long-term care needs. In addition, as I mentioned to the House last year, we will allow private insurers to introduce additional severe disability coverage on top of CareShield Life, with premiums payable from MediSave.

3.30 pm

The third pillar is ElderFund, a safety net for lower income and severely disabled Singaporeans. It supports those who are unable to benefit from schemes like ElderShield with monthly cash payouts, and opened for applications on 31 January.

Mr Faisal Manap asked if patients with physical impairments can obtain support from MediFund for transportation costs. This is an area where new measures complement the existing schemes to provide multiple layers of support. We provide means-tested subsidies of up to 80% for patients requiring transport for centre-based services, dialysis or medical appointments at polyclinics and also at SOCs. Patients who need additional assistance may tap on cash payouts under ElderFund or other schemes, to defray the costs of travel to and from medical appointments. So, we look at the overall framework and these are the schemes that sit outside that supplement and work with the existing framework.

Financial concerns represent only some of the challenges that Singaporeans face when loved ones encounter disease or disability. Beyond being able to afford care, we want Singaporeans to feel supported in caring for each other as well.

Ms Yip Pin Xiu has asked about our long-term plans for eldercare. Over the years, we have improved the accessibility of aged care services and also deepened the range of services and options available in the community and residential care settings.

Last year, for instance, we launched the Care-giver Support Action Plan to support those caring for seniors on their care-giving journeys. Since then, we have been working with the Agency for Integrated Care (AIC) and various community partners to roll out new initiatives.

Some initiatives focus on care navigation and care-giver training. Care-givers can obtain information and access referral services at four new AIC Links touchpoints in Toa Payoh, Nee Soon, Pasir Ris and also Choa Chu Kang, which complement the eight existing touchpoints already existing in our heartlands. We have also worked with healthcare professionals to introduce a course on the "ABCs of Care-giving", with customised components to help care-givers with the different mobility needs of their loved ones.

Within the eldercare landscape, there is a range of care-giving options. Many families engage foreign domestic workers (FDWs) to provide care and Ms Yip Pin Xiu asked if care-giver training initiatives will be extended to them as well.

There are, indeed. merits to training FDWs and families can decide on how best equip them. We have initiatives to support those who choose formal training for their FDWs, such as the Eldercarer FDW Scheme which we have run since 2016. Training is done before placements in the households that they serve and includes both classroom theory and as well as on-the-job practical training in managing the day-to-day care-giving needs of an elderly person. Care-givers can tap on an annual $200 subsidy under the Care-givers' Training Grant to offset the costs of training for their FDWs or other approved courses.

Mr Christopher de Souza has asked about our measures to provide respite care and how effective they have been. Mr de Souza will be pleased to hear that we have respite care options at more than 20 eldercare centres and 40 nursing homes, where more than 3,700 so far have benefited.

We have recently expanded the range of respite care options as well, starting with a respite care pilot in September 2019 for care-givers of cancer patients on home palliative care and a night respite care pilot in December 2019 for care-givers of persons with dementia, who experience behavioural and sleep issues at night. And sometimes, these difficulties cause the care-giver not to have his or her own rest. So, that option is available.

We have also been helping care-givers access respite care at short notice. Care-givers under our Go Respite pilot launched in April last year were able to pre-enrol for these services and activate the respite care at short notice. To-date, 450 care-givers have been pre-enrolled.

Beyond expenses for home and community-based services, care-giving expenses can take many forms and we recognise that.

So, in October 2019, we launched the Home Care-giving Grant, which replaced the previous Foreign Domestic Worker Grant with an enhanced quantum of $200 per month. By providing cash support directly to care recipients with permanent disability, care-givers have greater flexibility as to how best to deploy these resources.

We have since approved more than 4,900 applications for the Home Care-giving Grant, bringing the number of beneficiaries under the scheme to over 16,000.

Allow me to share the story of one care-giver, to illustrate how our schemes address the care-givers' different types of needs.

Mr Shahril lives with his wife, three children and a 79-year-old father, who is bed-bound after a stroke and heart attack. In October 2019, Mr Shahril needed a break from care-giving duties, as his helper had left the country for home leave. He shared this with the AIC Link staff at Changi General Hospital where his father was treated. Within two weeks, they enrolled Mr Shahril's father in AIC's Go Respite programme at the NTUC Health Nursing Home, across the road from their home, across the road from where they live, and he began his three-week stay there. This arrangement made it easier for Mr Shahril to continue to provide for his own family, with the assurance that, at the same time, his own father was being cared for during this period.

At the same time, Mr Shahril also applied for the Home Care-giving Grant. Today, his family receives a monthly payout of $200, which they use for essential items, such as diapers, milk supplements and other disposables, as well as for his father's medical expenses. All in all, our schemes have given Mr Shahril the flexibility and the assurance to care for his father in the long term.

I have shared how the Ministry is taking important steps to help address the cost of care, both financially and otherwise.

These will support Singaporeans in seeking the necessary care. But at the same time, we must take bold steps to encourage healthier lifestyles. I think Members have heard that narrative from the speakers before me. This will delay the onset of disease and reap downstream savings for our healthcare system.

Members will also be, nonetheless, familiar with our efforts on this front. Minister had previously described some of our efforts to promote healthy living under the war on diabetes initiative.

Although we have made progress in encouraging Singaporeans to exercise more and eat healthier, our daily sugar intake, as some Members have pointed out, remains high. In particular, beverages contribute to more than half of the sugar intake.

Both Mr Charles Chong and Mr Gan Thiam Poh asked for an update on our plans to control the consumption of such beverages. The same issues and questions have been raised by Dr Intan Azura Mokhtar in the House last week, while Mr Leon Perera also made suggestions what else we could do should these measures not prove to be effective.

As a start, let me outline what we will do. As a start, we will implement two new regulatory measures for pre-packaged beverages: a nutrient-summary label and an advertising prohibition for beverages with high sugar and saturated fat content. So, two elements – sugar and saturated fat. We want to provide Singaporeans with the right information to make their own healthy choices and also, at the same time, encourage the manufacturers to reformulate their products and create healthier options, a point that Mr Perera also raised.

