Committee of Supply – Head O (Ministry of Health)

Head O (cont) –

Resumption of debate on Question [6 March 2024],

"That the total sum to be allocated for Head O of the Estimates be reduced by $100." – [Dr Tan Wu Meng].

Question again proposed.

10.57 am

The Second Minister for Health (Mr Masagos Zulkifli B M M): Chairman, I thank Members for their questions and suggestions. I will start on how we can build a Singapore where our families and seniors can flourish. Strong families are the building blocks for an ecosystem of care within our communities. They help to ensure the health of their children and are pivotal to supporting our seniors to age well.

Ageing well starts from home and families should always be the first bastion of care. Studies show that most seniors prefer to age in the community, close to their families and friends. Likewise, many families have a desire to care for their loved ones at home.

To support these aspirations, the Government will dedicate at least S$3.5 billion over the next decade, to support the implementation of Age Well SG, of which S$1.9 billion will be dedicated to the Ministry of Health's (MOH's) initiatives.

Age Well SG is led by MOH, the Ministry of National Development (MND), the Ministry of Transport (MOT), with other partner agencies like the People's Association (PA), the Ministry of Social and family Development (MSF) and other volunteer organisations, to enable seniors to lead vibrant and fulfilling lives in the community with their families.

The whole village will work together to realise the Age Well SG plans.

First, we will invest in Active Ageing Centres (AACs), which will be a key enabler for seniors to Age Well within the community. Ultimately, we want seniors to be engaged and connected with their friends and families, which is key to keeping healthy. We would like to make it easier for seniors and families to access available care services and resources in the community.

The AACs are expanding the quality and range of their programmes and adapting their offerings to suit the preferences of seniors living in the vicinity. To make it easier for seniors to join in, most AACs also extend these programmes at community spaces, like PA's Residents' Network.

I am told that seniors can participate in classes and activities, and there are also programmes which have been proven to help seniors to age well physically and cognitively. Take learning as an example. The National Silver Academy (NSA) offers a diverse range of courses at about 60 AACs, ranging from topics like health and wellness, financial literacy, to information technology and science. There are also courses for seniors to pick up practical skills, like taking professional photos or floral arrangements. Most of these courses held at the AACs are affordable and around three-quarters of them are eligible for SkillsFuture credits.

11.00 am

Mr Yip Hon Weng asked about our plans for the roll-out of AACs, our outreach efforts, especially for those who might be socially isolated and how our initiatives can help to foster inter-generational bonding. I will address these points below.

We are scaling up our network of AACs. Since the implementation of the AAC service, we have grown to 157 AAC centres and have seen a steady increase in seniors engaged yearly – from 17,000 in 2021 to more than 49,000 seniors in 2022. We will do more and expand the network of AACs to 220 by the end of 2025. This means that by 2025, eight in 10 seniors will have access to AAC activities near their homes. AACs serve all seniors regardless of housing type. Therefore, if you have seniors among your loved ones, especially those living on their own, please encourage them to join a nearby AAC.

Secondly, under Age Well, we envision all seniors to be supported within the community, regardless of whether they live alone or with family. This is where the community is key. We have started this community effort. Together with volunteer ambassadors, the Silver Generation Office has engaged more than 330,000 seniors in the past fours years through house visits, including those who live alone or may have no family. They help to connect the seniors to community events or activities organised by AACs, such as communal dining.

As such, in addition to participating in activities at the AACs, we also hope for our seniors to join in our efforts in reaching out to other seniors in the community, together with their family and friends.

Let me share about Mdm Yuling Siah. For about eight years now, Mdm Siah has been actively reaching out to fellow seniors in the community through home visits and telephone engagements. Mdm Siah says that she finds it especially meaningful when she has good conversations with the people she reaches out to, who have now become her friends. And Mdm Siah is 72 years old!

Her spirit has caught on and now her daughter, granddaughter and son-in-law, have also joined in. We are happy that Mdm Siah is finding such meaning in her senior years and their volunteering has fostered and strengthened inter-generational bonds across the family.

Ultimately, we want our communities to be places where seniors gather with friends, keep active and stay healthy, starting with AACs.

Thirdly, we will enable seniors to be active and move around their neighbourhoods with ease. We will enhance our infrastructure. MND and the Ministry of Transport (MOT) will be making our flats, neighbourhoods and streets more senior-friendly through EASE 2.0, the upgrading of selected older precincts and MOT's Friendly Streets initiative. I am sure Members have seen how Silver Zones and the lifts at Pedestrian Overhead Bridges bring much joy to our seniors.

We will also make enhancements to the home environment. Dr Tan Wu Meng and Mr Yip Hon Weng would be happy to note that we will also introduce in-flat fall detectors to provide a peace of mind for families with seniors.

While we want seniors to be able to age in the community, with their families and friends, we recognise that families caring for seniors with care needs may face additional stresses. Therefore, we will do more to support these families in caring for their loved ones.

We have increased access to home medical care and improved affordability.

Today, the Government provides up to 80% means-tested subsidies to patients for home care services such as Home Medical, Home Nursing and Home Therapy. Since October 2023, MediSave500/700 and Flexi-MediSave schemes have been extended to homebound patients receiving home medical care from MOH-funded providers.

Dr Tan Wu Meng and Ms Mariam Jaafar asked about allaying costs beyond medical expenses. MOH's primary focus is to ensure healthcare services are affordable for all. Our mainstream financing Subsidies, MediShield Life, MediSave, MediFund (S+3Ms) framework, is thus focused on covering acute care, primary care, as well as long-term care services.

Nevertheless, we recognise that there are ancillary costs associated with caregiving and that health and social care are closely related. Hence, MOH has targeted grant schemes to better support families to defray other caregiving expenses, especially for the lower-income. This includes the Medical Escort and Transport (MET) services to help frail seniors attend medical appointments or travel to Senior Care Centres, the Home Caregiving Grant and Seniors' Mobility and Enabling Fund. We will continue to monitor and review. We try to help, but there is a limit to how much we can cover. Expanding scope of our financing will further push up national healthcare expenditure and ultimately result in a greater burden on people. To better support families and caregivers within the community, we will improve existing services and pilot new care models, as Dr Tan Wu Meng, Mr Yip Hong Weng and Mr Henry Kwek have suggested.

We are studying more options for home care, via an ongoing pilot. Under "HPC+", seniors are assisted in their daily activities, and this also includes housekeeping services.

As of January 2024, there are 328 clients enrolled under the HPC+ pilot. We will evaluate the pilot by end-2024, before determining whether to expand it nationwide.

We thank Mr Henry Kwek for his query on the stay-in shared caregiving sandbox which was launched to mitigate the impact of shrinking family sizes on family caregiving. Under this sandbox, a shared caregiver assists a group of seniors living in public or private estates with their activities of daily living. This sandbox will be in place for at least a year until the first quarter of 2025.

MOH will review its outcomes and take Mr Henry Kwek's feedback into consideration when determining next steps, which we will announce when finalised.

MOH will also introduce standardised care assessments and progressively appoint bundled-services providers, so that seniors can enjoy more seamless care delivery. This reduces the need for multiple assessments and unnecessary referrals by different care providers.

For seniors who require further care in Nursing Homes, the median wait time for nursing home placement is around one month. In the interim, the Agency for Integrated Care (AIC) works closely with the seniors and their caregivers to make alternative interim care arrangements as needed. These efforts will go some way to support families and caregivers. We want to make it easier for them to manage the cognitive and physical load of providing care for their loved ones at home. This includes senior caregivers who may be caring for senior family members.

In addition, we will provide caregivers with resources so that they can be supported in caring for their loved ones. Since November 2023, caregivers have also been able to use their SkillsFuture credits for eligible caregiver training courses. This year, we will be enhancing the Caregivers Training Grant from the current $200 per year to up to $400 per year per care recipient, to subsidise the cost of caregiving training conducted by approved training providers.

With these schemes, caregivers can receive more affordable and accessible caregiver training to help them care for their loved ones in the community.

I would like to assure Ms Carrie Tan that support for caregivers can be found in the community. Today, caregivers can access the AIC hotline and online resources available on AIC's website, as well as a Care Services Recommender on the Support-Go-Where portal.

We will also progressively level up all AACs as community touchpoints to provide information and referral services. For example, families and caregivers can visit an AAC to discuss how they can obtain the appropriate care for their seniors. There are also nine AIC links located in public hospitals to provide caregivers who are planning for the discharge of their loved ones from the hospital.

AIC also runs CREST and COMIT teams that provides support for seniors and caregivers with mental health needs. For socio-emotional support, caregivers can also tap on the Caregiver Support Networks (CSNs) and WIN Caregivers Network by PA.

Chairman, we have an ambitious vision to be a society where we age well. We are rolling out plans in the community that enable seniors to live active lives. We are investing in infrastructure across neighbourhoods. We are supporting families in caring for their loved ones. But, ultimately, it is about the heart ware, each of us looking out for one another, helping our seniors lead vibrant and fulfilling lives in the community.

Even as we are investing in more support for our seniors, we are also enhancing support for our young families to have healthy and happy lives.

In 2021, we set up the task force on Child and Maternal Health and Well-being, or CAMH in short. Comprising an interdisciplinary team of policy-makers and practitioners from across the health, social and education domains, the task force came together to explore how children and their families can attain good health and well-being.

I thank the task force members for their hard work over the past three years. They engaged parents and caregivers, brainstormed with partners and developed sound recommendations. Relying on evidence-based research, such as the Growing Up in Singapore Towards Healthy Outcomes, or GUSTO, study, we were able to formulate ways to improve the health of our children and families.

I am glad to announce that the task force has completed the development of the CAMH Strategy and Action Plan. Recommendations under the Strategy have been translated into 48 initiatives under the Action Plan. Currently, 28 out of the 48 initiatives have been or are being implemented, while the remainder are under review in preparation for launch. A detailed report will be shared later this year.

Let me now speak on two recommendations that exemplify our commitment to strengthen support for children and their families.

One of these recommendations is to enhance support for couples from pre-conception and pregnancy, through to parenthood. Many parents-to-be recognise that antenatal care is important as they prepare for the birth of their child. However, not all parents have access to resources and support.

Therefore, we have looked into increasing access to antenatal care. I am pleased to share that we will be piloting antenatal education classes for parents within the community. Those who attend these classes will have convenient access to subsidised antenatal support close to their homes.

Couples can look forward to learning about nutrition and exercises during pregnancy and after delivery and be equipped to care for their newborn. The classes will be conducted via a hybrid model, incorporating online lectures and videos, so that parents can easily access these useful resources virtually.

It is important that we support and celebrate active fathering too. In collaboration with the Families for Life Council and Centre for Fathering, we are strengthening the participation of fathers in parents' support groups in schools. This will provide more avenues for fathers to share and learn valuable parenting insights and tips.

We will continue to support fathers who may require more support in their parenthood journey.

11.15 am

At the Committee of Supply (COS) debate last year, I shared how the National University Hospital (NUH) expanded the Women's Emotional Health Service Plus (WEHS+) pilot, extending mental health support services to fathers in need. This support is important at the antenatal and postnatal stages as they take on the new role of a father. This pilot has also since extended support for mothers up to six years postnatal, up from the previous one year.

We want couples to feel supported and assured during their parenthood journey, even and especially when they meet challenges.

Let me share how Ms S and her husband benefited from the programme. As Ms S experienced postnatal depression and anxiety, the team followed up with regular check-ins and emotional support to ensure she was coping well. The team also ensured that her husband received timely assistance and treatment. Both are faring better now and the good news is that Ms S is expecting another baby. I am glad that this programme has given them the confidence and reassurance that they are well-supported in their journey.

Over time, Ms S and her husband will be able to transit to Family Nexus, which supports families with children aged zero to six, enabling them to access cross-domain services at a one-stop community touchpoint near their homes.

Last year, I announced the launch of the Family Nexus pilot at Our Tampines Hub. I am delighted to update that the Family Nexus pilot has been rolled out to three more sites in Singapore, at Choa Chu Kang, Punggol and Sembawang polyclinics, to extend support to more families.

Helping our children pick up good habits for good health during their formative years paves the way for better long-term health. Therefore, we want to empower parents with more resources and information to nurture healthy habits in their children. This, too, is one of the task force's recommendations.

