Committee of Supply – Head O (Ministry of Health)

Head O (cont) –

Resumption of Debate on Question [12 April 2016],

"That the total sum to be allocated for Head O of the Estimates to be reduced by $100." – [Dr Chia Shi-Lu].

Question again proposed.

MediShield Life and Overseas Singaporeans

Ms Sylvia Lim (Aljunied): Mdm Chair, MediShield Life provides Singaporeans and Permanent Residents some coverage for hospitalisation bills and certain outpatient treatments, without age limit and for life. While the scheme benefits those of us based here, requiring all overseas Singaporeans to pay for compulsory coverage does not seem fair to some of them and merits a review.

The Ministry of Health (MOH) has stated that overseas Singaporeans should contribute to the national risk pool as "part of collective responsibility". The Ministry says this will also enable them to benefit from MediShield Life protection anytime they choose to return to Singapore.

This stand makes sense for those overseas Singaporeans who know that they expect to return to Singapore to live. However, there are Singaporeans who have made their home in other countries for decades. These include Singaporeans married to foreigners and raising children overseas, sometimes because the foreign spouses are not able to find suitable work in Singapore. They enjoy high standards of healthcare in these countries, which they pay taxes for. Others have emigrated as families and now have access to healthcare at prices more affordable to them. Some chose to live abroad because they could only obtain adequate coverage for their serious health conditions there. These Singaporeans are better covered overseas and will probably never tap on MediShield Life.

Will the Government review how it could allow such overseas Singaporeans to opt out of the scheme? Is there a compelling case that no opt-out should be allowed at all?

Integrated Shield Premiums

Mr Pritam Singh (Aljunied): Mdm Chairperson, the prospect of rising healthcare costs is a cause for concern, especially for the middle-income or the sandwich class. In fact, rising MediShield Life premiums will be a reality for many Singaporeans as the subsidy threshold is progressively reduced from this year up to the year 2019, when MediShield Life subsidies come to an end.

MediShield Life means coverage for all, including the most vulnerable among us. In fact, when MediShield Life was introduced, it was expected to account for a bigger chunk of Integrated Shield payouts. However, this prospect was quickly put to rest with the announcement by the various insurers that any rise in the top-up portion of premiums would only be frozen for 12 months. As this moratorium will only last until November this year, what are the prospects of higher premiums next year? Can the Ministry consider informing the insurer that the moratorium should also include a freeze on riders as well, since this would have been a backdoor to work around the moratorium, insofar as keeping healthcare costs affordable as a whole?

Secondly, while rising healthcare costs for a number of public reasons, such as larger bills, greater healthcare consumption and costly procedures, are a reality, can the Ministry share how it intervenes, if at all, to ensure that any rise in premiums from the Integrated Shield providers are audited by the Government? How does the Government work with the insurers to check on any unjustified rise in premiums and to what extent can the Government intervene, if and when premiums are unjustifiably raised?

In view of this new environment of data analytics, will the Ministry release more data in conjunction with the insurance companies so that the public will be in a better position to track and appreciate the rising trend of claims and specifically identify areas of over-consumption? What does the Ministry do to ensure that private hospitals and doctors do not take maximum advantage of private insurance plans? Does the Ministry consider this to be a growing problem and how does it plan to mitigate it?

Finally, details of the standardised B1 plan were recently made public. Prior to launch, the plan was framed as an affordable Integrated Plan providing greater choice to consumers. To this end, will the Ministry consider increasing the MediSave withdrawal limit amount for Singaporeans of all ages, especially older Singaporeans who choose this plan, so that they can be paid for completely through their MediSave account?

Preventive Healthcare

Dr Lily Neo (Jalan Besar): Mdm Chairman, "prevention is better than cure" is a dictum that we would accept wholeheartedly. Preventive medicine is a topic I am passionate about and I have been advocating this preventive healthcare.

In the year 2000, I was privileged to spearhead the two-year islandwide "Check Your Health" programme to screen those above 50 years of age for diabetes, hypertension and high blood cholesterol. Some 40,230 people were screened. About 60% of them had never attended any screening before and 60% of them, who had no past history, were detected with abnormal results. Although we are in a better situation now with more people readily going for regular health screening, we must continue to push for the detection and treatment of these three chronic diseases, and especially so for diabetes.

Diabetes is a killer disease that slowly steals life away. It can slowly destroy body organs, resulting in blindness, lower-limb gangrene, kidney failure, stroke, cardiac disease and so on. If we can promote better control of diabetes, we will see less of these complications that cause pain and burden upon sufferers and their family members. Presently, one in three diabetics has poor control of their diabetes.