Under this new regulatory framework, all pre-packaged beverages will be given a colour-coded nutrient-summary label, called the ‘"Nutri-Grade". With your permission, Mr Chairman, may I display an example of the label for Members?

The Chairman: Yes, please. [A slide was shown to hon Members.]

Mr Edwin Tong Chun Fai: On the screen, Members see an example of the label: Grade A, corresponding to the lowest sugar and saturated fat thresholds, is in dark green; while Grade D, corresponding to the highest sugar and saturated fat thresholds, is in red.

This provides a quick, at-a-glance summary of the nutritional quality of the beverage, allowing consumers to compare across products at the point of purchase. Besides the grade, we will indicate the sugar level of the beverage as a percentage of the total volume. So, if you see 12% on the label, it represents 12% sugar of the total volume in that particular product.

This provides Singaporeans with more information so that they can compare sugar levels across beverages within the same grade. With your permission, Mr Chairman, may I display a slide summarising the grading system?

The Chairman: Yes, please. [A slide was shown to hon Members.]

Mr Edwin Tong Chun Fai: Thank you, Sir. Pre-packaged beverages will be graded on a single set of nutrient thresholds, based on their sugar and saturated fat content. For example, beverages with more than 5% sugar content will be graded C, while beverages with more than 10% sugar content will be graded D. But beverages may subsequently be "downgraded", at the point in time, be downgraded to D, if they also contain a high amount of saturated fat.

We encourage all manufacturers to label their products with the Nutri-Grade, but the label will only be mandatory for beverages in Grades C and D.

The label is intended to facilitate Singaporeans' decisions when they go and purchase these products at the point of purchase. It will therefore not only be displayed on the front of product packaging, but also at points-of-sale the where customers do not have direct access to the product. For example, at e-commerce websites, vending machines, drink fountains, they will be displayed at the point-of-sale as well.

In addition to labelling requirements, we will prohibit advertising for Grade D beverages on all media platforms, including traditional and new media platforms across all time belts. This will reduce the impact of advertising on consumer preferences and encourage manufacturers to reformulate.

We will continue to allow advertising of Grade A to C beverages, as well as all brand advertising, as we want to encourage manufacturers to reformulate. The point is not to deprive Singaporeans of their favourite drinks, but to encourage manufacturers on their journey towards reformulation to create a wider and broader range of healthier options for Singaporeans to enjoy.

The new regulations will be published at the end of 2020, coming into effect a year later.

If manufacturers start today, they will have almost two years to reformulate their products in line with these regulations and avoid being in groups, Grade C or D where they have to compulsorily put on the label.

The Health Promotion Board (HPB) will continue to support industry reformulation efforts through initiatives such as the Healthier Ingredient Development Scheme. And HPB will also launch a campaign to educate consumers on using the Nutri-Grade labels to guide purchase and consumption decisions.

At the same time, we have heard strong calls from all quarters to also regulate – beyond just the pre-packaged – the freshly prepared beverages, such as herbal drinks and bubble teas. It is clear that they are a substantial and growing source of sugar intake for many Singaporeans. Dr Intan Azura Mokhtar, in particular, asked whether there are plans to extend our regulations to these drinks.

Over the past few months, I have met representatives from the freshly prepared beverage sector to hear their views on how we can work with them as well to help consumers make that transition to healthier choices.

Most understand the need to inform consumers about the nutritional quality of their products and they support our objective of reducing Singaporeans' overall sugar intake.

After a careful review of the local landscape, we have decided to extend the labelling and advertising measures to freshly prepared beverages. As a start, these measures will apply only to the larger chains, which are more likely to have consistent recipes, as well as significant reach and impact locally. We will study the local landscape to determine the appropriate criteria for what comprises a "large chain".

Other jurisdictions with mandatory labelling in F&B settings have, in their own countries, adopted thresholds of 10 to 20 outlets as being the definition of "large chain". But we will study this in our own context. We will take reference from what has been done in other countries, which means that small businesses with one or two stalls, such as those in hawker centres, would not be affected in the first instance. Nevertheless, we will monitor the impact of these measures, and may gradually seek to extend them to more establishments – along the vein of what Mr Perera had mentioned earlier.

Concurrently, we encourage F&B outlets not considered "large chains" to voluntarily adopt these measures. We will continue to engage the industry in the coming months to finalise details of these measures, including how to implement them in a cost-effective manner. More details will be shared when they are ready.

All these initiatives are part of a longer term approach to reshape consumer behaviour towards healthier living, not just in the choices that they make, but in consumption.

Some have suggested stronger measures, such as an excise duty or an outright ban. These will require further study, like those suggestions that Mr Perera raised. In the meantime, we will work closely with industry partners to support Singaporeans in making those healthier choices.

Finally, as a complement to our regulations, we also want to encourage Singaporeans to just go for more plain water instead – zero calories and very healthy on the overall grading scale.

So, on that front, we have been working with agencies like NEA, HDB, LTA and also NParks to increase the availability and accessibility of drinking water in the community.

Water dispensers are available in 30 hawker centres – Members might be pleased to know – and are also easily found in parks across Singapore. By mid-2020, more water dispensers will be installed in the remaining 82 hawker centres.

3.45 pm

In addition, 14 bus interchanges and terminals already have water coolers and we will work with LTA and public transport operators to install water points in bus and MRT stations where suitable. In mid-2020, HPB will launch a nation-wide campaign to promote plain water, as part of their nutrition literacy campaign. Whether you are exercising in our public parks, enjoying a meal at the hawker centres, taking a bus, about to take a bus, or in the MRT station, we encourage you to choose plain water and we will make the options available as much as possible.

Mr Chairman, to conclude, the Government will continue to enhance the affordability of healthcare and expand support for care-giving. Policies such as the enhanced MediSave700 scheme will provide additional peace of mind for those with chronic illnesses.

At the same time, we will pursue downstream savings for our system by encouraging healthier living and supporting Singaporeans in making healthier and we believe, therefore, wiser choices in what they consume. Better health for us all is a vision and responsibility we must all share. We urge Singaporeans to partner with us as we strive for a healthier Singapore not only in 2020 but beyond. Thank you, Mr Chairman.