During our engagements, many parents shared that they were on the lookout for accessible and reliable information to support them in nurturing their children. We shared about Parent Hub in 2022, a one-stop resource portal to provide timely information on pregnancy and parenting to families. Since its launch, Parent Hub has garnered over three million views, with over 100,000 page views monthly. We will continue to expand on these resources, such as by making new interactive evidence-based resources on nurturing healthy eating in childhood and other relevant topics available on the portal.

To better support individuals in nurturing healthy eating habits in children from young, I am happy to share that KK Women's and Children's Hospital and the College of Paediatrics and Child Health Singapore, launched the Singapore Guidelines for Feeding and Eating in Infants and Young Children last month. These guidelines support those involved in the care of children aged zero to two in nurturing healthy eating habits, providing goals and milestones in the transition from infant feeding to eating as a young child. I urge parents, caregivers and healthcare professionals to refer to these guidelines to promote a positive environment for the adoption of healthier eating habits in our young children, which would be beneficial to them in years to come.

We will make resources available beyond the early years. Students will be able to access online interactive resources through MOE's Student Learning Space this year. These resources will help students learn more about healthier eating habits and ways to have a balanced meal. These efforts are aligned with the GUSTO research study which shows that children's eating behaviours, such as portion size, food choice and nutrition, are key risk factors for childhood obesity. Allow me to summarise in Malay.

(In Malay): [Please refer to Vernacular Speech.] The MOH has developed plans for strategies and action for the health and well-being of seniors, as well as children and mothers.

We have completed the development of CAMH, which focuses on various stages from prenatal to adolescence, developing initiatives to support children and families in areas, such as prenatal care, parental support and healthy eating habits.

These initiatives will empower and support our families in caring for our seniors and children.

(In English): In closing, families are fundamental to enabling our seniors to age well and to fostering a nurturing environment for our children to grow, learn and thrive. We will continue to strengthen support for families. Together, we can build a society where every family is empowered to grow and age well and enjoy a life of health and well-being.

The Chairman: Minister Ong.

The Minister for Health (Mr Ong Ye Kung): Thank you, Chairman. I will devote a large part of my speech to address two pressing issues for healthcare: one is the hospital capacity crunch; the other is healthcare cost. Then, I will talk about the major transformation that we are bringing about in our healthcare system which will further address these two concerns.

Mr Pritam Singh, Mr Ang Wei Neng and Assoc Prof Jamus Lim raised the issue of capacity and waiting times at polyclinics and hospitals. Post-COVID-19, indeed, this is the experience of many countries around the world. Waiting times have gone up all around the world.

In Singapore, what is driving up hospital bed occupancy is the increased number of seniors with complex conditions post-COVID-19, and we saw a surge in the numbers. I have reported to the House earlier that average stay in hospital went up from about six days to seven days pre- and post-COVID-19, and that alone represents a 15% increase in patient load. This is happening against the backdrop of a rapidly ageing population, which compounds the problem and makes it a long-term challenge.

Mr Singh suggested that we provide dynamic waiting times of emergency departments (EDs) across hospitals publicly, in real time. It is possible, but we have been reluctant to do so, I think for a good reason. Ambulances today already have a process in place to ferry patients needing urgent care to the nearest appropriate hospital for priority treatment. However, at the EDs, 40% of cases are not life-threatening or urgent, but they ended up there anyway. So, our worry is that giving dynamic information may perversely drive more non-urgent cases to hospitals and worsen the overall situation.

I know it is very uncomfortable, very unsettling for a patient who is quite unwell to have to wait many hours for a bed. But please be assured that hospitals will triage patients quickly upon arrival and start treatment for urgent cases, even if the patient is waiting for a bed.

Mr Ang Wei Neng raised the issue of Changi General Hospital which was also reported in a Straits Times article. Changi is an old structure. It only has four ambulance bays. [Please refer to "Clarification by Minister for Health", Official Report, 6 March 2024, Vol 95, Issue 131, Correction By Written Statement section.] So, the queue will build up quite fast.

But actually, that is not the limiting factor. We can always triage in the ambulances. It is a small problem. What we need to watch out for are Intensive Care Unit (ICU) occupancy, resuscitation occupancy. If those are full, we divert the ambulances. Ambulance bays are full, we can handle. On the surface, it looks bad; but actually, operationally, it is not a huge problem to overcome.

Assoc Prof Jamus Lim suggested using more Urgent Care Centres (UCCs). UCCs have been useful and effective. We have also been using the General Practitioner (GP) First scheme, especially around Changi area, and that is also useful, and we will continue to deploy all possible methods to alleviate patient loads at the EDs.

To tackle the challenge more fundamentally, we need to expand capacity and catch up with the time lost, due to the COVID-19 pandemic.

We opened about 640 new acute and community hospital beds since June last year. They make up the over 11,000 public hospital beds that we have today. That is the stock we have – 11,000. We intend to add another 4,000 beds by 2030. And we should see new capacity coming on stream every year, from now to 2030.

Starting this year, and next, in 2024 and 2025, Woodlands Health will commission up to 700 beds. In 2026, Sengkang General Hospital and Outram Community Hospital are expected to expand by about 350 beds by converting non-clinical areas into hospital wards. Then in 2027, the Elective Care Centre at Singapore General Hospital (SGH) is expected to open; that has 300 beds. In 2028 and 2029, the redeveloped Alexandra Hospital is expected to open progressively. Then in 2029 and 2030, the new Eastern General Hospital Campus is expected to open progressively. Then we move into the early 2030s, that is when we hope to see the completion of a new regional public hospital that we have started work on.

We have just completed one in the North, Woodlands Health. We are building another one in the East. We are expanding SGH in the central region. So, the next new public hospital should be in the West. We are planning to site it in Tengah Town, which is an emerging population centre. It will best complement current hospitals in the West. The new hospital in Tengah will be run by the National University Health System cluster. Mr Ang Wei Neng is nodding his head.

Notwithstanding this plan to expand capacity, we should not be trapped in the mindset of "building hospitals" when thinking about capacity. There is potential to better anchor care outside of hospitals, in the community.

Not all patients require high acuity care and constant monitoring in a hospital throughout their treatment course. Many need convalescent care and rehabilitation, with the assurance that medical help is readily available nearby. That is why we have built more community hospitals for sub-acute and rehabilitation patients, and Transitional Care Facilities for patients who are waiting for longer-term care arrangements.

With our efforts, the number of long-staying patients have come down and these are patients defined as medically stable for discharge but they have been staying in the hospitals while waiting for longer-term care and they have been staying for longer than 21 days. This is what we refer to as long-staying patients. Two years ago, it was about 300 such patients at any one time in our hospital system. Now, it is under 200 patients at any one time and there is still room for improvement.

To facilitate appropriate transfers from acute hospitals to community settings, we will also be making a few policy changes, as follows.

One, more funding for community hospitals. Acute hospitals have experienced friction in transferring suitable patients to community hospitals. Why? For example, certain diagnostic services, such as computed tomography (CT) and magnetic resonance imaging (MRI) scans and certain more expensive drugs, are not subsidised in community hospitals today. This is based on the consideration that these are recovering patients and they may not need these interventions. Unfortunately, this means operational delays in transferring patients to community hospitals. There are patients who are medically ready to be transferred, but they are just waiting for a follow-up scan. They should be transferred without delay and do the scan at the community hospitals.

Others worry that after transfer, what if, unexpectedly, I need a scan for some reason. Hence, they insist on staying in the acute hospital, just in case. To remove this friction, from the last quarter of this year, we will allow more diagnostic services like CT and MRI scans and relevant drugs to be subsidised at community hospitals.

More broadly, we will also align the community hospital subsidy framework to the acute hospital subsidy framework. It used to be different. That way, patients receive the same subsidy rate, which is 50% to 80% throughout their inpatient stay, regardless of settings. With this enhancement, most community hospital patients will see smaller hospital bills.

The second change is to make Mobile Inpatient Care at Home (MIC@Home) a mainstream service. What is MIC@Home? This is a pilot project where we set up virtual hospital beds at the homes of patients, and have doctors and nurses visit them, as if they are in the hospital. Dr Tan Wu Meng, Mr Pritam Singh, Ms Ng Ling Ling and Ms Mariam Jaafar have asked or talked about such a scheme.

11.30 am

At the end of last year, more than 2,000 patients have benefited from the scheme. This translates to around 9,000 hospital bed days saved. Having done this for several months, we are convinced that the scheme works well for the patients and has great potential to relieve stress at hospitals.

Hence, from April this year, MIC@Home will become a mainstream model of care in our public healthcare institutions. As a result, patients can be assured that they will not pay any more for MIC@Home than they do for acute inpatient care in a public hospital. All our hospitals intend to price MIC@Home similar to, or lower than, a normal hospital ward. Patients will be supported by subsidies, MediShield Life and MediSave, no different from a physical inpatient stay.

In response to Assoc Prof Jamus Lim's suggestion, I do not think we therefore need to give an incentive for transition to home care now. It will be better to develop MIC@Home into a well-accepted mainstream mode for acute inpatient care. We will also further expand the capacity of MIC@Home, as a first step, from 100 in 2023, to 300 in 2024, with the potential to scale up further.

The third change is to encourage telehealth. Sir, 40% of attendances in a typical polyclinic are for chronic care management. Last year, we extended subsidies and allowed the use of MediSave for the use of telehealth, for chronic care. By the second half of this year, we will also expand MediSave coverage to telehealth consults for preventive care services, such as follow-up reviews after regular health screening. This represents another 10% of polyclinic attendances.

With this change, telehealth is treated almost the same way as physical consultations in terms of financial support. The only difference is telehealth for common illnesses, that is, when patients experience symptoms, like cough, cold and fever. Patients still cannot use MediSave for such consults for common illnesses. Also for a good reason. We are holding this back as many people have been using such teleconsults as an easy way to get medical certificates (MCs). So, there will need to be greater discipline in issuing MCs before we consider this final move.

Another key aspect to expanding capacity is to enhance manpower. Mr Ang Wei Neng and Dr Tan Wu Meng asked if we need to produce more doctors to meet demand. Yes, we have been and will continue to do so. In fact, intakes into our local medical schools have increased by about 30% over the past 10 years, to about 500 now. If you consider each cohort, it is now slightly over 30,000. About half of them, 15,000 or so, 15,000 to 17,000 go to university; and out of that group, 500 are training to be doctors. [Please refer to "Clarification by Minister for Health", Official Report, 6 March 2024, Vol 95, Issue 131, Correction By Written Statement section.]

Still, more are training to be Allied Health Professionals and nurses. So, we are taking quite a lot of talent. We are also offering awards and grants to actively attract Singaporeans who graduated from overseas medical schools back into the local public healthcare system.

Where does Singapore stand, in terms of our doctor to population ratio? Ours, in terms of practising doctors, is about 2.6. Let us put that number into some perspective. Compared to developing countries, we are ahead, we are higher. Compared to developed economies in Asia, we are similar. Korea, Hong Kong and Taiwan are all around 2.6. Japan is also 2.6 and despite having actually aged much earlier than us, with about 30% of their population 65 and older.

Then, if you compare to developed Anglo-Saxon countries – the United Kingdom (UK), United States (US), Canada – we are just slightly behind.

It is really when we compare to European countries – continental European countries, Australia – that we are a notch behind. Why is that so? I think there are various reasons. It could be a legacy of the welfare state. It could be the fact that European countries do not really have a tradition of planning for manpower.

We can explore if further increases are needed, but we have to recognise that talent is in short supply across all sectors. And healthcare, we should attract our fair share, but not disproportionate share of talent. Beyond this fair share, countries can also end up chasing its own tail.

Why is that so? For one, it is not a simple numbers game. The right mix of doctors is just as important as the sheer number of doctors. If, somehow, doctors get registered but do not practise, it does not help. If doctors are practising, but they go into areas like aesthetics, it also does not help very much.

In Singapore, graduates from medical schools are already finding it more competitive to get residency positions to be trained as specialists, because there is not much of a shortage in many of these specialist areas. On the other hand, we are facing shortages in areas like family medicine, internal medicine, geriatric medicine and rehabilitation medicine.

This is because as Singapore becomes a super-aged society, we have more patients with complex and multiple medical conditions, needing doctors with these more broad-based skillsets. Hence, MOH has been increasing the number of training positions in these specialist areas.

We have also seen in many countries, how supply of doctors creates its own demand. As more doctors compete for business, there will be a tendency to prescribe more tests, scans, medications and procedures. Patients are not likely to say no because your health is at stake, and especially if healthcare is free or insurance covers all the costs.