Non-compliance is a serious problem in diabetes. Patient non-compliance is not only limited to the failure to take medications, but also the failure to make lifestyle changes, undergo tests or keep appointments with physicians. Non-compliance can be due to factors that are patient-centred, therapy-related or healthcare system-associated. The patient-centred factors can be demographic, such as age, gender, educational level and marital status, and psychological, such as patients' beliefs and motivation towards the therapy, negative attitudes, patient-prescriber relationship, patients' understanding of health issues and general knowledge.

The therapy-related factors include the route of medication, duration of treatment, complexity of treatment and the side effects of the medicines. The healthcare system-related factors include availability or accessibility of care and the physician. Could MOH address these non-compliance factors and mitigate them in order to have better success with diabetes?

An area that can make a difference is to enhance lifestyle-change reinforcements. Thus, would MOH consider promoting less-calorie food intake within our population, such as disclosure of calorie content in the food available? Would MOH also incentivise people to stay healthy with token rewards?

Home and Continuity Care

Dr Tan Wu Meng (Jurong): Our home palliative care services do good work for Singaporean patients from all walks of life. I have seen it myself when I visit residents and attend funeral wakes in Clementi. They tell me about how their loved ones were helped at home during terminal illness. I have seen how they looked after my own cancer patients that I see in a professional capacity. And I also saw how they brought comfort to my father, during his last days, as a cancer patient, terminally ill.

These nurses and doctors make the greatest difference because of the human touch. A human touch for patients at home, patients from all walks of life. Home visits, listening to patients and their families, giving advice and guidance to caregivers. And they can teach us as well, at the systems level, how to look after other patients at home – the chronic sick, the frail, the very elderly – because travelling to a clinic takes time. It can be challenging for some patients and their families if the patient is bed-bound after a stroke or if your loved one cannot sit up for long because of pain.

Can MOH give an update on our home-care and community care plans? Can MOH tell us how we can further empower and support caregivers? And can MOH advise us on how we can ensure care can be delivered near to home – or even at home – in a holistic, integrated, sustainable way so that we can look after all our Singaporean patients, those who are mobile, those less mobile and those who are unable to leave the home easily?

Action Plan for Successful Ageing

Ms Joan Pereira (Tanjong Pagar): Mdm Chair, the Action Plan for Successful Ageing report contains several initiatives to improve healthcare for seniors in areas, such as health and wellness, active ageing and aged care services.

For many seniors, age becomes almost irrelevant when they are physically, mentally and socially healthy, and they will have the freedom to do as many things as the young can do. I would like to know what are the initiatives to help our elderly live healthy lifestyles, monitor their health conditions and exercise.

As a firm believer in preventive health, I would like to know how the Ministry can encourage and enable medical follow-ups of seniors found to have at-risk conditions. I have always found it challenging to encourage our seniors to go for their follow-up treatments and therapies. Some are worried that they would discover more serious medical conditions and would prefer not to know. Others are concerned about costs. And yet others claim they have no time.

Whatever medical conditions they have, if treated early, it can prevent deterioration, escalating healthcare costs and poor quality of life. An idea I would like to propose is to tap on the community network of seniors, where elderly neighbours and friends can encourage their peers to see their doctors for follow-ups.

Seniors want to age in familiar environments surrounded by people they know and who understand and care for them. They also need easy access to care centres and doctors. Their caregivers also need support from the community in caring for their senior family members. What are the major initiatives for aged care services?

Seniors' Action Plan

Assoc Prof Fatimah Lateef (Marine Parade): The Action Plan for Successful Ageing includes about 60 initiatives covering 12 areas. The Action Plan, "A Nation for All Ages", is targeted at the individual level, the community level, as well as the city level.

Can I ask about MOH's action plan for community level health promotion for our seniors and what community networks they can tap on, bearing in mind that we also want to align with those that are existing in the constituencies?

As we know, we cannot disengage an individual from his/her community and, in fact, the latter has a value-added effect and positive impact on well-being, mental wellness and happiness. Having a trusted group of friends and "kakis", the seniors can be made to feel differently and a lot better.

Will we see a more well integrated range of services and networks, readily available to our seniors at no or low cost, up close and personal, near their residences? Can we make these stimulating, broad ranging and exciting as well for our seniors in their active ageing years?