The Senior Parliamentary Secretary to the Minister for Health (Mr Amrin Amin): Beyond Healthcare to Health – going upstream and supporting healthy living. This is part of our ongoing transformation. To push this transformation, we will do three things which I will cover in my speech.

First, better financial support. Second, better community partnerships. Third, better use of technology.

On better financial support, we want Singaporeans, regardless of income or social background, to enjoy good health. We will do so in a fiscally sustainable, targeted and effective manner. I am happy to announce three initiatives.

(a) First, full subsidies for nationally recommended childhood vaccinations and developmental screening.

(b) Second, subsidies for nationally recommended adult vaccinations.

(c) Third, subsidies for nicotine replacement therapies for eligible participants at smoking cessation pilots.

The effective dates for the vaccinations subsidies and child developmental screenings will be before the end of 2020 – exact dates will be announced later.

Today, only recommended childhood vaccinations against infectious diseases with high outbreak potential such as measles and diphtheria receive full subsidies, and this is only available at polyclinics in the primary care setting. There are currently no subsidies for adult vaccinations and smoking cessation in the primary care setting.

Full subsidies will be given to Singaporean children for all vaccinations recommended under the National Childhood Immunisation Schedule or NCIS. These also include pneumococcal and HPV vaccines. Subsidies will be available at polyclinics and at CHAS GP clinics across Singapore.

For Singaporean children up to the age of six, full subsidies for child developmental screenings will be extended from polyclinics to include CHAS GP clinics. We are doing this to ensure early detection and timely intervention for developmental delays for all Singaporean children. This measure is part of our ongoing efforts to ensure Singapore remains one of the best places to raise a child. So I urge parents to take advantage of the free vaccinations to give our children the best possible start.

All eligible Singaporean adults will enjoy subsidies for vaccinations under the National Adult Immunisation Schedule or NAIS at polyclinics and CHAS GP clinics. The NAIS covers seven types of vaccines that protect against 11 diseases, including influenza and pneumococcal disease. NAIS recommends vaccination to two main groups of adults: The first group, persons with certain medical conditions such as diabetes, chronic heart diseases and chronic respiratory diseases; and the second group, seniors aged 65 and above.

Subsidies will be means-tested. At polyclinics, eligible lower to middle income Singaporeans will get 75% subsidy. This corresponds to CHAS Blue and Orange cardholders at CHAS GP clinics. Other eligible Singaporeans will get 50% subsidy for the vaccinations. Pioneer Generation get an extra 50% subsidies and Merdeka Generation get an extra 25%, off the remaining co-payment amount.

Let me illustrate. Now Singaporeans pay about $70 to $80 for PPSV23 pneumococcal vaccination at a polyclinic. Assuming you fall within the NAIS recommendations and qualify for the subsidies, you can expect to pay about $20 to $40, depending on means-test. Pioneer and Merdeka Generation gets additional subsidies.

Singaporeans can continue to pay out-of-pocket amounts using MediSave. Singaporean adults will receive similar levels of means-tested subsidies for these vaccinations at CHAS GP clinics. We will share details when ready.

To ensure vaccination subsidies are passed to eligible Singaporeans at CHAS GP clinics, MOH will introduce fee caps for NAIS and NCIS vaccinations done at CHAS GP clinics. It is quite tongue-twisting. MOH have also worked with vaccine manufacturers so CHAS GP clinics can get these vaccines at favourable prices. We are studying ways to help those who may have difficulties going to polyclinics and CHAS GPs, such as nursing home residents, to benefit from these subsidies.

I mentioned earlier about providing the subsidies in a fiscally, sustainable and targeted, effective manner. Let me explain.

First, the NAIS scopes the group of people whom the Expert Committee on Immunisation (ECI) has assessed to be more vulnerable to certain diseases and are therefore recommended for the vaccinations. So, targeted group based on need.

Second, our aim is to reduce the number of people who fall ill from vaccine-preventable diseases. Singaporeans with chronic medical conditions are particularly vulnerable and fall sick more easily. If diseases can be prevented, we can gain system-wide savings in the long run. Essentially, this is what we are doing: keep out vaccine-preventable diseases through vaccinations, keep our people out of hospitals and keep them healthy.

Mr Perera asked about the coverage of childhood vaccinations and how we can raise adult vaccination coverage in Singapore. Coverage for childhood vaccinations in Singapore is high, with most vaccinations exceeding 95% coverage in the past five years. This is due to efforts in health promotion, comprehensive childhood immunisation services and a robust school health service. All childcare centres and kindergartens require immunisation certifications for compulsory vaccinations under NCIS before enrolment. Parental inertia and lack of awareness are some of the reasons a small minority of children are not vaccinated.

We have a two-pronged approach to increase children and adult vaccinations. The first is to make vaccinations affordable through subsidies and the second, public education. Public education has taken on renewed importance with misinformation from the anti-vaccination camps. We aim to increase vaccination coverage among adult Singaporeans to over 50% by 2025.

Smokers will get more support to quit. Subsidies will be given for nicotine replacement therapy, if found suitable, in smoking cessation pilots. New smoking cessation models will be piloted in our public healthcare institutions such as hospitals, polyclinics and our national specialty centres.

Singaporeans can benefit from intensive behavioural support, follow-up for up to a year and a 3-month nicotine replacement therapy, if found to be suitable.

MOH is evaluating the pilot proposals. The pilots will target 10,000 smokers. We plan to start the pilots after Public Healthcare Institutions (PHIs) resume normal operations. This will depend on how the COVID-19 situation develops.

Mr Charles Chong asked about existing measures to assist smokers to quit and their efficacy. Success rates for smoking cessation programmes in Singapore have ranged from 10% for telephone-based interventions to 20% for programmes that combine intensive counselling and pharmaco-therapy.

Smoking is one of the biggest risk factors for poor health. Standardised packaging for tobacco products will start in July 2020. The minimum legal age for smoking will be raised to 21 next year. This will set a good momentum to drive down our smoking rates further.