Hence, while Mr Ang Wei Neng provided numbers to show that Singapore's doctor-to-population ratio is lower than some Organisation for Economic Co-operation and Development (OECD) countries, this did not translate to poorer health outcomes, less accessibility or affordability in Singapore. For example, we know that the US healthcare system is not the most accessible unless you have the right insurance.

The UK's higher doctor-to-population ratio than us, has eight million patients on their waiting lists and is suffering from a chronic capacity crunch. Germany, also much higher than us in terms of the ratio, is facing a major challenge meeting the healthcare needs of their seniors across their länders or their states. Conversely, Singapore, we are delivering quite good healthcare outcomes.

A commonly accepted broad measure is the expected health span and lifespan of our people. In Singapore, a person is expected to live up to 74 years old in good health, one of the highest in the world; compared to 66 in the US; 70 in the UK; 71 to 72 in Germany, France, Denmark, Netherlands, Australia and so forth.

Singapore achieved this by spending about 5% of our gross domestic product (GDP) on healthcare, compared to 10% to 13% in most developed countries; 17% in the US. In short, we have better outcomes with less spending and lower hospital beds and doctors-to-population ratios than many OECD countries, because it is not just a numbers game.

The quality and the mix of doctors, the geographical spread of the country, how the whole system is run, the behaviour of patients – all makes a big difference. We have a lot of room for improvement, but there is no reason to feel bad about ourselves or to envy others. We are, in fact, in a good place as we continue to learn from others and strive for improvements.

Chairman, let me now address the next concern, which is rising healthcare costs. Dr Lim Wee Kiak, Ms Mariam Jaafar and Ms Ng Ling Ling asked, what is driving up healthcare costs? In this section, I will talk about the likely reasons for rising healthcare costs, explain the realities of healthcare financing and then what we are doing to try to moderate costs.

A major factor for rising healthcare costs is that we are getting older, and as we get older, we are more likely to fall seriously ill. Over the last five years, the number of Singaporean seniors increased by almost 20%, from 560,000 to 690,000 now. We are on the verge of becoming a super-aged society. These are not macro numbers, it directly affects individuals and families. So, when in a family, one member grows older and falls seriously ill, the entire family feels the burden of healthcare costs and also the caregiving burden.

The second reason, advancement in medical technology. Technological advancement can make a car or a smartphone cheaper and better. But in healthcare, it is often not the case. New treatments may work better, but always cost more. For example, advancement in orthopaedic surgeries have made knee replacements much easier to do. In my constituencies, I met many seniors who have gone through knee replacements. Sometimes, they have gone through both and when I meet them – I have gone through one – we end up comparing our battle scars.

In the past, people with degenerating blood vessels in their eyes due to old age, they will lose their central vision. Now, the condition can be treated and controlled through repeated intravitral injections. These advancements allow a person who cannot walk, to walk again; allow a person who would have been blind, to see again.

The value to the patients is priceless. The cost to the patients has also gone up.

Third, healthcare costs inflation. Even for the same treatment, not talking about medical advancement; the same treatment, the cost has gone up. Inflation all around the world has gone up in recent years and that has also affected healthcare costs. A key component of healthcare delivery cost is manpower.

In Singapore, manpower is more than half of the cost to run the healthcare system. We all agree we need to compensate our healthcare workers fairly and competitively. As healthcare demands have gone up in many countries, the competition for medical manpower is now international and has become more intense. And this pushed up manpower costs and, therefore, healthcare costs.

Finally, insurance. Insurance gives us peace of mind. But when the coverage becomes too generous down to the last dollar, we start to see excessive prescriptions and tests and even unnecessary treatments. This is the classic buffet syndrome, which has driven up claims. Already paid for, might as well overeat.

It has driven up claims and, therefore, it has driven up insurance premiums. Yet, it is frustrating to see insurance companies continue to offer unsustainable terms – presumably they are competing for market share. So, how do we address rising healthcare costs? We need to first recognise two truisms in healthcare financing.

The first truism is that, ultimately, the people always pay. Let me explain with a personal example. When my wife and I moved to Switzerland for a year for me to do my Master's programme, that was in 1999, we had to make a social security payment. I cannot remember the name, but it was not cheap. A few thousand Swiss francs for the both of us. It was compulsory. If we do not pay, we could not live in Switzerland. Then, we got pregnant. My wife found a good gynaecologist. Each time we visited her, we can just go in and go out. We did not have to pay anything. Was it really free? Not really. We paid for it already, through the rather expensive social security fee.

In Britain, the National Health Service (NHS) operates by the principle of free healthcare at the point of delivery. No UK government has ever touched that principle. It continues to be free at the point of delivery.

But is it really free? Not really. The British have to pay high taxes to finance the NHS, because there is no cost at the point of healthcare delivery, the waiting times at the NHS are very long. I talked about eight million people waiting. So, British patients are also paying with their time and their patience.

There are different ways to pay for healthcare: by taxes, by compulsory social security payments, through insurance premiums or personal savings or your personal time. Ultimately, the people always pay one way or another. That is truism number one.

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This leads to the second truism, which is how we pay affects how much we pay. If a government uses taxes to make healthcare "free" at the point of delivery, then it will likely lead to the buffet syndrome that I just mentioned. There will be over-consumption, wastage and high-cost inflation. If a government leaves the people to buy their own health insurance, people will tend to be very careful, which can moderate healthcare expenditure. But if someone did not buy insurance and is uninsured, they will be underserved.

That is why in Singapore, we weaved together a more robust way to pay for healthcare. It comprises subsidy funded by taxation; MediSave which is own personal savings; MediShield Life which is a national insurance scheme; and MediFund which is the final social safety net – what we termed S+3Ms. S+3Ms ensures universality because it provides all Singaporeans access to quality healthcare. It is also a targeted system, focusing assistance on those who need it the most.

To illustrate, subsidies of up to 80% are extended to C Class wards in public hospitals, but not A Class wards, not private hospitals. MediShield Life covers a significant part of the remaining bill after subsidy, but we ensure some co-payment by patients, mostly through MediSave, so that there is less of a buffet syndrome. MediFund comes in for the lowest income who cannot afford the co-payment.

This is a key reason why we can achieve good health outcomes with national healthcare spending of 5% of GDP, compared to jurisdictions with blanket assistance schemes. With these two truisms in mind, what can we do and what are we doing about rising healthcare costs?

First, let me start with the S, of S+3Ms. Subsidies will have a big role to play.

When I first joined the Government in 2015 and entered this House, I was the Acting Minister for Education. The Ministry of Education's (MOE's) budget was the second largest amongst Ministries, at about S$12 billion, and only behind the Ministry of Defence's (MINDEF's). MOH's was the distant third, just over S$9 billion. Today, nine years later, I am now the Minister for Health. MOH's budget has far surpassed MOE's, to almost S$19 billion and not very far behind MINDEF's.

MOH's budget is tax-funded. It is channeled to fund many aspects of the healthcare system: build new healthcare infrastructure, operate hospitals, polyclinics and nursing homes, procure medicines and equipment, developing new IT systems, hiring doctors, nurses and all our medical personnel. MOH's budget is tax-funded and constitutes healthcare subsidies, which have been rising significantly over the years.

Then, the second M – MediShield Life – will also need to work harder. To this end, we will be conducting a comprehensive review of MediShield Life. MediShield Life, as I mentioned, is a national health insurance scheme. It covers everyone for life, even those with pre-existing illnesses. It is specifically designed for the great majority of subsidised patients who are encountering a major health episode.

The last sentence needs some deciphering. It contains a couple of important phrases, which I will explain. I said it covers great majority of subsidised patients, because most Singaporeans seek subsidised care and the "great majority of them" need financial assistance to foot their healthcare bills.

Hence, for a C Class Ward patient, he will find that after subsidy, MediShield Life claims should substantially pay for the rest of his hospital bill. For a patient that goes to a private hospital, he will find that MediShield Life covers only a modest part of his hospital bill. That is how MediShield Life is focused on the subsidised patients, especially those that uses C Class wards.

Then "a major health episode", because this upholds the spirit of insurance, which is to protect us against rare occasions when we incur a big hospital bill because we fall seriously ill.

With that context, let me report the state of MediShield Life today. It was designed such that nine out of 10 subsidised bills are adequately covered. Nine out of 10. What remains are relatively small and expected co-payments, which can be paid from MediSave. However, this nine in 10 benchmark is being eroded, because the size of hospital bills is getting even bigger. Bill sizes have grown by 5% annually in public hospitals and by 7% annually in private hospitals over the last few years.

As a result, the proportion of subsidised bills adequately covered by MediShield Life has come down to around eight out of 10 and is expected to slip further. What is the practical impact? Subsidised patients are seeing hospital bills that are unexpectedly large. And after subsidy and MediShield Life, there is still a substantial out-of-pocket component left. This is when higher healthcare costs really start to bite.

MOH has, therefore, tasked our MediShield Life Council – which is from various stakeholders led by a private sector person – to comprehensively review the scheme, but we have given the Council some direction.

First, enhance MediShield Life to give Singaporeans greater assurance against large bills. This means increasing how much a patient can claim from MediShield Life – this is what we call claim limits – for both surgeries and hospital stays.

We envisage a fairly significant increase in the claim limits. For example, for an episode involving angioplasty where a stent is placed into your heart to open up a blocked artery, plus, say, a few nights in ICU, the claim limits may need to double, times two. This will reduce out-of-pocket costs significantly.

Second, enhance other outpatient coverage. We also need to raise the claim limits for treatments, such as kidney dialysis, to reduce out of pocket expenses for patients. The Council will also explore extending coverage to more types of outpatient care.

Some of the most costly outpatient treatments are for cancer. Ms Sylvia Lim asked if we could improve financial literacy for patients to better plan against such a disease. There are resources available online and we will raise the public's awareness to them. But I think the issue goes beyond financial literacy. It is actually more serious than that. We are facing an especially difficult challenge for cancer, as treatment costs were rising uncontrollably. So, I am not surprised at the survey results that you cited at all.

Hence, we recently reviewed cancer drug financing and introduced changes that will allow us to negotiate for lower prices for cancer drugs. As a result, prices for approved cancer drugs have since dropped significantly, some by up to 60%. The impact is still playing out and we will continue to monitor the situation.

Third, the Council will consider expanding MediShield Life coverage to new groundbreaking treatments, specifically Cell, Tissue and Gene Therapy Products (CTGTPs).

Medical science is advancing rapidly and CTGTPs have the potential to revolutionise healthcare and deliver effective treatment of previously incurable diseases. Some describe these as the equivalent of a moonshot for healthcare. Essentially, the treatment involved is, we extract blood from a patient, then with the blood, you teach and equip the cells in the blood to target and kill, say, cancer cells, then you put the cells back into the patient's body to do its work. It is a one-time treatment. However, while the technology is promising and advancing fast, it is nascent and very expensive. It could cost anything from a few hundred thousand dollars to a few million dollars, per treatment.

We want to start including CTGTPs under MediShield Life. But, we need to put in place safeguards to ensure that financing of CTGTPs is sustainable. For instance, we will need to extend MediShield Life coverage only to treatments that are assessed to be safe, clinically effective and cost effective. In other words, if a treatment costs a few million dollars with a small hope of curing a small group of people, it is not cost effective. This is a significant step to help all Singaporean patients, regardless of their income levels, have access to cost effective, novel, state-of-the-art therapies.

These proposed changes will better protect subsidised patients against major health episodes. MediShield Life premiums, however, will inevitably go up.

The last time we reviewed the scheme, premiums went up by 25% on average. But, rest assured that we will do the necessary to ensure that, as far as possible, premiums can be paid fully by MediSave. For example, we will consider enhancing premium subsidies, or have MediSave top-ups for specific groups. We may have to use more MediSave for small hospital bills, so that MediShield Life can better focus on big hospital bills, and in that way, we moderate premium increases. No one will lose MediShield Life coverage due to a genuine inability to afford the premiums. We will share more details when the Council completes its review in the second half of this year.

Mr Chair, while we address these immediate concerns, we should not lose sight of the longer-term, strategic direction of healthcare. That is, continue to build health and not just treat illnesses.

We have crystalised this strategy around Healthier SG. Ms Ng Ling Ling, Mr Yip Hon Weng and Dr Syed Harun asked for an update on Healthier SG. I am very glad to say that it has been progressing encouragingly.

Let me report some data. Since the programme was launched in July last year, we have invited 2.4 million Singapore residents, aged 40 and above, to participate. As of last month, 765,000 have enrolled with a family doctor of their choice. Sir, 60% are enrolled with GPs and the remaining with polyclinics. This is a good split, because a key thrust of Healthier SG is to empower our GPs to play a greater role in population health.