As we also plan to integrate the seniors with their multigeneration families and extended families, can the Ministry also consider family-friendly activities and networks which will be appealing to all ages, in order to target multi-generational involvement? One of the initiatives that has been announced include co-locating eldercare and childcare facilities in new Housing and Development Board (HDB) developments to maximise opportunities for interaction among the different generations.

National Seniors' Health Programme

Ms Joan Pereira: Mdm Chair, it is important to promote good health in seniors so that they can enjoy and spend their longer years meaningfully. One of the initiatives of the Action Plan for Successful Ageing is the National Seniors' Health Programme. The programme will include healthy lifestyle campaigns, community activities and interventions for mature workers at workplaces.

I welcome these initiatives for I have encountered many elderly who may not know how to select nutritious food and do the appropriate physical activities to keep fit. Would the Ministry consider providing general guidelines, taking into account age bands, that show the recommended types of physical activities that a senior can do if he has certain medical conditions?

Teaching them, their family members and community volunteers to recognise signs of illnesses, including dementia, is also important as early detection and intervention will contribute to more effective treatment.

Would the Ministry share further details of the National Seniors' Health Programme to promote good health in seniors? What kind of interventions will be introduced at their workplaces? How does the Ministry plan to encourage more seniors to participate in such programmes and activities?

The Chairman: Ms Tin Pei Ling, please take your two cuts together.

Health Programmes for Seniors

Ms Tin Pei Ling (MacPherson): Madam, there is a concerted push for active ageing amongst our seniors in Singapore. One critical aspect that we must not neglect is the health of our seniors. Without health, our seniors cannot be active and lead a meaningful life. We must also ensure that seniors do not think that active living is only for the young and fit. That would undermine this important exercise. Therefore, I would like to ask the Minister to share and update what is his plan in promoting and supporting seniors to keep healthy.

Community Networks for Seniors

I am heartened by the slew of pro-elderly measures introduced over the past years. These are needed to enable a graceful and meaningful retirement for all Singaporeans. But to achieve a truly caring society, we cannot rely only on the Government or a few charitable organisations. Every one of us has to do our part.

I see the Community Networks for Seniors being critical in this aspect, as they have the potential to ensure our seniors continue to be plugged in to social and support networks. It also ensures that the human touch will not be lost as we work towards more efficient eldercare and as we embrace greater use of technology.

I would like to ask the Ministry, firstly, how does the Ministry see the Community Networks for Seniors fit into the Action Plan for Successful Ageing?

Secondly, does the Ministry see scope within this initiative for the more abled seniors to be recruited to reach out to and help other seniors? I believe this is a very meaningful way of engaging seniors who are fit and keen to do something constructive in their retirement. This keeps them active. Moreover, seniors can also relate to seniors better, as they may share common challenges and language. Perhaps, this initiative can be akin to the Pioneer Generation Ambassador (PGA) programme in which volunteers are empowered through proper training and given a modest honorarium. Some of the PGAs in my constituency are Pioneers themselves and they take great pride in their work as ambassadors.

Thirdly, can the Community Networks for Seniors help to simplify the process of delivering assistance and care to our elderly, so that the elderly only need to approach one touch point? The coordinating nature of the Community Networks for Seniors can also ensure that resources and support are fairly distributed to all seniors.

The Chairman: Minister Gan Kim Yong.

The Minister for Health (Mr Gan Kim Yong): Mdm Chairman, I would like to thank Members for their comments and suggestions. With your permission, may I display a few slides to facilitate the discussion?

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

Mr Gan Kim Yong: Madam, our healthcare system has served Singaporeans well. The average lifespan of Singaporeans born in 2014 is now 82.8 years, 7.5 years longer than in 1990. Life expectancy in Singapore is among the highest in the world and our Health Adjusted Life Expectancy, which measures years lived with "full health", is among the top three globally. In short, Singaporeans can expect to live longer and healthier.

There are encouraging signs that more Singaporeans are choosing a healthier lifestyle. The proportion of adult smokers fell from 18.3% to 13.3% over the last 20 years. We are also choosing healthier foods. Today, more than a quarter of Singaporeans consume at least one serving of wholegrain products per day, more than three times the rate in 2004. But the picture is not all rosy. There are some worrying trends which I will elaborate later.

But, first, let me give an update on our Healthcare 2020 Master Plan.

First, on accessibility. Over the last five years, MOH has expanded our capacity in all sectors. In 2015 alone, we opened three new acute and community hospitals progressively and added over 900 beds − Ng Teng Fong General Hospital and Jurong Community Hospital in the West, and Yishun Community Hospital in the North. The three hospitals will continue their ramp-up this year and are expected to bring online another 270 beds.