I shared in 2018 our stretched target of reducing our smoking rate to below 10% by 2020. Smoking rate in Singapore dropped to 10.6% in 2019. We will do our best to reach that stretched target.

SPS Faishal asked about community health promotion activities. Indeed, cultural connections and understanding are strengths we are tapping on to mobilise the community towards a healthy cause.

HPB's Jaga Kesihatan, Jaga Ummah (JKJU), which means take care of health, take care of community is one good example. JKJU started in August 2017. JKJU brought together MUIS, 28 mosques and Malay Activity Executive Committees. I am proud that they have reached out to over 35,000 Malay participants in 2019. This is important, involving the community and powering community institutions to take ownership and mobilise people to action. Truly a healthy development.

Masjid Maarof organised piloxing, zumba, a skit on coping with dementia and urged congregants to give up a cigarette puff for a less calorie curry-puff ("A Puff for a Puff"). Masjid Al-Ansar offered circuit training and stretch-band exercises for seniors.

We are stretching out to involve more partners and people. Our Regional Health Systems (RHSes) will partner JKJU to bring more quality programmes and deepen outreach. This will help greatly, it is a promising partnership. Because RHSes treat patients who are residents in the area, they know the local ailments and the common problems within the community. RHSes can help local partners like JKJU shape programmes, provide targeted interventions customised to local needs and offer medical expertise to raise awareness on community trending topics.

I am also proud of the excellent work of Chinese and Indian community groups, 27 churches and 10 temples have worked hard to organise health promotion programmes. From health screenings, national step challenge roadshows to physical activity workouts.

The Hindu Endowment Board, SINDA and Narpani and various places of worship partnered HPB and reached out to 5,000 people in 2019. The Hindu Endowment Board partnered National Healthcare Group to conduct health screenings for 1,500 people at Sri Perumal Temple in 2019.

Senior Parliamentary Secretary Baey Yam Keng asked about helping lower income Singaporeans stay healthy. HPB will pilot the "Healthy Living Passport" in mid-2020, beginning with five sites located in Boon Lay, Woodlands, Jurong Spring, Chua Chu Kang and MacPherson. We aim to reach at least 15,000 residents, about 5,000 families, over a three-year period.

Healthy Living Passport seeks to improve health literacy and promote healthy lifestyles, customised to the needs of lower income residents. Lower income residents have specific concerns. They shared with us about working shifts, not having enough sleep and missing out on various community exercise programmes. They shared that healthier food such as vitamins, vegetables and low-calorie options tend to be more expensive. They raised stress as a concern and many, unfortunately, turned to smoking to unwind. We cannot brush these concerns aside. We should try to address them and hear them out.

Healthy Living Passport is a modest effort, a sincere outreach to help our fellow Singaporeans lead healthy lives. Let us work together.

We are still working out the exact parameters of Healthy Living Passport. Broadly, we are focusing on equipping participants with knowledge on shopping for budget, healthier ingredients and prepare healthier, tasty meals and promote physical activity, oral health and mental wellness.

We are targeting to impart health tips to both parents and children in a fun and interactive way. Volunteers from HealthySG Buddies will encourage and support families to use this Healthy Living Passport and embark on a meaningful and fulfilling journey.

Mr Charles Chong asked how MOH empowers and supports community care providers. We are committed to supporting community partners deliver better care to Singaporeans. One way is through funding support. An example is the Tote Board Community Healthcare Fund. This fund helps non-profit organisations pilot and scale innovative projects in preventive health and community care. The Tote Board Community Healthcare Fund has committed approximately $230 million since FY2009.

The Tote Board Community Healthcare Fund funds the Wellness Support Package. This package supports nursing homes to upskill their manpower and implement senior-friendly activities such as table-top gardening and wheelchair taichi. Seniors enjoy these activities and homes reported improvement in seniors' mood, well-being and self-esteem. Twenty-five nursing homes have benefited from this.

We are working more closely together. For instance, the RHS-HPB Integrated Volunteer Network and the Shared RHS-HPB Learning Hub. We recruit, train and deploy HPB Health Ambassadors and RHS volunteers together to promote health in the community.

4.00 pm

Since April 2019, volunteers in the Integrated Volunteer Network reached out to over 4,000 patients and residents in areas such as rehabilitation, health screening and quit-smoking programmes.

In 2020, we aim to bring volunteers from all public hospitals on board the Integrated Volunteer Network.

Advances in technology present opportunities to better tailor programmes and messages, and engage residents and deliver effective programmes to the right person, at the right time, at the right place.

In the next few years, HPB will develop a Population Health Data Hub. This will be a national data hub containing information such as demographics, lifestyle and health information.

The Hub will help us better understand Singaporeans’ lifestyle, behaviour and health. Interventions and nudges may be customised to individual’s needs and lifestyle, empowering behavioural change and driving health outcomes. This will help us to better address the causes of ill health early, and reduce incidence of chronic diseases.

We are developing a virtual Health Booklet (vHB) that can send personal reminders, empowering individuals to better manage health. We expect to launch the virtual Health Booklet in end-2020.

We are making good progress with HPB’s National Steps Challenge. Now in its fifth season, more than 850,000 participants have taken part. Participants have grown more active with more step counts and higher intensity physical activity.

Mr Chong asked about screening rates. Screening rates have gone up from 45.1% in 2010 to 66.3% in 2019. Under Screen For Life, over 62,000 individuals aged 40 years and above have gone for cardiovascular screening at CHAS GP clinics. Of those with borderline and abnormal screening results, 84.4% have gone for medical follow-up as at 9 January 2020.

We want more Singaporeans to attend screening and follow up on their screening to reduce risk of developing chronic diseases. This year, we will pilot tele-coaching for people found to be at risk of cardiovascular diseases through the Screen for Life programme. HPB's health coaches will reach out to selected individuals and invite participants to work on health goals through HPB or other programmes. Mr Chairman, in Malay, please.

(In Malay): [Please refer to Vernacular Speech.] Please allow me to put on record our highest appreciation to our frontline officers battling against COVID-19 and I would like to give a reminder on the importance of staying healthy through two poems.