Over half of the enrollees have started consulting their chosen doctors to develop a personal Health Plan and they have been rewarded S$20 worth of Healthpoints. More than 124,000 enrollees have received their free vaccinations and health screenings.

Over the past year, the number of participants in exercise sessions organised by the Health Promotion Board (HPB) has increased by 16%, from 133,000 to 154,000. For sessions organised by PA, participation has gone up 12%, from about 400,000 to 450,000. For SportSG's sessions, it has increased by 20%, from 117,000 to 140,000.

So, we see a discernible increase in people becoming active and individuals are also up and about on their own. The change, I think, is somewhat palpable. This is the new Active Singapore.

Ms Ng Ling Ling asked if we expect prevalence rate of chronic illnesses to come down due to Healthier SG. That is certainly our aim. With a strong start to Healthier SG, we certainly hope this will happen. But it will take time.

We have recently raised chronic drug subsidies for Healthier SG enrollees seeking care at their Healthier SG GP clinics. In the coming year, we plan to implement further improvements to the scheme.

First, expand the range of health protocols. GPs are guided by Healthier SG Protocols, to ensure that residents enjoy consistent and quality care. There are 12 protocols so far, which include screening, vaccination and management of common chronic diseases.

MOH will expand the range of protocols to cover more conditions, such as stable ischemic heart diseases and stable stroke. We will start to roll them out in early 2025. As announced earlier, we are also starting to work on including aspects of mental health into the protocols.

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Second, we will improve the health plans. Currently, your enrolled doctor will co-develop a health plan with you as part of the preventive care consultation. It covers essential action items, such as regular health screening and vaccinations. But on the lifestyle, the advice is always quite generic, such as "exercise more", "eat better". In 2024, we will start to make the advice more specific. For example, it may recommend you do aerobic exercise three times a week. You can then use the Healthy 365 app to identify suitable exercise activities near your home. Key features in Healthy 365 will be made multilingual.

Third, we will continue to roll out interventions for our seniors through the Age Well SG programme, which Second Minister Masagos has elaborated.

Fourth, we will continue to fight against overconsumption of sugar and sodium. Our Nutri-Grade labelling of pre-packaged drinks have been useful in changing consumer behaviour. I will regularly and personally inspect the drinks in the Members' Room. Some of you saw me do it. [Laughter.] I am glad to report they are all graded "A" and "B", and passed the MOH Ministerial inspection.

There is one drink, however, "zero sugar salty lychee". So, I texted my staff to say what do we label this for? For sugar or for sodium? They told me to just drink it.

I also encountered students who are asking for less sugar in their bubble tea, so that it qualifies for Nutri-Grade "B". As the Minister for Education, I always tell students, do not be so grade conscious. But in this case, it is good to be grade conscious and go for "A" and "B".

We have recently extended Nutri-Grade to freshly made beverages. I met the two key coffee shop associations recently and sought their support. The association leaders are fully on board. Together they represent over half of the coffee shops in Singapore, and they intend to start serving "siu dai" or less sugar beverages by default. This means when you order a kopi in future, they give you "siu dai", even though you do not say it. If you want even less sugar, I recommend just drink "kosong".

Sodium is the other culprit that can lead to heart diseases and strokes, if over-consumed. It is found in salt, soya sauce, belachan and other sauces. With much effort from the HPB, over 60% of wholesalers of salt are now supplying lower-sodium salt. About 30% of the catering industry are supporting our "Less Salt, More Taste" movement since it was launched late last year. 20% of the food and beverage industry are also doing so.

I recently saw an encouraging programme on Channel 8. There were two lady hosts, they went on a 21-day challenge to take less salt and less soya sauce. At the end of the 21 days, their blood pressure measurements had moderated somewhat, but more importantly, their taste buds had become much more sensitive to salt. They could now taste the ingredients better, they never knew when they taste something, there are undertones of garlic, ginger, spices. They used to just taste soya sauce and belachan, and they prefer to eat less salt now. It took 21 days to change a lifelong habit.

Remember, because we eat every day, the effect of food accumulates through our lifetimes. Over our lifetimes, food can be medicine, food can also be poison. As a wise traditional chinese medicine (TCM) physician once told me, if you eat well, there is no need for medicine; if you do not eat well, medicine is of little use.

Mr Chairman, Dr Tan Wu Meng urged that healthcare needs to be delivered across time and space, which we agree. This is, in fact, a key aspect of the transformation we are striving for. Whereas sickness often needs to be treated in clinics and hospitals, health almost exclusively has to be built up in communities and in our homes. MOH has been working on this transformation and we have made a few strategic policy changes over the last couple of years.

Patient data needs to flow across care delivering settings, from hospitals to clinics, to senior care and rehabilitation centres. This piece of work is almost done. What remains is a new law, which I hope to table in this House in the later part of this year. Regulation needs to move from being premises centric to services centric. So, we do not regulate hospitals or clinics, but the services delivered, regardless of settings. That is why we revamped our legislation to enact the new Healthcare Services Act (HCSA).

Financial support needs to be settings and premises neutral. But we cannot simply apply this based on first principles, as it is bound to lead to abuse and unintended behaviour. Instead, we progressively identify the situations and circumstances where premises-neutrality should apply, and then make deliberate rule changes. We made a few changes last year on the mutual recognition of MediFund and extension of MediSave support to manage chronic illnesses via telehealth. This year, I just announced further moves on community hospitals, MIC@Home and MediSave support for telehealth.

Most importantly, we need to be decisive and deliberate in making investments in preventive care and health of our population. We often hear calls for investment in hospital capacity, in our medical manpower. This is valid. But what is more important for the long term is capacity expansion in communities and society, in its ability to prevent sickness and build health. We are doing so via Healthier SG, and we are starting to see a change. More residents are coming forward to exercise, cycle, run or brisk walk. People are watching their sugar intake.

Sodium takes a while more. Food and beverage (F&B) players are switching to lower-sodium salt. Christine Lock, who sells nasi lemak, she was the first to do so at Bukit Canberra Hawker Centre. She did so voluntarily, because she had a loved one who suffered a heart attack. She said, "I want to take care of my customers."

Film Director Jack Neo has started a brisk walking group for seniors, started during the pandemic. It is called "趴趴走". In English, it means walking around for fun. His event is every week, and it will attract almost 1,000 participants, young and old, from all over Singapore. If they descend on one of your communities, you will immediately notice. A thousand people gathering somewhere. For them, brisk walking has become a new habit, and they made new friends. Jack and his team even composed a song about "趴趴走" and incorporated messages of Healthier SG. They did not consult me. So, when I joined them two weeks ago, everyone sang the song. Everyone knew the song except me.

Let me also share the story of Ms Cynthia Phua. Many Members will know her, she was a former Member of Parliament. She agreed to let me share her story with you today. She enrolled into Healthier SG late last year, with a GP clinic near her home. The GP noticed that she had not done a mammogram for three years. So, repeatedly reminded her to do. Eventually she did, late last year. That was when Cynthia found out that she might have breast cancer and it was later confirmed through a biopsy. Fortunately, it was discovered early. She has since gone through an operation to remove the tumour and no further tumours were discovered in her body.

Cynthia is now resting and undergoing treatment. She is in good spirits. We wish her all the best. She wants me to tell everyone – please push for Healthier SG in your communities. You know how persistent Cynthia can be when she calls for action, because it can change lives and it can save lives.

The UK Legatum Institute ranks healthcare systems in the world in a holistic manner. They do not just take into account of your doctor to population ratio or your healthcare capacity, or what kind of state of the art equipment you use, but they also evaluate population health and preventive care systems. They ranked Singapore as having the best healthcare system in the world in 2023. This is a valuable vote of confidence in our system. It encourages us to improve and do better.

It is said that there is an unbreakable iron triangle in healthcare. The three aims in healthcare: affordability, quality and accessibility. They are also trade-offs, such that improvement in one area always comes at the expense of the other two areas.

I have outlined how, by using MIC@Home and right-siting, we can increase capacity without necessarily building more hospital beds. In other words, improve accessibility, without compromising quality of care. By weaving insurance and co-payment, we reduce out-of-pocket payment for patients, while containing excessive demand for healthcare. Hence, improving affordability, without undermining accessibility. And more importantly, by building better health through Healthier SG, we achieve all three aims at the same time and enable people to lead longer, healthier and more meaningful lives.

Healthier SG is not a Government programme or a financing scheme. It is a movement for Singaporeans, a new way of life, a new compact between people, the community and the Government. We may not have broken the iron triangle to open a straight and easy line to good health. But we have made a good start and carved our own path to achieve greater happiness and probably prosperity, depending on how you look at it, for ourselves, our families and our nation. [Applause.]

The Chairman: Senior Minister of State Janil.

The Senior Minister of State for Health (Dr Janil Puthucheary): Mr Chair, our population is ageing rapidly. As we age, we become more susceptible to developing serious diseases. As a nation, we have become less healthy in the past decade, with a general rise in the prevalence of chronic diseases, such as hypertension.

Life expectancy in Singapore has improved over the last 10 years. Seniors are increasingly living alone, and this trend is expected to continue as our population ages and average household size decreases. For all these reasons and others, the strain on individuals and their families and the impact on our healthcare system will increase significantly in the coming years.

We need to strengthen our healthcare system to meet these challenges by proactively encouraging healthier lifestyles and preventing or delaying the onset of poor health. This involves strengthening healthcare services in the community closer to individuals' everyday environment and leveraging our extensive network of family doctors and community partners as necessary. While we continue to invest in building new healthcare infrastructure, upgrading existing ones, we are also expanding our primary and community care services.

Studies have shown that individuals with a regular family doctor experience better health outcomes, including fewer hospitalisations and emergency department visits. Beyond managing our acute and chronic illnesses, the primary care team also plays a vital role in preventing the onset of serious illnesses. An ongoing relationship with a regular doctor allows for deeper understanding and familiarity with patients' medical conditions, sensitivities to medications and foods, and their day-to-day lives of the patient. This results, ultimately, in better care.

Mr Ang Wei Neng asked about plans to build more polyclinics to cater to the increasing demands of our ageing population, particularly in the Western region. There are 25 polyclinics and over 1,000 Healthier SG GP clinics today. By 2030, we will have 32 polyclinics and we hope to have more Healthier SG GP clinics. There will be three new polyclinics in the western region: one in Tengah which will be completed by 2025, another in Yew Tee by 2027 and the third in Taman Jurong by 2028. The existing Clementi Polyclinic and Jurong Polyclinic will also be redeveloped by 2030 to increase their capacities.

I agree with Dr Tan Wu Meng on the need to ensure adequate accessibility between polyclinics and major transportation nodes. For the redeveloped Clementi Polyclinic, MOH has worked with the Land Transport Authority (LTA) to ensure that sheltered pedestrian access will be provided between the building and Clementi MRT station's nearest exit, save for the junction across Clementi Ave 3, where such shelters will not be practical, because the junction is wide and there are double-decker buses passing through.

As our society ages, we need to ensure that seniors' social and health needs are adequately supported in the community. Having strong social support networks have been shown to contribute to better health outcomes. This is particularly important for seniors who live alone and are at risk of social isolation. AACs will collaborate with healthcare providers, including family doctors, as well as work with other community providers and Government agencies for active ageing programmes.

In addition to physical health, we also need to look after our mental health. At the Parliament Motion on advancing mental health last month, this House recognised the importance of mental health as a health, social and economic issue, and affirmed the importance of a robust national mental health ecosystem to enhance mental health and well-being.

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Mr Keith Chua asked about key areas that the National Mental Health Office (NMHO) will be focusing on. The Office is expected to be fully established by 2025, comprising officers from MOH, MSF and MOE. It will oversee the implementation of various plans under the National Mental Health and Well-Being Strategy and shape the development of future mental health initiatives, building upon previous efforts such as the National Mental Health Blueprint and the Community Mental Health Masterplan.

Under the Office, we will scale up mental health services in the primary and community care settings and strengthen access to community-based care. Specifically, initial plans include building the competencies of professionals and frontline personnel. We will include staff in religious organisations to support persons with mental health needs, to address Dr Wan Rizal's question about involving religious organisations in community mental health support. Other plans include promoting early care access through publicising key mental health first-stop touchpoints and ensuring better care coordination among service providers through the development of a practice guide. The Office will also track indicators to monitor the progress and outcomes of these plans, as reflected in the National Mental Health and Well-being Strategy Report.