Mr Low Thia Khiang asked about wait times for our Specialist Outpatient Clinics (SOCs). From 2013 to 2015, SOC attendances increased by 5%, largely due to the increase in subsidised attendances by our seniors, which grew by 26%. These patients would have benefited from higher subsidies, especially for the Pioneer Generation (PG). During the same period, private SOC attendances actually fell by 5.3%.

Despite the increasing workload, the median wait times for subsidised new appointments remained fairly constant, at about 29 days over the past three years, while the 95th percentile wait times increased from 110 to 125 days. For private patients, median wait times stayed about the same at eight days, while the 95th percentile wait times also increased, from 47 to 58 days.

Nevertheless, we have made improvements in the 50th percentile and 95th percentile wait times for specialties, such as Rheumatology and Immunology, Gastroenterology, Ophthalmology and Neurology, despite increasing attendances at these SOCs.

SOC wait times vary across hospitals. At Alexandra Hospital, for example, the overall median wait time is less than a week and, at the 95th percentile, 12 days. So, patients who need an earlier appointment can ask their doctor to refer them to hospitals with a shorter wait time.

For patients with more serious and time-sensitive conditions, our hospitals and polyclinics have protocols in place to arrange for faster appointments at our SOCs. For example, the median wait time for new subsidised appointments for urgent cardiac conditions and suspected cancers was around one week. In fact, for cardiology and cardiothoracic surgery, the median wait time has improved from 14 days to six days.

We have been managing the wait times for our SOCs in three ways. First, we optimise the SOC appointment system to give priority to urgent cases. We also reduce "no-shows" by reminding our patients of their appointments via messages. Second, we are working with polyclinics and general practitioners (GPs) to ensure that only patients who need a specialist's care are referred to our SOCs and, for patients who have recovered and are well, to help them transition back to primary care. Third, we have added new SOC capacity through developments, such as the Nnational University Hospital (NUH) Medical Centre, National Heart Centre and Ng Teng Fong General Hospital.

Mr Low Thia Khiang cited the case of a patient experiencing a long wait for an appointment and biopsy results. I would like to explain that the usual turnaround time for laboratory biopsy results is around three days. So, I would be happy to look into the circumstances of the specific case if Mr Low can provide the details.

Mr Low also asked about the time taken for computed tomography (CT) scans. For the first quarter of 2016, the median wait time for a routine subsidised outpatient CT scan was between one and three weeks for most hospitals and has remained stable over the past three years. I should explain that the timing of the CT scans may also be a result of scheduling to coincide with the reviews by doctors. For conditions that require urgent scans, hospitals are able to fast-track these cases, whether in the wards, in the SOCs or at the accident and emergency (A&E), on the same day or the following day.

Other than hospital capacity, we have also added about 1,200 nursing home beds and 60% more home-care, day care and home palliative care places between 2011 and 2015.

Looking forward to 2020, we are on track to add more than 6,600 places in community care, home-care and palliative care, as well as 7,900 beds in acute hospitals, community hospitals and nursing homes.

Mr Leon Perera asked about wait times at our polyclinics. Polyclinic attendances have been growing over the years, from 4.5 million attendances in 2011 to 4.9 million in 2015. Median consultation wait times have improved from 32 minutes in 2011 to around 14 minutes in 2015. Mr Perera is correct that wait times for patients with appointments is, indeed, lower than wait times for walk-in patients. Over the past few years, polyclinics have been encouraging more patients to use the appointment system. Currently, all patients with chronic conditions, many of whom are elderly, are offered appointments for their next chronic visit. In 2015, 70% of these chronic patients visited the polyclinics by appointments. We will continue to help more patients use the appointment system.

In the meantime, we are adding capacity and improving processes to meet the primary care needs of our population. The last four years, we redeveloped the Geylang and Tampines Polyclinics and have just completed an expansion of Marine Parade Polyclinic. Currently, we are redeveloping Bedok, Ang Mo Kio and Yishun Polyclinics and are on track to open new polyclinics in Jurong West, Punggol and Bukit Panjang, and a new primary care facility in Sembawang by 2020.

Madam, many Singaporeans choose to visit polyclinics, instead of private GPs, because of the significantly lower costs at polyclinics as a result of Government subsidies. Lower and middle income patients and all PG patients now have an alternative as they can tap on the PG package and the Community Health Assist Scheme (CHAS) to enjoy subsidised primary care at private GP clinics instead.