This first poem is an ode to our healthcare workers who are the heroes that we admire and respect. The second poem is a reminder to everyone to wash their hands with soap and to practise this good habit daily.

Our primary objective is a healthy society. Regardless of income or background, we want all Singaporeans to enjoy good health and a good quality of life.

I am happy to announce that MOH will introduce three new subsidies this year: first, full subsidies for nationally recommended childhood vaccinations and childhood developmental screening; second, subsidies for nationally recommended adult vaccinations; and third, subsidises for nicotine replacement therapies (NRT) for those selected at smoking cessation therapies.

First, subsidies for childhood vaccinations. They will receive full subsidies. In other words, all vaccinations recommended under the National Childhood Immunisation Schedule (NCIS), including pneumococcal and HPV vaccines, will be provided for free to all Singaporean children. These subsidies will be available at all polyclinics and CHAS clinics in Singapore.

Full subsidies will also be provided for childhood developmental screenings for Singaporean children aged six and below, at all polyclinics and CHAS clinics. Early detection and recovery will result in better outcomes.

To quote a Malay proverb – bend a bamboo while it is still a bamboo shoot. We want our children to start their lives healthy. This is an on-going effort to ensure Singapore remains one of the best places to raise children and have a family.

Second, subsidies for vaccinations recommended for adults. This subsidy will be given for vaccinations recommended under the National Adult Immunisation Schedule (NAIS) for some groups of adult Singaporeans. First, seniors aged 65 and above; and second, those with chronic medical conditions.

NAIS covers seven types of vaccines that protect against 11 diseases, including influenza and pneumococcal disease. The subsidies will be means-tested. At polyclinics, lower to middle income Singaporeans will get a 75% subsidy. In general, these are the CHAS Blue and Orange cardholders. Other Singaporeans will get a 50% subsidy. The Pioneer Generation receives an additional 50% subsidy while the Merdeka Generation receives an additional 25% off the remaining co-payment amount.

I urge all Singaporeans, especially parents and seniors, to take advantage of this subsidy. Prevention is better than cure.

Singaporeans can continue to pay out-of-pocket amounts using Medisave. For instance, the pneumococcal vaccination (PPSV23) now costs about $70 to $80 at polyclinics for seniors. With the subsidies, Singaporean seniors pay only about $20 to $40. It is even lesser for the Pioneer and Merdeka Generation. Singaporean adults will receive similar subsidies if they go to CHAS clinics. We will share more details next time.

Third, subsidies for nicotine replacement therapies for those undergoing smoking cessation therapies. One in four Malay Singaporeans are smokers. We will commence the smoking cessation pilot programme in public healthcare institutions after the COVID-19 situation subsides and normal operations resume.

This programme will target 10,000 smokers and will offer counselling, nicotine replacement therapy if suitable and follow-up consultations up to a year. Do not wait until it is too late. Do not wait until you fall ill to quit smoking. We have done so much together. These include the "Kita Dah Cukup Manis" campaign to reduce sugar consumption, the "Puff for a Puff" programme to quit smoking, and the "Get Fit for Haj/Umrah" and "Move and Be Happy" programmes to invite everyone to be more active.

I thank the community for their strong support. I am heartened and confident that there is a noticeable change. I have experienced it myself. When I was out for Hari Raya visits, I was often served plain water and reminded that "We are already sweet enough, aren't we?" Yes, definitely sweet enough.

Let us enhance our efforts together to stay healthy and have a sweeter life.

(In English): Mr Chairman, truly, health is wealth. We are reminded of how quickly things can change and how fragile life is with COVID-19. Let us support one another to stay healthy.

The Chairman: Clarifications. Dr Chia Shi-Lu.

Dr Chia Shi-Lu: Thank you, Chairman. I just have two clarifications for Senior Minister of State Lam and two for Senior Minister of State Edwin Tong.

For Senior Minister of State Lam, besides building new polyclinics, are there any plans to redevelop or refresh existing polyclinics, given that many of the polyclinics are growing long in the tooth.

Secondly, I asked the question whether there were any enhancements to the PHPC system. I may have missed his answer but I was wondering whether there are any plans to improve the system or to strengthen the system.

For Senior Minister of State Edwin Tong, I think I am very heartened to hear about this new Nutri-Grade labeling system. But I saw on the slide that the label was "subject to change". I was just wondering whether Ministry has tried it out or done some test-bedding of these labels to see how effective they are, how clear they are.

And my second question is, I note that he said that 70% of these pre-packaged drinks would be classified as C or D. I was wondering of that percentage, how many are actually under D.

Finally, does this information also extend to those dispensed drinks, at soda fountains or at drink machines?

Dr Lam Pin Min: I would like to thank Dr Chia for those supplementary questions. With regard to polyclinics' development, in addition to those that we have announced for new developments, which is up to 32 polyclinics by 2030, we do have existing polyclinics that are being redeveloped, one of it was Ang Mo Kio Polyclinic which was redeveloped some time back. And moving forward, we are also going to redevelop Toa Payoh Polyclinic. Of course, we will review and look at the requirements on the ground and for those polyclinics that can be redeveloped to cater to the increased capacity, we will do so.

As for PHPC, currently, we do not have plans to enhance it. We feel that with the current 800 to 900 PHPC clinics on the ground, in fact, it is serving its purpose well but having said that, I think we will see how the COVID-19 situation evolves. If need be, we can enhance it as and when necessary.

Mr Edwin Tong Chun Fai: On Dr Chia's two questions, the Nutri-Grade label, yes, it is subject to change as we look at the design. But he will be heartened to note that we have already looked at it very closely. We had about 12 focus group discussions and also studied with the food science people, people who looked at it from a behaviourial perspective. In fact, after this we will be putting up on our website the report of the findings that we have gathered from these focus group discussions.

And so, generally, the label is designed, having in mind simplicity, giving fullest of information in terms of the choice, but also easy to recognise so that those who are not so conversant, the elderly, may be able to distinguish them.