While persons with severe mental health conditions may seek psychiatric care at hospitals, those with mild to moderate mental health symptoms would benefit more from care delivered in the community, as compared to being institutionalised for treatment or being removed from their daily routines and social networks.

Dr Syed Harun asked if mental health will be a focus of Healthier SG implementation plans. Let me elaborate on how we are scaling up mental health services in the primary and community care settings.

Today, 19 out of the existing 25 polyclinics provide mental health services. In addition, over 450 GPs have been trained to support persons with mental health needs under the Mental Health General Practitioner Partnership (MHGPP). To bring mental health services closer to where individuals live, we will expand mental health support in all polyclinics and Healthier SG clinics by 2030. MOH will also be developing mental health protocols and incorporating mental health care and support, as part of the scope of practice for GPs in Healthier SG clinics.

We will also be strengthening mental health outreach and intervention in the community. Today, we have 73 Community Outreach Teams (CREST) that detect and help individuals with mental health needs. By 2030, we will expand the number of outreach teams to 90.

For those who require more intensive mental health support, they can be referred to any of our 29 Community Intervention Teams (COMIT), which will be expanded to 50 teams by 2030. These teams support GPs in the provision of psychosocial interventions for persons with mental health needs in the community. This also addresses Dr Wan Rizal's question on what is being done to enhance the accessibility and integration of mental health services within the community.

Sir, there are critical structures and policies to support the effective delivery of preventive healthcare. Our primary care teams need to be suitably sized and equipped with the right skills. They also need to be adequately supported to provide team-based and integrated care, through Primary Care Networks (PCNs) and consultations with specialists and by leveraging on technology.

Mr Yip Hon Weng highlighted the need to ensure GPs in participating Healthier SG GP clinics have the necessary resources and expertise to effectively manage chronic conditions. Ms Ng Ling Ling also asked how the Government intends to support the professional development of GPs, especially in areas that they may be increasingly involved in, such as social prescriptions to influence patients' lifestyle choices for better health outcomes and treatment of common mental health conditions. Dr Syed Harun asked about retention plans for healthcare professionals to support Healthier SG and the shift towards preventive health.

MOH is working closely with Institutes of Higher Learning (IHLs) to increase local training pipelines. We are also committed to the development of family doctors in primary and community care and have placed a stronger emphasis on family medicine training, such as encouraging more doctors to take up postgraduate Family Medicine training like the Graduate Diploma in Family Medicine (GDFM) and the Masters of Medicine in Family Medicine. Postgraduate training in Family Medicine is also strengthened to help family doctors be more equipped to manage a wider range of complex conditions across different age groups. Training is delivered through various modalities including video conferencing and webinar platforms, allowing GPs more flexibility as they keep up to date with the latest developments in family medicine.

At the same time, we are increasing the number of nurses, pharmacists and other allied health professionals in the community, and are providing interdisciplinary training to empower them to practise at the highest level of their licences. We will also expand the role of community pharmacists and other allied health professionals in primary and community care to improve care delivery in the community. We will also train more lay extenders. These are non-medically trained persons who can undertake tasks, such as arranging the initial health screening and coordinating referrals to community programmes. Healthcare professionals can then focus on clinical care.

Primary care teams will be supported with Healthier SG Care Protocols to ensure consistent, quality care for patients. These care protocols lay out clear processes, referrals and data flows to guide GPs in managing each health condition. Twelve care protocols were released during the launch of Healthier SG on the management of common chronic conditions, such as diabetes, high cholesterol and preventive health, such as smoking cessation and weight management. More care protocols will be developed to cover more chronic diseases in the future. We recognise that some GPs may have more experience in managing certain chronic conditions than others. Therefore, we will work closely with the College of Family Physicians Singapore (CFPS), AIC and healthcare clusters to roll out training for GPs and their care teams for each care protocol. We will also support GPs in the provision of holistic care for patients with mental health needs by strengthening the links to COMIT for non-pharmacological mental health support.

Sir, Dr Tan Wu Meng asked if MOH is reviewing the time required by GP clinics to deliver holistic care. As we mobilise family doctors to co-develop health plans with their patients, which can include adjustments to lifestyles and regular health screening, we expect that the percentage of patients requiring longer clinic consultations to increase. This has been taken into account when planning for future primary care capacity. To allow family doctors to focus on optimising clinical care, we have adopted a team-based care approach in polyclinics and private GP clinics. In polyclinics, patients with chronic conditions are assigned to multidisciplinary care teams comprising family physicians, nurse care managers and care coordinators.

In private GP clinics, PCNs anchor and strengthen team-based care for chronic diseases, by pooling resources to organise core ancillary services provided by nurses and care coordinators who work with GPs to jointly manage the patients' conditions. The number of clinics participating in a PCN has grown, from 340 clinics in 2018, to more than 1,000 clinics today.

Our clusters will also step up as regional health managers, working with family doctors and other partners to address health and social needs of residents in their region and anchor care in the community. Family doctors may work with specialists or hospital doctors in the management of patients with more complex needs, for example. Upon discharge, the hospitals would refer patients to the family doctor they are enrolled with, to ensure continuity of care between the hospital space and the primary care space.

Dr Syed Harun asked about systems integration plans to support Healthier SG. To facilitate holistic, integrated and coordinated care provided by multiple healthcare providers across hospital-based and community care settings, we need to simplify how our healthcare providers access and share data. The importance of a well-integrated and reliable IT system to connect healthcare providers has been highlighted by many GPs.

The National Electronic Health Record (NEHR) is a key tool for supporting holistic and integrated care. It serves as a centralised repository of key health information that healthcare professionals can access and can contribute to. Its capabilities will be enhanced to cater to a wider spectrum of care providers in a safe and secure manner, enabling healthcare providers in different care settings to make better decisions when caring for their patients.

The upcoming Health Information Bill will also establish the framework to govern the collection, access, use and sharing of selected health information across various settings to facilitate the continuity of care.

Specific to primary care, we have supported GP clinics and their IT vendors to upgrade their IT systems, to simplify administrative processes and to improve data flows, while ensuring data sharing is secure. For example, under Healthier SG, we have rolled out the Clinic Management System Tiering Framework for Primary Care to ensure that IT systems used by private GP clinics are integrated with national programmes, for a more seamless delivery of care.

We have also enhanced our national digital health app, HealthHub, to empower residents to manage their own health. Through HealthHub, residents can enrol for Healthier SG, view their personalised health plans, manage medical appointments and view their health screening results and vaccination records. We plan to expand the type of health records available through HealthHub in the future.

Dr Lim Wee Kiak and Ms Mariam Jaafar suggested making use of technology and artificial intelligence (AI) to optimise healthcare delivery for cost effectiveness and improved patient outcomes. Our healthcare institutions use proven, cost-effective technology extensively to automate manual tasks and augment clinical decision-making. For example, the Outpatient Pharmacy Automation System helps to automate packing and dispensing of pharmacy medication.

Patients can also utilise HealthHub to arrange for medicine refills and manage their medical appointments. This all helps to reduce waiting times and enhance the patient experience. MOH is also exploring the use of AI-assisted radiology diagnosis systems for pathology detection, to automate the analysis of medical images, support clinicians to identify patients with urgent care needs and help radiologists to generate radiology reports.

Dr Wan Rizal suggested utilising AI to improve the accessibility of mental health care. Currently, Mindline employs an AI-enabled chatbot that allows people to share their emotional struggles anonymously and guides them to self-help resources such as psychotherapy exercises and counselling services where needed. While we embrace innovation and leverage technology, patient safety remains of paramount importance. MOH will continue to evaluate these new technologies for clinical and cost effectiveness and assess their safety and suitability for various uses in our healthcare system.

Ms Mariam Jaafar asked for an update on value-based care initiatives that have been piloted and whether these initiatives have been scaled up across the healthcare system. MOH has been placing increasing emphasis on value-based care efforts since 2015. These efforts aim to improve health outcomes while simultaneously managing the attendant cost increases in a sustainable way. These initiatives range from national system initiatives to programmes that target individual doctors and specific procedures.

Since the implementation of the Cancer Drug List (CDL), which focused MediShield Life and Integrated Shield Plan coverage on clinically proven and cost-effective cancer drug treatments, CDL drug prices in the public sector have been brought down by an average of 30%, and over 60% for some drugs. This has also allowed us to subsidise more drugs and improve affordability. In the long run, we expect this to moderate the costs of cancer drugs. We are shifting our focus more upstream and are applying value-based care to payment models, like capitation and preventive efforts through Healthier SG.

Sir, it will be a long-term, multi-year effort to work towards a healthier population. The Government and healthcare providers will provide quality healthcare to residents, but individual responsibility is crucial. Each of us must take charge of their own health, adopt healthier behaviours, build relationships with our family doctors and proactively manage any chronic diseases. Concurrently, healthcare providers will re-orientate towards preventive care, while the Government sets up systems, programmes and incentives to support healthcare providers in delivering care to residents in the community.

In the future, through the Government's efforts in strengthening preventive care and a shift in residents' health-seeking behaviour, the aim is for all of us to visit a regular family doctor as a first point-of-contact and for ongoing support to holistically manage our own health. Consistent and evidence-based care will be delivered across the diverse primary care landscape, and all of us can take proactive steps to keep to a personalised health plan. Together, all of us, everyone, can play a part in improving our health.

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The Chairman: Senior Parliamentary Secretary Rahayu Mahzam.

The Senior Parliamentary Secretary to the Minister for Health (Ms Rahayu Mahzam): Mr Chairman, let me begin with healthcare manpower.

Dr Syed Harun has rightly pointed out that healthcare manpower needs to keep pace with the growing demand for healthcare.

We factor in population needs into the planning of our healthcare manpower. Over the last 10 years, we grew our healthcare manpower by about 40% and increased our local healthcare student intakes at our IHLs by a similar margin, translating to a combined intake of 3,600 healthcare students in 2023. We will continue to grow our healthcare workforce sustainably, while moderating demand through innovative ways of delivering care.

To this end, we will continue to work with public healthcare institutions (PHIs) and the community care sector to attract and retain manpower across the board.

For nurses, we announced the Award for Nurses' Grace, Excellence and Loyalty (ANGEL) scheme last month. This would allow us to improve the attractiveness of the profession and retain the nurses we have.

We are engaging Allied Health Professionals to better understand their needs and to co-create the vision for their professions, with a view to come up with a National Allied Health Strategy. We are working on the PharmForce initiative to look into manpower development, shaping pharmacy practice to meet population needs, promoting wellness and building resilience of our pharmacy workforce and increasing visibility and recognition for the profession.

Operations and support staff play important roles in our public healthcare system. Our healthcare clusters have embarked on job redesign initiatives to enhance the career value proposition and better attract and retain them.

Across the board, PHIs will continue to keep salaries competitive. For example, starting salaries for nurses, allied health professionals and pharmacists were increased by up to 12% in 2023.

We have done the same for the community care sector with the recent salary guidelines to keep salaries competitive and provide greater transparency to jobseekers and workers in the sector. These guidelines will be reviewed regularly to ensure that they are up-to-date. We hope that the guidelines will help attract and retain workers across all job groups, including support staff.

We will continue to provide funding to community care organisations and PHIs to support them in keeping their salaries competitive.

I also stressed the importance of ensuring the well-being of our healthcare workers. I thank Mr Ang Wei Neng and Mr Louis Ng for their concern on workload of junior doctors and rest time for nurses.

We are working with clusters on measures to support the welfare and well-being of healthcare workers, including doctors and nurses. For doctors, this will include clearer work hour guidelines, reviews on work processes to improve efficiency and workload balancing and to enhance support for staff. As the context differs from healthcare institutions, these changes may take time to effect.

On ensuring sufficient rest for nurses, our healthcare clusters no longer actively roster nurses on the PAPA shift pattern. However, this may happen occasionally when there are operational exigencies, such as when there is unplanned absence amongst staff and the ward needs to ensure the appropriate skills mix amongst nurses on duty to ensure patient safety. When this happens, measures are in place to support affected nurses, such as by rostering them on shorter shifts that week and allowing flexibility for swaps.

In 2023, we also exceeded our national target of bringing 4,000 new nurses into our workforce and, with that, we can expect the situation on the ground to improve.

Additionally, we announced our tripartite framework on the prevention of abuse and harassment of healthcare workers and, in the coming year, we will be putting out additional publicity to raise awareness.