Madam, our healthcare professionals are at the heart of delivering quality patient care. To meet the increasing healthcare demand, we have grown the healthcare professional workforce of doctors, nurses, pharmacists and allied health professionals by 24% from 46,000 to 57,000 between 2011 and 2015.

We have also made significant moves in addressing Singaporeans' concerns over affordability. In 2014, we launched the PG Package which provided 450,000 Singaporeans with more help with their healthcare costs.

For lower- to middle-income Singaporeans, we have raised the subsidies for outpatient drugs and specialist care. As of December 2015, 715,000 Singaporeans have benefited from these enhanced subsidies.

With CHAS, I spoke about this just now, about 1.4 million Singaporeans, including Pioneers, are able to benefit from Government subsidies at participating GPs and dentists close to their homes. Since 2012, we have more than doubled the number of participating clinics to 1,500.

We have introduced more flexibility in the use of MediSave to help Singaporeans with their healthcare costs. Today, Singaporeans can also use up to $400 per MediSave account per year to pay for their outpatient chronic disease management.

Last November, we introduced MediShield Life to provide better protection for all, for life. To date, many Singaporeans have benefited from MediShield Life. Take, for example Mdm Sung, a Pioneer living in Ang Mo Kio. Late last November, Mdm Sung had a stroke and her family brought her to Tan Tock Seng Hospital where she was warded for 11 days. She continued her rehabilitation and recovery for eight days at the Ang Mo Kio Thye Hwa Kwan Community Hospital near her home.

The total bill for the stay came up to $16,900 and, after subsidies, Mdm Sung needed to pay $6,400. Before MediShield Life, Mdm Sung, who was uninsured, would have had to pay the full $6,400, but with MediShield Life coverage, she only had to pay about $3,300, close to half the original bill. And all of this was paid through her MediSave.

Today, Mdm Sung is back to living with her son and his family. She has four children, 10 grandchildren and six great grandchildren – a great example for our population strategy. A few weeks ago, the whole family came together to celebrate her 85th birthday. We wish Mdm Sung and her family the best of health.

Overall, from last December to February this year, MediShield Life approved about $136 million for 95,000 claims, or about $45.3 million per month. This is a 29% increase, compared to the average monthly claim for MediShield in 2015. MediShield Life, together with Government subsidies, MediSave and MediFund, will continue to help many Singaporeans like Mdm Sung and low-wage workers mentioned by Nominated Member Thanaletchimi in her Budget speech earlier, giving them greater peace of mind that their medical treatment will be affordable.

Ms Sylvia Lim asked about the coverage for overseas Singaporeans. MediShield Life was introduced to give all Singapore Citizens and Permanent Residents assurance of universal healthcare coverage, regardless of their health condition, situation and background. MOH is aware that Singaporeans based overseas are concerned that MediShield Life coverage is mandatory. We recognise that the overseas Singaporean community is diverse and individual circumstances vary considerably.

The MediShield Life Council will conduct targeted engagements with overseas Singaporeans as part of their MediShield Life coverage review, while bearing in mind the principle of universal coverage.

Madam, the report on the Action Plan for Successful Ageing released in February outlined our strategy to develop a senior-friendly nation and a caring community.

The effort to pilot Community Networks for Seniors announced by the Minister for Finance earlier, is a whole-of-Government approach to "close the last mile" in supporting successful ageing for seniors in our community. As highlighted by Assoc Prof Fatimah Lateef and Ms Tin Pei Ling, this pilot is not about introducing another new service for seniors in the community, but an effort to strengthen partnership and coordination among key stakeholders, such as agencies and community organisations, so that we can work together, as a team, to better meet the needs of our seniors and build a stronger community for our seniors to age in place.

12.00 pm

We have studied the system in other countries. Many developed countries with ageing populations are facing similar challenges as us. One important lesson we can learn from them is that doing more of the same cannot be the solution. We need a paradigm shift in our approach to ageing and health.

Singapore can and must be different. It will take time, but we must start now. We must make good use of the next few years to plan ahead and design a system that meets our growing needs in a cost-effective and sustainable manner beyond 2020. We can do so, with three paradigm shifts: first, to move beyond the hospital to the community; second, to move beyond quality to value; and third, to move beyond healthcare to health. Let me elaborate.