The Member's second point about the 70%, the figures approximately are 70% will fall into C and D. And of that, about 25, 26% will be D. Looking at these numbers, you can see why we have said earlier that there is a strong desire for us to encourage the market to reformulate on their own. Because much as you design the Grading system, what we also want to ensure – and we do not ban the items – so what we want to ensure is that the market, on its own, corrects it, and – I think, it is a point that Mr Perera made – manufacturers do appreciate that the market is looking out for healthier options. This is one of the ways, along with the advertising ban, that we want to push market in a particular direction.

On the Member's final point about the soda fountains, yes, I mentioned that to the extent that we are not able to have the consumers review the product grading – the Nutri-Grade – before it is actually purchased, then at the point of sale, in other words, perhaps at the cashier or at the place where the orders are taken, that summary label will also be available.

The Chairman: Dr Lily Neo.

Dr Lily Neo: Thank you, Mr Chairman. May I ask the Minister whether there is a possibility of more widespread community spread of COVID-19? And will MOH be able to cope with this? And whether does our Government have more specific measures in place to cope with this scenario?

Mr Gan Kim Yong: Mr Chairman, I thank Dr Lily Neo for this very important question. As I mentioned in my speech, we do expect to see more cases coming in, given the emerging cases all around the world. Many countries are beginning to see confirmed cases of COVID-19. In quite a number of countries, there are already significant community spread within the country and, therefore, there is a high risk of exportation of these cases to Singapore. We have raised precautionary measures: as you have seen, in recent days. We have introduced new travel advisories as well restrictions and we have also introduced a swab practices for those passengers or travellers who are showing signs of being unwell. These will help us to prevent or to minimise the number of imported cases.

But some of these cases may still be imported because it is not possible to stop every case. Many of them may enter without symptoms because it is still within the incubation period. They may begin to fall sick while they are in Singapore. And there may also be Singaporeans returning from these areas – they may also develop symptoms, after arrival in Singapore.

Therefore, we do expect to see a significantly higher number of cases in time to come. With a higher number of cases in Singapore, the risk of community spread will also increase. Therefore, it is important for us to re-emphasise the need for us to pay attention to public health and personal hygiene.

That is why I mentioned that the SG Clean campaign is very important. Through this campaign, we hope to build a strong foundation of public health, raise the standard of public health – whether it is in our food outlets, in our public areas, in our public toilets – and at the same time, also entrench a higher standard of personal hygiene, and look at how we can improve some of the social practices like common servicing spoons and chopsticks in our restaurants.

4.15 pm

These will go a long way in helping us to minimise and reduce the risk of widespread community transmission.

As of today, we still do not have evidence of widespread transmission in our community here, but we cannot allow our guard to come down. We have to continue to be mindful and to exercise and practise high levels of personal hygiene.

The Chairman: Ms Irene Quay.

Ms Irene Quay Siew Ching: Thank you, Chairman. Senior Minister of State Lam shared about this national antimicrobial surveillance report. I just wanted to ask if the results are ready and how are we faring in terms of our antibiotic utilisation in the community? What are our national targets and what are we doing about it?

Dr Lam Pin Min: I would like to thank Ms Irene Quay for the supplementary questions. As I have mentioned, the first joint report of antimicrobial utilisation and resistance in Singapore will be published later this year. So, I would not be able to let Ms Irene Quay know what the initial results are. Please be patient. The report will be released for public viewing.

The Chairman: Ms Joan Pereira.

Ms Joan Pereira: I have got two clarifications for Senior Minister of State Amy Khor. Earlier, she mentioned the Community Care Nursing Leadership Programme, or CCNLP. May I know how this complements the Community Nursing Scholarship that was earlier announced in 2017 to develop the pipeline of nursing leaders in the community?

The second clarification is on assisted living. Though the Senior Minister of State shared that the Government is rolling out assisted living flats to expand housing options for seniors, I still wonder whether there will be enough assisted living flats for all seniors, especially with an ageing population.

Dr Amy Khor Lean Suan: With regard to the Member's first question about the Community Nursing Scholarship and how this relates to the Community Care Nursing Leadership Programme. The Community Nursing Scholarship is for fresh school leavers, whether they are "A" Level or existing nursing students. So, they are fresh. What we are doing is trying to inject fresh talent into the community care sector – those with leadership potential and who have a passion to serve in the community care sector. As the Member has said, that started in 2017. Between 2017 and 2019, we have got 17 of these scholars. Although, of course, the class sizes in the Polytechnics are bigger, but those under this scholarship programme, there are 17 now.

For the Community Care Nursing Leadership Programme, this is a talent development programme. It is leadership development for the existing cohorts who are already registered nurses. They do not have to be in the community care sector. So, any registered nurse with good, strong clinical skills as well as nursing experience, and who are interested to join the sector, could apply for this. They will have an individual development plan for them to become leaders, take leadership positions in the sector.

Regarding assisted living, the Member's question was whether there will be enough. Firstly, let me say that there is already a range of housing options for seniors. One of them, of course, would be 2-room flexi flats. They can also choose to stay in their existing flat and get the Home Improvement Programme (HIP) and the Enhancement for Active Seniors (EASE), and then, get services like home care, day care and so on, and with the support of family. Or they can sell and use the housing grant of up to $30,000, the Proximity Housing Grant, to stay near their children or stay with their children.

What we have done is work with MND, and also based on feedback to look at another housing option for seniors – assisted living, which is not just the hardware, the physical space, but is actually the flat twinned with a basic service package that will be sold to the seniors. It is really to meet different preferences, needs as well as lifestyle aspirations. This might be useful for a group of seniors who want to be independent, live independently, may not have very strong family support, who feel that as they get more frail, they will need more services. In addition, they want to prevent themselves from being socially isolated, they want to have some kind of communal living and yet have some privacy. So, that is what this assisted living housing form is for.

We will monitor the demand for this. This is a pilot. We will monitor the demand and decide if we will build more of this housing form. As I have said, we are also looking at a pilot in the private housing market.

The Chairman: Ms Anthea Ong.

Ms Anthea Ong: Thank you, Chairman. I first want to thank Senior Minister of State Amy Khor for announcing to the House that there will be a whole-of-Government and multi-Ministry effort to address mental health as a national priority. It is very sweet, D grade-worthy news, I think. But I hope that it is not just the elderly and the youths that we are looking at, because the sandwiched ones are the very ones who are playing a big role in the mental well-being of our youths, and they are also the care-givers of our elderly.