I will now talk about our efforts to support Singaporeans to achieve healthier lifestyles.

We have supported Singaporeans in adopting healthier diets and an active lifestyle through various initiatives over the years. For example, we have introduced easy-to-use symbols and labels to help Singaporeans identify healthier products, and ensured access to healthier and affordable ingredients through the Healthier Ingredient Development Scheme. A wide range of physical activities have also been provided island-wide.

We are starting to see positive results from these efforts. The National Nutrition Survey 2022 revealed that average daily sugar intake has decreased and more Singaporeans were meeting the recommended sugar limit. Participation rates in exercise programmes have also increased.

Despite these, we must remain vigilant about other health trends. Based on the National Nutrition Survey, Singaporeans are eating more and 90% have exceeded the recommended daily limit of two grams of sodium. The National Population Health Survey 2022 also showed that the prevalence of obesity has continued to increase, from 8.6% in 2013, to 10.5% in 2020, and 11.6% in 2022.

We can make small shifts to incorporate healthier habits in our lives. Continue to use the suite of user-friendly symbols and labels to make healthier purchases. Plan, monitor and moderate calorie intake using the Meal Log tool on the Healthy 365 app. When dining out, ask for less gravy and sauces and avoid drinking all the soup in soup-based dishes. Access a myriad of physical activities on the Healthy 365 app and participate in those of your liking.

Another health risk is smoking. Mr Gerald Giam asked about a Tobacco Cohort Ban. The idea has been raised by several Members in the past. Our focus is on protecting public health and we do not rule out any measure that would help us achieve that effectively. As Mr Giam pointed out, New Zealand had reversed their initial plans to implement a Tobacco Cohort Ban. A salient point to note here is that New Zealand allows vaping and was prepared for people to switch from smoking to vaping. Similarly, Malaysia recently reversed their decision.

That leaves the UK, and we will monitor closely how they intend to implement the ban. For a Tobacco Cohort Ban to be effective, we need to consider various implementation issues. For example, can someone older buy cigarettes for someone younger who is affected by the ban? If not, how should we go about enforcing? Does the ban apply to tourists?

Mr Giam mentioned that gains from existing measures have diminutive impact. That is not the case. We have made good progress in reducing smoking prevalence in Singapore. Our recent efforts include the Standardised Packaging measures, raising the Minimum Legal Age of smoking to 21 years old and raising tobacco taxes by 15% last year. Cessation support is also strengthened through Healthier SG. These efforts have continued to suppress smoking prevalence and we have achieved an all-time low of 9.2% in 2022. And it is still declining.

Hence, even as we study the feasibility of a Tobacco Cohort Ban, we will continue efforts to reduce smoking prevalence.

As several Members and Singaporeans have raised, the emerging and urgent issue, is vaping. There is a growing body of evidence that e-vaporisers are harmful, as they contain nicotine, a highly addictive substance, that can also harm the developing brains of youths. The cancer-causing chemicals and other toxic substances in e-vaporisers also increase the risk of heart and lung diseases.

To Mr Ang and Dr Wan Rizal's questions, vaping is a multi-faceted issue and requires coordinated whole-of-Government efforts to tackle. MOH, along with the Health Sciences Authority (HSA) and the HPB, take a serious view on vaping. The public can access information on the prohibition of e-vaporisers and its health harms across HSA and HPB's websites. We have worked across Ministries and agencies to step up enforcement and education measures, to protect our population and prevent e-vaporisers from taking hold in Singapore.

Upstream, all sales and advertisements of e-vaporisers are prohibited under the law, in Singapore. Digital platform owners are expected to proactively moderate content by detecting and removing sales and advertisements of e-vaporisers. We will continue to work with the Ministry of Communications and Information (MCI) and the Infocomm Media Development Authority (IMDA) to engage platform owners.

At the borders, HSA has worked with the Immigration and Checkpoints Authority (ICA) on a series of joint operations at Changi Airport, Woodlands and Tuas Checkpoints, and will continue to collaborate on a regular basis. In the community, HSA is already working with agencies, such as the National Environment Agency (NEA) and National Parks Board (NParks), which have stepped up, and will continue to step up enforcement checks at public places. In addition, the Singapore Police Force (SPF) and Central Narcotics Bureau (CNB) continue to refer cases to HSA, when detected in the course of their duties.

In schools and IHLs, MOE continues to take a firm stance against vaping and strengthen detection and enforcement efforts. Schools and IHLs take disciplinary actions against students caught using or possessing e-vaporisers, including suspension, or caning for boys in schools, and refer them to HSA for penalties under the law.

We have also strengthened efforts on the education front to increase awareness about the harms and illegality of vaping. In 2023, HPB launched a vape-free campaign targeted at youths and younger adults. In schools, HPB has shared these messages with close to 90,000 students. Parents, who are important stakeholders in this effort, are also kept up to date on the harms and illegality of vaping through advisories and resources available on Parent Hub.

We will continue to support those who smoke or vape to quit. Cessation programmes are accessible across various settings, including healthcare institutions, workplaces, uniformed services, education institutions and in the community, through initiatives, such as HPB's "I Quit" programme and Healthier SG. In 2023, HPB supported 4,700 adults and 2,300 children and youths in their quit journey. I strongly urge all who are smoking or vaping to seek advice from a healthcare professional and quit as soon as possible. Those with family or friends who smoke or vape should also encourage them to lead a nicotine-free lifestyle.

Even while we step up enforcement and education efforts, we will be reviewing the legal penalties to ensure a strong deterrence against vaping and related offences.

Allow me to move on to talk about how we have strengthened targeted support as well.

To Dr Wan Rizal's question, we have kept up the momentum of our efforts to support ethnic minority groups to lead healthier lifestyles. I am encouraged to share that with the strong support from community leaders and organisations, over 40,000 Malay/Muslim residents and over 32,000 Indian residents participated in healthy living programmes encompassing physical activities, health talks and Saham Kesihatan programmes, as well as healthier groceries distribution during the festive periods of Ramadan, Hari Raya and Deepavali, in 2023.

With the roll-out of Healthier SG, in the Indian community, we have also partnered SINDA to set up a Health Task Force, comprising members from private and public healthcare institutions and other health-related organisations. The Health Task Force will strengthen efforts to encourage Healthier SG enrolment among the Indian community to supplement HPB's existing collaborations with the Hindu Endowment Board, Sikh Welfare Association, among other partners. Mr Chairman, please allow me to say a few words in Malay.

(In Malay): [Please refer to Vernacular Speech.] In our Malay/Muslim community, we have recently introduced a focus area, which is FA5, "A Healthy Community for All". This effort aims to promote healthier lifestyles and empower individuals and groups to organise and scale up community-led initiatives.

One key emphasis of FA5 is encouraging enrolment in Healthier SG in the Malay/Muslim community. For those who are still contemplating whether to enrol or not, I would like to share how Healthier SG can be the next step in your preventive care journey.

Mdm Shamima has been volunteering as a health ambassador since 2011, actively promoting knowledge about health and participating in HPB roadshows. Her fervent desire to motivate others to adopt a healthier lifestyle stemmed from her own transformation through HPB's Lose To Win programme, where she managed to shed about 16 kilogrammes. She has also been actively participating in a variety of physical activities available on the Healthy 365 app, including Zumba, yoga, pilates and kickboxing. You may be wondering how would an active resident, like Mdm Shamima, benefit further from enrolling in Healthier SG?

Mdm Shamima decided to enrol in Healthier SG, in order to gain a better idea of her health, so that she can make the right decisions for herself. Through her first Health Plan consultation with her family doctor, she is now more aware about her food intake and the importance of taking her medication on time, so that she can better manage her sugar levels. Through the regular follow-up consultations scheduled, her family doctor can provide her with guidance and encouragement to lead a healthier lifestyle.

I would like to continue encouraging everyone to step up to take charge of your health, like Mdm Shamima, by enrolling in Healthier SG today.

FA5 will continue efforts to address key health issues in the Malay/Muslim community, such as screening, smoking and mental well-being, as Dr Wan Rizal mentioned. We will adopt a suitable approach for the Malay/Muslim community to achieve a more effective outcome.

(In English): Another dimension of providing targeted support is ensuring affordability, particularly for those who need it more. We thank Members for your questions on how we are doing so.

First, at the earlier Budget debate, Ms Jessica Tan requested clarifications on our means-testing criteria for long-term care subsidies. These subsidies are means-tested using per capita household income (PCHI) and Annual Value (AV) of residence to ensure that subsidies are targeted at those who need it more. While these are not perfect proxies, they are the best available to measure an individual's means and family support, and only a small minority of long-term care clients do not qualify for subsidies because of the AV criterion.

To ensure that those with greater needs receive continued support, the Government recently raised the PCHI and AV thresholds for all means-tested social support schemes and grants. Seniors who face difficulties paying for their long-term care expenses may apply for the discretionary financial assistance.

Second, Dr Tan Wu Meng has made two suggestions on empowering more organisations to assist with MediFund applications and taking a holistic approach to Migrant Domestic Worker Levy Concession applications. We agree with the intent to smoothen help-seeking processes for needy patients. This is why, today, Singaporeans identified by Social Service Offices to receive ComCare assistance automatically receive MediFund assistance at approved healthcare institutions. We have recently introduced guidelines to institutions to allow mutual recognition of MediFund assessments for more types of circumstances.

On the ground, institutions have also put in place patient-centric processes and leverage IT platforms to smoothen the application process. While tapping on other organisations could improve convenience of applying MediFund for some patients, it introduces an additional layer in the process and, therefore, needs to be studied further to avoid lengthening the application process inadvertently.

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As for the Migrant Domestic Worker Levy Concession, Activities of Daily Living (ADLs) remain a relevant basis for purposes of assessing these applications. Frail patients with multiple conditions, or those at end-of-life, tend to require some assistance with at least one ADL and would qualify for the concession. Exceptions will be assessed on a case-by-case basis. We will continue to review the adequacy of financing schemes to support caregivers and their seniors.

Regarding the case raised by Dr Tan, Dr Tan would be aware of the correspondences together by the AIC and Ms See. There was a positive outcome after she was re-engaged by AIC. Unfortunately, there was an earlier miscommunication where AIC was led to believe that Ms See's cousin was the employer of the migrant domestic worker when it was, in fact, Ms See. She eventually qualified for and received the concession and Home Caregiving Grant, both backdated to when she qualified.

Third, to Mr Gerald Giam's question, we support the needs of persons with disabilities (PwDs) and persons with special needs through various financing schemes, including subsidies, national insurance schemes, MediSave, grants and safety nets, such as MediFund. We have recently enhanced some of these schemes. For example, in 2023, the payouts under the Home Caregiving Grant were increased, from $200, to up to $400 per month to further reduce caregiving costs. In general, healthcare subsidies are not based on specific conditions and are instead tiered based on income level, to target those who need more help.

Fourth, to Mr Ong Hua Han's question on the support for patients with spinal muscular atrophy, there are a few treatments available currently, including drugs and a CTGTP. We are reviewing the clinical and cost-effectiveness of these treatments and are engaging pharmaceutical companies to achieve reasonable prices. As the Minister mentioned, the MediShield Life Council is considering extending coverage to eligible CTGTPs and studying the safeguards needed to ensure that any such extension is sustainable. In the interim, those who face concerns may apply for discretionary funding support through MediFund or the Rare Disease Fund.

Lastly, a few Members have also asked about the support that is provided for those who are planning for a family. There are a few considerations that guide our approach in designing the financing schemes to better support this group of Singaporeans. These include clinical safety and effectiveness of fertility tests and treatments, ensuring affordability for those who need it and keeping our financing schemes sustainable.

We have answered Mr Louis Ng's question on support for fertility screening previously. Fertility tests are offered to couples who are medically indicated as there is currently no evidence to support the need for early fertility checks for the general population. At our public specialist outpatient clinics, these couples can enjoy subsidies of up to 70% for their fertility tests. Those who face financial difficulties can also apply for MediFund for assistance. This offers more targeted support for those with needs, while safeguarding MediSave to ensure it remains adequate for other needs and keeping Central Provident Fund (CPF) contribution rates reasonable for all.

Co-funding also applies to those who are undergoing in vitro fertilisation (IVF) at public assisted reproduction centres. These public centres currently have sufficient capacity, with utilisation rates of about 61%. Currently, you can get an appointment at our public assisted reproduction centres for a first consult within a week, if you are open to seeing any of our IVF specialists.