Beyond hospital-centric to community-based care, we are transforming our healthcare delivery system from one that is built around the hospital, to one that is directed at meeting the needs of Singaporeans. We will make it easier for patients to access appropriate care, help them recover faster and enhance health outcomes while keeping costs affordable and sustainable. To do this, we need to reshape our health delivery system.

The first aspect in reshaping our system is to link up care through the Regional Health System (RHS). Over the last few years, we have done this by building up the primary, intermediate, long-term and home-care sectors, and the networks between hospitals and these care partners. These have helped to streamline processes, enable shorter hospital stays and support faster recovery for patients. We will need to further strengthen the integration of RHS.

An example of this is to develop structured care pathways to better care for patients across settings. Let me illustrate. The Eastern Health Alliance RHS has introduced an integrated care pathway for patients with hip fracture, across providers. Patients who have sustained hip fractures are quickly identified and put on the hip fracture pathway. The pathway organises the different care providers in the RHS into a coherent workflow to efficiently care for the patients, allowing for a more timely surgery, shorter acute hospital stays, and faster transition to rehabilitation at St Andrew's Community Hospital next door. This is crucial, as starting the rehabilitation process early leads to better mobility outcomes. Upon discharge, patients attend day rehabilitation near their homes, as needed, to optimise their functional outcomes.

Such pathways require various partners in the RHS, and sometimes among RHSes, to work closely to deliver seamless care to patients, for better outcomes.

Our vision of "One Singaporean, One Family Doctor" remains relevant. We want to transform primary care to be the first and continuous line of care so that Singaporeans can access good quality care in the community. As Dr Chia Shi-Lu pointed out, the key is to build a trusted relationship between GPs and Singaporeans, so that your family doctor has a deeper understanding of you and your family's health needs and can, therefore, provide better guidance and more appropriate treatment when needed. Minister of State Lam Pin Min will elaborate on how we are strengthening the primary care sector later on.

As we reshape our health delivery system and move beyond the hospital to the community, we need to make similar shifts in how we develop and deploy our healthcare workforce. Our healthcare workforce must be future-ready, so that healthcare professionals can continue to enjoy fulfilling careers and can readily acquire new skills and capabilities. Senior Minister of State Amy Khor will talk about how we are creating good healthcare jobs for Singaporeans and fostering industry-relevant skills through the national SkillsFuture framework.

MOH, together with our public healthcare institutions, will be looking into job redesign and the use of technology to not just simplify the work for our healthcare teams, but to also work in a different way to deliver care to our patients. Minister of State Chee Hong Tat will share how productivity and innovation can support our healthcare workers and improve patient care.

Dr Chia Shi-Lu said we must care for Singaporeans from birth to death, and I agree. The issue of death is a sensitive one, especially in our "pantang" Asian society. These are difficult conversations which we must have, not just among family members, but also at the national level, that is, if we want our loved ones and family members to have dignity, comfort and peace of mind as they walk through their last journey. This requires a whole-of-society approach and we are encouraged to see organisations, such as the Lien Foundation, raise these topics at the national level.

Through the Agency for Integrated Care (AIC), we have also been working with our hospitals and community partners to raise the awareness of Advance Care Planning (ACP). ACP allows individuals and their families to better understand their preferences towards the end of life and to fulfil their wishes.

Take, for example, the late Mr Phang who was admitted to Dover Park Hospice after being diagnosed with terminal cancer. Through ACP, the hospice staff were able to establish that his preference was to pass on at home, so that he was able to spend his last days in a familiar environment, together with his wife. This was a great source of comfort to his wife. She was grateful to the hospice staff for establishing his end-of-life wishes.

Madam, we need to continue this conversation. Minister of State Chee Hong Tat will be elaborating on further enhancements we are making in palliative care.

As we transform our healthcare system, we have to be mindful of the long-term implications on sustainability. Our healthcare budget has more than doubled from $4.7 billion in financial year (FY) 2012 to $11 billion this year. This has come about partly because of ageing and the need to invest in infrastructure, but also because of the Government's policy shift to take on a greater proportion of healthcare costs.

The current challenging economic outlook is a timely reminder of the need to ensure sustainability, not just for ourselves but for future generations. Therefore, we need to choose care that is appropriate to needs, so that we can make the best use of our limited resources.

It is for this reason that we have a co-payment feature throughout our healthcare system. For example, MediShield Life has co-payment features like claim limits, deductibles and co-insurance to help guard against over-consumption or over-provision of services. However, many Singaporeans have private Integrated Shield Plans that are "as charged", which means they have no claim limits, and some buy extra riders to cover the deductibles and co-insurance.