So, if the Senior Minister of State will indulge me, I have four clarifications and one comment, from the four cuts.

I understand the Ministry is not intending to bring to parity the limits for MediSave and MediShield in terms of physical and mental health conditions, which, to me, would be the loudest anti-stigma signal, with that parity. Can I urge MOH to conduct its own public consultation or studies to examine the many affordability issues that were raised in our own rudimentary public study that I shared both in the Budget debate speech and earlier.

I know because I think we all understand that the treatment process for mental health conditions is a lot —

The Chairman: Ms Anthea Ong, given the number of clarifications we have, could you keep it to just clarifications, please?

Ms Anthea Ong: Sure. Thank you. So, a lot more nuanced and protracted, so there is a cost implication.

The Senior Minister of State also confirmed that Obsessive Compulsive Disorder (OCD) is now included in Chronic Disease Management Programme (CDMP), but I just checked the MOH website and it is still not there. Earlier, Senior Minister of State Edwin Tong also only listed four mental health conditions that are covered but not OCD. So, can Senior Minister of State Khor please confirm that.

I asked the Ministry about the plans to improve the waiting times, which is right now 27 to 28 days to see psychiatrists and psychologists. Can I please ask Ms Amy Khor to respond to this ask?

The next ask that I also filed in my cut, which has not been responded to, is – I asked the Ministry to consider MediSave to be used for community organisations that are providing mental healthcare services. Can I please have a response to that?

Last but not least, Senior Minister of State Khor assured that the Ministry will look at specific needs of the differently-abled in public mental healthcare. Can the Senior Minister of State also assure that the LGBTQ+ community, that their specific needs will also be looked at, as I had outlined in the dedicated cut on this.

Dr Amy Khor Lean Suan: I think it is more like six follow-up questions, not four. I will try and answer them.

First of all, this thing about parity between MediSave and MediShield Life. As I have tried to explain, when we set the withdrawal limits for MediSave or MediShield – say, inpatient, for the different types of treatment, different types of conditions, not just mental health but other conditions, we look at the bill sizes.

To give you an example, in 2018, the average daily bill size for inpatient psychiatric treatment at IMH is $90. But for acute hospital, the average bill size, taking out the cost of surgery procedures, is $480. So, if you talk about parity, we are talking about parity in terms of making sure that the withdrawal limits will cover a majority of the cost of the treatment for subsidised patients. Therefore, for MediSave daily withdrawal limit, it is $150 for psychiatric treatment.

And as I have said earlier, for inpatient MediSave withdrawal limit, less than one in 10 actually exceed their $5,000 yearly withdrawal limit and less than three in 10 exceed their daily limit. So, that is what the parity is. It is not the absolute amount but what is the bill size.

I assure the Member that we will and we have always continued to monitor to make sure that the withdrawal limits are adequate, to make access to healthcare affordable to our subsidised patients. And, as I have said for MediShield Life, the MediShield Life Council is reviewing the MediShield Life limits for the different conditions. So, the same thing with MediSave withdrawal for outpatient treatment.

The next question is on OCD. The word is not there. It is under "Anxiety disorder". So, if a doctor says under anxiety, it is OCD, it is covered. Dr Chia Shi-Lu is nodding his head. So, it is covered. The word is not there. I only listed a few, because I did not have enough time.

For wait time, as in for access to many other treatments, we are always mindful of the wait time. What we are doing to try and reduce the wait time is that for the hospitals and polyclinics, they are trying to see how they can review their work processes to optimise the appointment slots. For instance, you try to tighten the triaging, so, they call the patient before the appointment, to try and optimise these slots.

We are also looking at tiering of services to provide the appropriate level of care, because not everything has to go to the specialists. When it is possible to get care in the community or in primary care sector, then we will refer them to the primary care sector or community care sector.

For the Member's information, as I have said over the years, we have tried to increase access to treatment and we have now got about 210 GPs who are trained to provide mental healthcare. If they do not need to go to a specialist, they can be treated or cared for in the primary care sector. And, actually, there is no wait time, and they still can get a subsidy, through CHAS as well as through CDMP.

If they access care through the community intervention teams, the first referral is within two weeks – 14 days – a lot shorter.

That is what we are trying to do. And then, only for the more complex cases, they go to the specialist – to try and shorten the wait time.

Besides that, if urgent medical mental health assistance is needed or they need to see the doctor immediately, they can contact IMH through the 24-hour Mental Health Helpline or show up at the IMH 24-hour Emergency Services. Having said that, we are working on how we can reduce the wait time. So, I hope that answers the Member's question.

Regarding mental health of the LGBT community, as I have said earlier, healthcare providers who are caring for all persons with mental health conditions, are trained and they are supposed to provide these patients with empathy, sensitivity and due consideration to their specific care needs as well as risk factors. What we have done is to adopt a team-based approach to healthcare and ensure that different perspectives are considered. If need be, they can get the experts to come in to provide holistic care.

In addition to that, let me say that in 2017, the Institute of Mental Health set up the Gender Care Clinic. This clinic provides counselling and psychiatric treatment for persons experiencing emotional difficulties pertaining to gender identity, including the people who are diagnosed with gender dysphoria. And approximately 50% of these patients have a co-morbid psychiatric diagnosis. Majority of them will have anxiety and depressive disorders, and they are actually treated there. So, there are various avenues that we help this group of people.

4.30 pm

I think I have answered all the queries. Oh, one more. If the community care provider is working together, say, with the GP or with the polyclinic and they are referred to them, then I think they can access MediSave. But, of course, the community care provider must be qualified.

The Chairman: Mr Melvin Yong.

Mr Melvin Yong Yik Chye: Sir, my first question is for Senior Minister of State Amy. Besides raising the retirement and re-employment age ahead of schedule, what else is MOH planning to do to support older healthcare workers and maximise their employment at the workplace?