To Mr Louis Ng's suggestion, we do not advise couples to switch providers after failed IVF cycles as it breaks the doctor-patient relationship, and may result in additional cost and time from repeated investigations and assessments. The outcomes of IVF treatments at private and public assisted reproduction centres are also comparable. Nonetheless, we recognise that some couples may prefer seeking treatment at private centres and are reviewing whether to extend co-funding to these settings.

To Ms Hazel Poa's ask for financial support for egg freezing, married women will be able to tap on co-funding and their MediSave when using their frozen eggs for assisted reproduction treatment. This is to support couples who have decided to have a child, but may face challenges in conceiving.

We recognise the desire for women to freeze their eggs when they are young. It is a pre-emptive step, perhaps not different from buying private insurance. Providing financial support for it will be quite unprecedented in healthcare policy. We think it is better to focus our resources to directly help couples who are trying to conceive and who face difficulties.

Mr Chairman, I have shared about broad efforts to support Singaporeans in adopting healthier lifestyles. I have also shared about the targeted support for the ethnic minority groups and ensuring affordability for those who need it more, so that all Singaporeans can achieve better health and access care that they need.

Our efforts can only succeed with the strong participation of Singaporeans and support from families and the community. We are heartened that many have stepped up and made choices to lead a healthier lifestyle today, such as those who have enrolled in Healthier SG, made the switch to healthier eating, participated in healthy programmes and activities. Let us choose better health for ourselves and our loved ones today.

The Chairman: We have time for clarifications. Mr Pritam Singh.

Mr Pritam Singh (Aljunied): Thank you, Chairman. A question to the Minister on my cut. Emergencies can be defined by the patient and the medical professional differently depending on the sort of pain you are in. And to that end, the Minister shared that about 40% of cases at Accidents and Emergencies (A&Es) are not emergency cases. I would like to enquire whether that has been a stable number over the years because, if it has been, then it may be helpful to consider some sort of dynamic information to be shared with walk-in patients, because it will help them get attended to more quickly and also for the health workers and health staff in hospitals who may not be overloaded if these potential patients go to a hospital which is less crowded.

The second question pertains to my cut with regard to providing information beyond just the median vis-à-vis bed utilisation, and whether it can also be extended to bed utilisation at the 75th and 90th percentiles.

I have a final query on overstayers. Is this a significant problem in the hospitals? It would be helpful if the Minister could share some information on overstayers and whether there could be better coordination between medical social workers and the consultants and overseeing doctors, so that this problem can be abated somewhat.

The Chairman: Minister Ong.

Mr Ong Ye Kung: The definition of "urgent care" is actually standardised and practised. We have a nomenclature P1, P2 which are considered urgent; P3 onwards not so urgent and it goes up. So, therefore, this is based on a standard definition, and so P3 and above is 40%. I do not have the number on whether it is stable. I am hoping it has come down over time. But we had a pandemic in between. So, even if it is tracked over time, it may not be representative. But we are doing what we can educating the public, having UCCs, having GPFirst programme to reduce this number.

So, our concerns still stand, that the worry is that with dynamic information, we are encouraging more P3s, non-urgent, from coming to EDs. Sometimes, when the ED has a breather, maybe we should just let the doctors and nurses have a breather. So, we remain to have a concern. But as I said, we are not rejecting the suggestion, but we always had this concern.

As for bed waiting time beyond median, whether we can indicate 75th, 90th percentile, the issue remains this: that if there is urgent care needed, it will be given almost immediately, without delay, at the ED if possible. But I take Mr Singh's point that it is not the most comfortable place. The lights are on. There is a trolley bed, but it is not a proper ward. So, we will have to prioritise. Those who need urgent care in the ward, we will give them immediately. So, it is not just a matter of waiting time. The urgency and the clinical needs of the patient play a big part as well.

On overstayers, actually I have addressed that question. We used to have about 300 overstayers at any point in time. It has come down to 200, but there is still room for improvement.

The Chairman: Dr Lim Wee Kiak.

Dr Lim Wee Kiak (Sembawang): Sir, I have two clarifications.

First is on day surgery. We know that day surgery lowers the cost, as compared to an in-hospital stay, if they undergo some form of surgery. Would MOH be willing to explore to see how to expand day surgery, to change it to an outpatient surgery model instead? Which means that they do not have that 24-hour limit that is currently in place now. If we can extend it to 36 hours or 72 hours, that will actually allow us to have a bigger range of procedures to be done as day surgery. And day surgery really cuts costs. I think that is proven for a long time already.

The second supplementary question is on healthcare cost. We are concerned with healthcare cost increases because the total household medical expenditure will go up, whether it is premium from insurance, whether it is their MediSave or whether it is out of pocket, because out of all these three, these three will continue to go up. Our current private healthcare insurance premium now in Singapore is the third highest in the world. We are just after the US and Hong Kong. I hope that we will not climb further and overtake Hong Kong.

I understand that MediShield Life premium is under review now. It will go up. I would like to ask the Minister when the review will be completed, when this increase in premium will be announced and whether this increase in premium will also lead to other private insurance premiums to go up as well. Private insurance premium has gone up by about 20% per year and this is not a sustainable rate in my opinion.

Then last of all, for MediSave, it is still our money. MediSave uses have been expanded a lot now, including hospitalisation, clinic uses now, health screening cost. Is the current MediSave amount that we have now sufficient in consideration of an ageing population, as well as increased lifespan?

The Chairman: Minister Ong.

Mr Ong Ye Kung: I fully agree with Dr Lim on the importance of day surgery. Our public health institutions have been trying to convert as many surgeries as possible to day surgery and, like the Member mentioned, outpatient surgery if possible. We will continue to do that.

I mentioned length of stay increased pre- and post-pandemic, six to seven days. Without our push to convert many surgeries to day surgeries or even shortened stays, the impact actually would have been far worse. But we managed to contain it to six to seven days. Even that, as I mentioned, is a 15% increase in workload. And we will continue to work on this front.

First, on MediSave. The uses of MediSave have expanded. Is it currently enough? We did a study recently. As of now, we think it is quite adequate. But we will continue to monitor the situation, especially if we cannot contain the rise in premiums. Then, I think the drain on MediSave will be quite significant. But it is something we will have to monitor.

Dr Lim asked a couple of questions on MediShield Life, private insurance as well as premium. Let me put it straight. What I just announced and talked about is to reduce healthcare cost. Healthcare cost is increased not just because of insurance premium. It has an impact mostly because hospital bills, especially for significant episodes, are getting larger and increasing year by year. Therefore, if we want to control healthcare costs for the families, we need to raise claims limits. That is the whole purpose of this exercise. Increase the claim limits of MediShield Life, which means it is for subsidised patients when they have a major healthcare episode. Increase the claim limits, so that healthcare cost for them is manageable. Of course, this comes with an impact on MediShield Life premiums. But as I mentioned, we will try our best to help them pay for it through their MediSave. And I mentioned a few things that we can do: increase subsidies, do top-ups for specific groups if possible, find ways so that we can all manage. And I think this is a better way to manage healthcare costs.

The Member mentioned private premiums. These are private and commercially run insurance premiums and they have been going up. I am unaware that we have the third highest premiums in the world. I think we have to be comparing apples to apples, oranges to oranges, because it depends on what kind of insurance plans are they. What do they cover? Apply to which group? I am not aware, but we can take a look. But I do have to say, as I mentioned, with some frustration in my speech just now, despite rising premiums, I still see insurance companies competing for market share, offering terms that are obviously unsustainable. And I really hope that, at some point, they will rein this in and exercise more discipline so that we also moderate private insurance premiums.

The Chairman: Mr Gerald Giam.

Mr Gerald Giam Yean Song (Aljunied): Thank you, Sir. My clarifications are for Senior Parliamentary Secretary Rahayu.

I am glad to hear that the Government does not rule out a generational smoking ban. Can I ask whether the Government is actively moving forward on this plan and what is the timeline it is looking at? For the sake of the health of our future generations, I hope that we can move faster and be an early mover on this and not wait for other countries.

Secondly, on healthcare subsidies for PwDs, I note the Senior Parliamentary Secretary said that healthcare subsidies are not based on specific categories of people, but are tiered according to income.

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But first, does the Senior Parliamentary Secretary agree that this is not the case for the Pioneer and Merdeka Generation who get additional subsidies regardless of their income status? So, can this be applied as well to PwDs? And second, does healthcare means-testing always take into account the many other expenses that PwDs incur for their daily living, which will lower their ability to pay for healthcare regardless of their family income?

Ms Rahayu Mahzam: I thank the Member for the questions.

Firstly, on the issue of the tobacco cohort ban, I would just like to clarify again, as I have mentioned in my speech, that it is not as though nothing is being done at this juncture or there are no improvements or efforts with regard to our efforts against tobacco. As you can see from the results and the outcomes, we are doing quite well as compared to other places. In deciding what are some of the measures and approaches that we take, we really have to look at things in totality.

We take a multi-pronged approach. We looked at taxes, we looked at standardised packaging, we increased the minimum legal age; and this has actually to a large extent, shown very good results. On the other hand, as we are assessing the tobacco cohort ban, we are looking at the outcomes in other places and it may not necessarily generate the same outcome that we want.

So, I think it will take some time for us to assess whether there are other measures that are going to change this. And on that front, there are some more salient points or more imperative issues that we need to deal with, with regard to vaping for example. So, we do need to focus our energies in dealing with some of those emergent issues.

Your second question related to the support for the PwDs, I appreciate the point and I can understand. In fact, this is something I also raised with other Ministries, in terms of support for PwDs. We do really have to look at appropriate circumstances. At the moment, a lot of the support that we have given, we have looked at enhancing as it goes along.

And I can say, as a general principle, if there are specific issues of families who need help, we have our tiered-support system where they can definitely get the help they need. Having said that, I think this is something that we will continue to look at and see, where appropriate, we can continue to enhance.

The Chairman: Mr Ang Wei Neng.

Mr Ang Wei Neng (West Coast): Thank you, Chairman. I have a clarification for the Senior Parliamentary Secretary Rahayu on vaping.

Could Senior Parliamentary Secretary share, how many cases of feedback that the HSA received from the public, from the police and from the CNB respectively in 2023? And can she share, what is the size of the enforcement team at HSA and what is your assessment of the effectiveness of the enforcement action by HSA? These are the questions I have asked in my cuts.

The Chairman: Minister Ong.

Mr Ong Ye Kung: I do not have the numbers with me, but you are right, vaping is a problem. And more and more people, especially the young, are vaping. Vaping companies target the young. And it is not just us, it is around the world.

Senior Parliamentary Secretary Rahayu explained a holistic way of tackling the problem. How big is the HSA team? HSA is, largely, a scientific organisation. We can collaborate with the ICA to do enforcement at the border; but we rely on NEA, on NParks Board and other agencies, to help us enforce this. So, I think if our enforcement officers can multi-task and I think we can mount a fairly effective enforcement against vaping.

The Chairman: Mr Ong Hua Han.

Mr Ong Hua Han (Nominated Member): I thank the Senior Parliamentary Secretary Rahayu for addressing my cut. She mentioned CTGTP as a treatment option for spinal muscular atrophy (SMA) patients. While I appreciate that this may be true, to my understanding, it benefits young children rather than adults. Risdiplam seems to be the way to go for adults with SMA. May I ask, in MOH's discussion with pharmaceutical companies, whether they could make subsidising risdiplam a high-priority topic? I do not mean to press MOH on this, but SMA patients are really keen on this treatment which works to preserve their quality of life.

Ms Rahayu Mahzam: With regard to the Member's question, I note his point and actually beyond just the CTGTP, we are also looking at the effectiveness of treatments that are not in that field. I take the Member's point, and I think this is something we can consider and look at, as we are engaging with the pharmaceutical companies.

The Chairman: Ms Ng Ling Ling.

Ms Ng Ling Ling: For the Second Minister for Health, Minister Masagos; and two questions for Minister Ong. I am really very glad about the expansions of AACs. I wanted to ask, in the selection for the social service agency or the operator for the new AAC, will the Ministry or AIC put more considerations on existing agencies who are already operating existing AAC in the constituency? Because many times, they have already built very good relationships with the grassroots organisations and it is very important for local collaborations as more AACs emerge in the constituency.

The two questions for Minister Ong are: firstly, on the MIC@Home going to become a mainstream care option. I think it is good news, but the move from its pilot state to mainstream is relatively faster than a lot of the healthcare pilots that we know about. I wanted to ask, how will the quality of care and patient safety be monitored and assured as this option begins to scale-up nationwide, especially if there are situations of disputes and responsibility of roles between the families and the care team?