Such features could lead to a "buffet syndrome" since all the cost will be paid for by third parties, by someone else. This contributes to rising healthcare costs for everyone and eventually pushes up premiums. We will need to study this carefully to ensure sustainability.

Emerging healthcare technologies are becoming increasingly expensive and we need to ensure that the outcomes derived from these technologies are commensurate with the costs. As part of the "Choosing Wisely" campaign, medical bodies in the United States (US), Canada, the United Kingdom (UK), Australia and Japan have identified 400 areas of unnecessary or low value tests and treatments.

We, too, have recently set up the Agency for Care Effectiveness (ACE) to expand our capacity in evaluating the clinical and cost effectiveness of health technologies. ACE will look into high-cost treatments and technologies, systematically evaluate and develop guidance to guide the proper use of such treatments and technology, and encourage providers to manage costs while providing quality care.

This will help patients, care-givers and physicians to make more informed decisions on treatment and avoid over-provision of services that will eventually drive up costs.

As we move beyond hospitals to the community and beyond quality to value, we also have to move beyond delivering healthcare and focus on providing good health to nurture a healthy nation and a healthy people. To do this, we need to arrest the causes of ill health early and reduce the progression of long-term chronic diseases.

While the Health Adjusted Life Expectancy has improved over the years, as I mentioned earlier, Singaporeans are also living with ill health longer – one-and-a-half years longer than in 1990. We have observed several worrying trends in recent years. Decreasing activity across all age groups and the increasing consumption of excessive calories and fat leading to a rising obesity rate. Obesity is the major risk factor for chronic diseases, such as Type 2 diabetes.

As noted by Dr Lily Neo and Dr Chia Shi-Lu, diabetes is, indeed, fast becoming a major global healthcare concern. The World Health Organization (WHO) recently announced that the global number of adults living with diabetes has quadrupled since 1980 to over 400 million in 2014; and of this 400 million, over 400,000 are in Singapore – they are Singaporeans. Among Singaporeans, about 400,000 have diabetes, and one in three Singaporeans has a lifetime risk to develop diabetes; 30% lifetime risk.

What is one in three? When I sat in my seat, I looked to my left and I looked to my right. On my left is Mr Lim Swee Say and on my right is Ms Grace Fu. I looked at Mr Lim. I asked him yesterday, "Do you have diabetes?" He proudly declared, "No". So, I turned to Ms Grace Fu. I was too polite to ask her, but she does not look like she has diabetes. That is the good news. The bad news is: one in three means I have the highest risk of getting diabetes. [Laughter.] That is one in three.

But the good news is: we can change. We do not have to accept it and we can reduce the risk. Of those who have diabetes, one in three Singaporeans has not been diagnosed. And among those diagnosed, one in three has poor control of their condition.

The following images on-screen may be graphic but they are examples of what some Singaporeans endure daily. Left undetected, untreated or poorly managed, diabetes can lead to heart disease, stroke, kidney failure, blindness and amputations. In fact, four Singaporeans a day lose a limb or appendage due to diabetic-related complications. These complications reduce the quality of life for the patient and increase the burden on the individual, families and society as a whole.

A Saw Swee Hock School of Public Health study estimated the total economic burden of diabetes for working-age adults at more than $1 billion a year. However, the long-term cost of diabetes, taking into account the psycho-social burden, is far more than this.

We need to tackle the diabetes challenge. Therefore, I am declaring War on Diabetes. We want to help Singaporeans live lives free from diabetes, and for those with the disease, to help them control their condition to prevent deterioration.

This is a multi-year effort. We will engage stakeholders and develop detailed action plans together, but let me outline our broad strategy.

First, we will work on upstream prevention to promote a healthy lifestyle and reduce obesity rates in order to cut down on new diabetes cases. Broadly, we are doing this by ramping up our health promotion efforts through a twin food-and-exercise strategy. We will improve the dietary quality in schools, communities and workplaces, and learn from successful international regulatory strategies.

To encourage more people to exercise, we will expand ongoing programmes, such as the National Steps Challenge and Sundays@The Park, as well as introduce new programmes and bring them to schools, workplaces and our community. The risk of developing diabetes is 30% to 40% higher among active smokers than non-smokers, and we will be doing more to curb smoking rates as part of this plan.

Healthy habits start young. Minister of State Lam Pin Min will be leading our efforts in developing the NurtureSG Plan to tackle many of the preventable risk factors for our youths. We will be working closely with the Ministry of Education (MOE) to develop and implement this plan.