My second question is for Senior Minister of State Lam. He announced the introduction of the Integrated Youth Service in Woodlands with Care Corner. Could the Senior Minister of State share more details about what services are provided under this Integrated Youth Service?

Dr Amy Khor Lean Suan: The public healthcare institutions welcome older workers or mid-careerists to work in the public healthcare sector.

For us, manpower is a perennial challenge. So, we are doing everything we can to attract as well as to retain our mid-careerists and to re-employ older workers. Some of the things that we have done is firstly, to design age-friendly workplaces as well as put in place age-friendly employment measures. So, redesigning the job roles, flexible work arrangements, part-time, for instance. The nurses now have access to part-time work, more flexible work arrangements, as well as even preparing, what we call, pre-retirement preparatory training to prepare them to be re-employed again or to encourage them to be re-employed again.

And then, in the community care sector, we are also working to redesign jobs so that they can be broken up and seniors or older workers can do part-time work. A very good example is NTUC Health. They break up care roles so that seniors could be escorts to bring the patients to the senior care centre or care for them through active ageing programmes in a care centre.

Another one would be to reduce the manual burden or workload on the senior workers. So, patient uplifters, transfer aids and so on, which are really helpful to our healthcare workers, including nurses. Lastly, even within the healthcare institutions, we have got jobs that help to take some of the workload, say, from the nurses so that nurses can focus more on their clinical work, so "Basic Care Assistants", for instance. And we have got 100-odd of them now and more than half are actually above 50.

Dr Lam Pin Min: I would like to share Mr Melvin Yong that the new Integrated Youth Service (IYS) has been developed to provide holistic support for social and mental health services to at-risk youths. There are basically four services that IYS provide. First, which is to outreach for prevention which is to increase awareness and encourage help-seeking behaviours. This is done through activities like roadshows, talks and workshops on mental health topics.

The second service they provide is to identify needs and to provide a one-stop service for care coordination.

The third service will be for peer facilitation and mentoring. So, at IYS, we will look for model youths who will provide that kind of a role model for these youths at-risk as well as to look for youth volunteers who can actually better engaged these youth during activities like roadshows and outreach programme.

And the last service that IYS provides is to provide emotional support and monitoring. It can be done in the form of group sessions to improve resilience as well as coping skills.

The Chairman: Ms Tin Pei Ling.

Ms Tin Pei Ling: Thank you. I have two questions. Firstly, I would like to ask whether the Ministry will consider setting up a matching fund to boost the funds raised by community organisations, including grassroots with the aim of supporting seniors who need help with their healthcare financing. I declare my interest because in MacPherson, we have a MacPherson Care Fund since 2012. So, obviously, such a fun will help us stretch that dollar to help more seniors.

The second question is about bone health. I fully agree with this. The statistics about the risk of hip fractures to the health of seniors were very alarming. I would like to ask: what is the Ministry doing more upstream, perhaps what HPB is doing to help encourage Singaporeans to take care of their bone health earlier, perhaps even targeting women who are at higher risk because they may have given birth to children, prolonged nursing and so on? I think these are all factors that may contribute to calcium loss.

Mr Edwin Tong Chun Fai: I will address Ms Tin's first point. On the matching fund, MOH has set up the Community Silver Trust in 2012. That is to encourage donations and also additional resources to providers in the intermediate and the long-term care (ILTC) health space. And that is done by providing a matching grant, every dollar for every dollar, for eligible ILTC providers.

The Trust's matching grant supports providers in building capabilities, enhancing the quality of care. The matching grant also frees up charity dollars, which organisations can then channel towards defraying the costs of healthcare for their seniors.

Dr Amy Khor Lean Suan: Let me say personally that I also felt that many people may not realise they only have a very limited amount of time to build up bone health. And for women, I am told is actually even before 30 years old. You will maximise your bone health and after that, either you try and keep it or you are going to lose it. And from menopause onwards, it is a steep decline if you do not do anything.

For seniors, we have been working with seniors on bone health. But as the Member has rightly pointed out, what we want to do now is to go upstream. We are not the first. In the US, they provide a guide to the parents about how to build up strong bones in their kids from young. So, what we are doing is to work with HPB and Osteoporosis Society to trial this, to pilot this in 10 schools. We want to try and do it in a fun way. So, they are developing the curriculum as well as putting up videos to get students to understand and have a healthy lifestyle, good nutrition as well as exercise and so on.

The Member is right that one of the things is, under our Women Health Advisory Committee, we are also looking at how we can reach out to get more to understand that if they do not do this, fracture is really a very debilitating condition.

Mr Edwin Tong Chun Fai: I would also like to let Ms Tin know that the Trust is made up initially of a $1 billion injection by the Government. And Ms Tin might remember that in 2018, it was topped up by another $300 million. Since the inception of the Trust, it has matched up to $700 million in terms of donations from the eligible organisations.

The Chairman: Would Dr Chia like to withdraw his amendment?

Dr Chia Shi-Lu: Chairman, I wish to thank all Members who have taken part in this debate and, of course, Minister Gan, Senior Ministers of State Amy Khor and Dr Lam Pin Min and Mr Edwin Tong and also Senior Parliamentary Secretary Amrin Amin, together with all the staff at MOH for their replies and the work they have put in for the healthcare system for the benefit of all Singaporeans. On this note, I beg leave to withdraw my amendment.

Amendment, by leave, withdrawn.

The sum of $11,696,866,200 for Head O ordered to stand part of the Main Estimates.

The sum of $1,713,083,800 for Head O ordered to stand part of the Development Estimates.

The Chairman: I wonder whether we are suitably inspired by MOH to skip tea-break, eat less and be healthier? So, I will pose the question to you. The question is, we are inspired by MOH to skip tea-break, eat less, be healthier and happier. As many as are that opinion say aye. To the contrary say no.

Hon Members: No!

The Chairman: I think the noes have it, the noes have it. I propose to take a break now.

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

Mr Speaker: Order. I suspend the Sitting and will take the Chair at 5.00 pm. Order. Order.

Sitting accordingly suspended

at 4.40 pm until 5.00 pm.

Sitting resumed at 5.00 pm

[Mr Speaker in the Chair]