My final question is on the MediShield Life review that is upcoming and the premium that may be adjusted. One of the objectives for Healthier SG when it was first announced, was to blunt the healthcare cost increases that we are seeing internationally as well as in Singapore. But Healthier SG is in its very early phases; and I wanted to ask, how would the Council for the review take into consideration of the cost-blunting effect of Healthier SG in the review that is coming up?

The Chairman: Second Minister Masagos.

Mr Masagos Zulkifli B M M: To the Member's query, yes, we will consider directly appointing providers who already have an established local presence. And of course, they must have a good track record in engaging or serving residents living in the area among other criteria that will be considered.

Mr Ong Ye Kung: How to ensure quality of care of MIC@Home is maintained? Do it progressively. Do not be too ambitious and jump to a level that you cannot cope, where doctors and nurses cannot cope. Which is why I explained, from 100 to 300 institutions; feel this is something they can cope and they can maintain the quality. And also select the right patients. Not all patients are suitable for MIC@Home.

As for MediShield Life review, how to take into account the blunting effect of Healthier SG, I think it is too early. Healthier SG just started July last year. We are not even one year and this is really a long-term strategy. Hopefully, towards the end of this decade, we can see a blunting or bending of the cost curve as we call it. And at that point in time, of course, we will then take that effect into account as we conduct further reviews of the MediShield Life scheme.

The Chairman: Ms Hazel Poa.

Ms Hazel Poa (Non-Constituency Member): I have two clarifications.

As the Minister has pointed out, healthcare costs have risen. So, are there plans to revise the MediSave withdrawal limits? Will the Minister consider annual adjustments pegged to healthcare inflation similar to the way the basic retirement sum is reviewed?

Secondly, on the subsidy for egg freezing, I believe Senior Parliamentary Secretary Rahayu mentioned just now that it would be unprecedented. If I heard her correctly, I would just like to clarify that this is already being done in countries, like South Korea, Japan, Australia and France.

The Chairman: Minister Ong.

Mr Ong Ye Kung: MediShield Life limits withdrawal, I assume you meant for outpatient. For outpatient, we review it from time to time and we have been adjusting over the years. But as for MediSave limits that you can withdraw for big hospital bills, I think there needs to be corresponding adjustments. As claim limits goes up for MediShield Life, whatever that is remaining, you want to make sure that MediSave can also cover them. So, there will be a corresponding review as we increase MediShield Life limits.

The Chairman: Ms Carrie Tan. Sorry, Senior Parliamentary Secretary Rahayu, you wanted to add something?

Ms Rahayu Mahzam: Thank you, I thank the Member for the question. It is unprecedented with regard to our health policy. While we note that this is something that is being done elsewhere, we are monitoring. The effectiveness of elective egg freezing is not really something that has been proven. We are looking at the data from abroad and we see that the take-up rate from overseas is also very low.

Also, even if it is taken up, there is also evidence that suggests that the outcomes necessarily may not be very good. So, these are some of the considerations that we take into account. But when I meant unprecedented, it is unprecedented within our healthcare policy.

The Chairman: Ms Carrie Tan.

Ms Carrie Tan (Nee Soon): Thank you, Mr Chairman. I would like to address my clarification and query to Minister Ong. I think the MIC@Home seems to be very progressive and very promising. I am also glad that Second Minister Masagos announced that there will be enhancements to the caregiver training grants, as well as the SkillsFuture credits for caregivers who receive training.

I echo Ms Ng Ling Ling's query on what exactly does this MIC@Home look like from the caregiver's perspective; and whether the Government will consider that for those families where family members have to involuntarily give up employment to assume caregiving duties at home, given that it is skill-intensive and helps to supplement the formal health care system, whether care fare can be considered as an income supplement? I have met residents who say even though the family receives home caregiving grants, they do not feel like they can take that money from their elderly parents because there is a grant given to the care recipient.

Mr Ong Ye Kung: When we decide to mainstream MIC@Home, we are really approaching it from a clinical angle, which is, we think we are confident enough – by our hospitals – to set up the right equipment, train the caregivers and able to support the patient to recover at home. That is from a clinical angle.

But I think Ms Carrie Tan is coming from a different perspective, which is about home care grant and how to support a caregiver who may have to give up their employment and their job. Second Minister Masagos addressed some of these. I think it is something we have to review to see how best we can support caregivers, not just financially, but also in terms of their caregiving duties; giving them respite care services; proper training. These are all things that we will continue to review and as described by the Second Minister.

The Chairman: Assoc Prof Jamus Lim.

Assoc Prof Jamus Jerome Lim (Sengkang): I would just like to pick up on the point the Minister shared about the 40% of ED cases being non-critical. Of course, to be fair, I recognise that such behaviour is not unique to Singapore. In the US, ERs are often also flooded by overuse, albeit with different reasons that have to do with the uninsured. My suggestion for expanding UCCs is, therefore, I think, both complementary but distinct to the question of capacity in general.

My first question then is, if MOH agrees that UCCs can indeed be a complementary part of the secondary-care landscape, how do we increase their take-up? What sort of incentives or educational efforts can MOH provide to non-urgent cases to choose to access UCCs instead of our EDs?

My second question relates to his point about the doctor-to-population ratio. He shared that Japan has a comparable ratio in the face of a large elderly population. But I would venture that European countries, which he mentioned, are in fact better-prepared in terms of medical staffing for their super-aged societies. On that, I wonder if MOH will consider increasing the number of medical schools that it recognises from foreign countries. After all, as he said, the competition for talent is global and so, it seems unnecessary for us to further hamstring our efforts to recruit from abroad.

Mr Ong Ye Kung: I do not think we should describe as, whether MOH agrees that UCCs are useful. We came up with UCCs. In fact, the first one that started was in Sembawang Group Representation Constituency (GRC) and over the years, it greatly helped Khoo Teck Puat Hospital's ED, helped them manage their ED load and it has proven to be useful. And as I mentioned, if need be, if we need to set up more UCCs – this is a proven model – we will consider doing so.

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But there are competing models. GPFirst in the east has also worked quite well. So, between the two, either or, I think we should consider them.

As for doctor-to-population ratio, I explained to some extent in my speech, the European doctor-to-population ratio is somehow just higher than the rest of the world. Even in Asia, comparing developed economies, we are more or less about the same level. I do not know what is the reason, some say it is the legacy of the welfare state, others say they did not plan for manpower. But when you look at individual European countries, it is not that pretty a picture.

The Dutch, for example, they have stopped using nursing homes because there are not enough medical personnel nor doctors to man them. So, today, if you are an old person in Holland, in Netherlands, the default care model is actually home care with a lay person, maybe a nurse, maybe an allied professional visiting you twice or three times a day. That is what they have resorted to.

Germany, the doctors there told me they are in dire straits. Across the states, the hospitals are not efficiently configured and that is what they told me and therefore they are also, despite having more doctors, not delivering the healthcare that the people need.

So, as I mentioned, it is just one number. It is not a numbers game. Where they are trained and what kind of specialty, how the entire system is run, whether the insurance system of that country or the welfare system is creating oversupply, all these play a part. So we take all these into consideration as we manage our healthcare challenge.

As to our own doctor-to-population ratio, it has been increasing. Ten years ago, it was about 2.0, today it is 2.6. So, moving forward, there is some room for three local medical schools to take in slightly more perhaps. There is possibility of having more overseas-trained Singaporean doctors returning, all these we have to consider. Our ratio has been increasing, we are ageing, most likely we will increase further. But I would just caution the European model may not be the model that we want to emulate fully.

The Chairman: Mr Yip Hon Weng.

Mr Yip Hon Weng (Yio Chu Kang): Thank you. My clarifications are for the Second Minister. I am heartened to hear that there are many initiatives to help our seniors age well in the community. I have two clarifications. First is on the National Silver Academy (NSA), which offers many useful courses for learning for seniors. However, awareness of the courses and training are still quite spotty on the ground. So, how can we improve awareness and take-up rate amongst our seniors for these courses?

Second, I am glad to note that the waiting time for nursing homes is about one month. Minister mentioned that there are interim care options for those who are on the waitlist. Can he share what are these options and how can caregivers get access to these options?

Mr Masagos Zulkifli B M M: I would like to say that the courses run by the NSA is doing very well. In fact, 100,000 places were taken up in FY2020 and it has doubled in 2023. The agency, or the body, that runs and takes care of this programme is the Council for Third Age and we will work with them, as suggested by the Member, to increase even more awareness about the programmes. They will do this through the usual publicity channels like social media, roadshows, community touchpoints, partnership events. For example, even the annual National Celebration of Seniors events will be one marquee event, where they will be present and to bring up the awareness of the availability of all these programmes that our seniors can meet their aspirations and their interests.

On the waiting time for nursing home, while waiting for placement at nursing home, there are ways which we can help our patients – particularly those, for example, who are medically stable in our public hospitals. They can be referred to the transitional care facilities. There, they can work out the longer-term arrangements while waiting for a nursing home to be available if they are not. There is one touchpoint in every hospital, which is the AIC Link. In nine hospitals, they are available and I hope that residents or caregivers of these patients can go and meet up with the staff at these centres, where they can provide both plans for short-term post discharge, as well as the longer-term needs of their parents or the people they are caring for.

The Chairman: Dr Syed Harun.

Dr Syed Harun Alhabsyi (Nominated Member): Thank you, Chairman. I have two clarifications, mainly towards Minister.

The first is regarding MIC@Home. Heartened to see that safety as well as outcomes are comparable as it stands today, but Minister also mentioned that in terms of pricing, it is expected to be the same or less. I am just wondering whether, at least in my mind, should it not be less pricing in absolute terms, given that the care is based now at home and auxiliary services, such as the bed, change in linen, meals, utilities would be much less. I appreciate there are other costs, but I wonder whether the Minister could clarify that.

The second is on the planned increase for COMIT as well as CREST. I would like to ask the Ministry whether they would consider increasing the number in greater proportions, given that the emphasis on mental health will be towards the community. I think a greater increase of COMIT and CREST teams would give some confidence to our GPs on the ground, in terms of dealing with mental health issues in the community.

Mr Ong Ye Kung: I will ask Senior Minister of State to comment on COMIT and CREST. As for MIC@Home, I agree with you. I think even as a policy of pricing, you want to price it at a gradient so that patients get a strong signal. MIC@Home, I pay less; plus I have S+3M, hospital bill will be less. So our public health institutions take this to heart, they understand and I think they are prepared to do so. But I wrote a careful statement that the price will be equal or less, so to give them some room.

Dr Janil Puthucheary: I thank Dr Syed Harun for his question on the CREST and COMIT teams. I agree with the sentiment that we need to make sure that our primary care practitioners and the whole community of community care practitioners is adequately supported. We have not yet achieved the increase that we are planning for, so we are increasing the teams.

What we do not really know is what the behaviour of patients and residents, people who are concerned about mental health behaviour; how that will change over the next 10 to 15 years as we are increasing our CREST and COMIT teams. We have put these plans in place. I think we need to ramp up the support available for the private and public sector practitioners in the community space, increase the number of teams, the capability of the teams that we have. But how that goes and how that matches with health-seeking behaviour, the worried well, the people who need interventions, people who have been in institutional care, who now need to come into the community; these are things that we will be monitoring and watching very closely through the NMHO and working with our partners and then assessing whether we have the right level of support. So, I agree with the sentiment, but I think it is a little bit too early to say now what we will be doing in 2030. We get going with our current plans first.

The Chairman: I do not see any more hands. Eleven Members raised their clarifications. Your clarifications were concise and so, too, were the responses. So, can I invite Dr Tan if you would like to draw your amendment?

Dr Tan Wu Meng (Jurong): Mr Chairman, I want to thank all who contributed to the COS debate, our MOH leadership and office holders and our Members of Parliament, our Members of Parliament who spoke as well. Deepest thanks to our entire healthcare family as well, our healthcare workers; our sisters and brothers, who care for patients and residents in the community; our public officers, who worked tirelessly behind the scenes looking after Singaporeans, in sickness and in health. Mr Chairman, I beg leave to withdraw my amendment.

Amendment, by leave, withdrawn.

The sum of $17,400,129,600 for Head O ordered to stand part of the Main Estimates.

The sum of $1,374,852,500 for Head O ordered to stand part of the Development Estimates.