Second, we will strengthen early screening and intervention to identify the disease early, especially those at risk. Screening plays an important role in our war by picking up cases earlier, starting interventions and, thus, reducing the likelihood of the gory images I showed you previously. This is like intelligence in warfare. But, follow-up after screening is equally important.

We hope that earlier intervention and basic lifestyle changes can even reverse the pre-diabetes state and get such individuals back to health.

In a US study published in the New England Journal of Medicine, pre-diabetics can reduce the overall incidence of diabetes by 58% through diet, exercise and behaviour modification. That is why I said we still have hope. These lifestyle changes worked particularly well for participants aged 60 and older, reducing their risk by up to 71%. So, you are never too old to make lifestyle changes and take back your health.

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Third, we will support better disease control to slow disease progression and reduce complications. For those with diabetes, we need to do our best to help them have a good quality of life, at all stages, by having good control over their disease. This can help to reduce or delay complications and give patients better quality of life. Madam, let me speak in Mandarin.

(In Mandarin): [Please refer to Vernacular Speech.] This year, we are going to declare war on diabetes. Many of my colleagues asked me, "Why so serious? Why do you want to say, 'declare war'? Why so aggressive?"

Diabetes is a problem that is getting more serious by the day. Our Singaporeans have a one-third possibility of contracting diabetes during their lifetime. The possibility of them contracting diabetes as they grow older also increases. And it is not just them who suffer. Their families and relatives will also suffer. Therefore, we have no choice but to mobilise the entire population to declare war on diabetes. We should not just talk. We should also, each of us, play a part by eating responsibly and exercising and ensuring our own health. At the same time, we also need to do intervention earlier and do screening much earlier. Together, we can also seek help if we need to. Together, nationwide, we can have a healthier lifestyle.

(In English): The key to winning the war on diabetes is for all Singaporeans to be engaged in the battle. The key partners in this war are the individuals, his family and the community. By working together, we hope to create an environment that makes healthy choices easy, but Singaporeans also need to play their part by eating healthily, exercising often and going for the recommended screenings and follow-ups. We can also play a part in encouraging and helping others to do so. We will be increasing public awareness about diabetes and empowering individuals to take control of their health.

To coordinate the strategies on the war on diabetes, I will be co-chairing a Diabetes Prevention and Care Taskforce together with Mr Ng Chee Meng, Acting Minister for Education. The task force will include representatives from Government agencies, private sector, patient advocacy and caregiver groups and will: (a) develop and implement a multi-year action plan for the war on diabetes; (b) reach out and mobilise the nation to fight the disease together; and (c) monitor and evaluate the outcomes of our efforts.

The war on diabetes will not be a quick battle, but a long war requiring sustained efforts. Results of our efforts can only be seen in the long term, but we must persevere. And if we succeed in shifting mindsets and changing habits, we will be able to curb not just diabetes but other related chronic diseases, such as heart disease, as well. And we will improve the lives of Singaporeans and reduce the burden on their families.

Madam, health is, ultimately, a personal responsibility. All Singaporeans need to play an active role in their health journey and in the war on diabetes. We all need to make sensible lifestyle choices and informed decisions in our health. The Government will do its part to provide a supportive environment, but we cannot do this alone. If we are able to do this together, we will achieve better health, better care and a better life for all Singaporeans.

The Chairman: Dr Lily Neo.

Community Mental Health

Dr Lily Neo: Mental health is very much an integral part of general health. Good or normal mental health is a state of well-being in which the individual, amongst other things, can realise his or her own abilities, can cope with the normal stresses of life, can work productively and is able to function normally in the community.

May I beseech MOH to review mental healthcare and to improve it? This is especially urgent for community mental healthcare which is almost non-existent. There is a problem of undiagnosed and under-treated mental patients in the community. They tend to be more prevalent in lower-income households and they usually cannot cope with employment and cannot fit well in society. Those that suffer from substance abuse also have violent tendencies. As the majority of Singaporeans live in densely populated HDB estates, we must be cognisant of the harm that mental patients can bring not only to themselves and their family members but also to neighbours and people in the community. There are many types of mental disorders; from mild ones like anxiety, personality disorder and depression, to moderate ones like kleptomania or compulsive stealing, compulsive gambling and substance abuse, to other severe psychotic diseases. In general, mild cases have good prognosis if treated early.

Is it possible for MOH to maintain a staff of psychiatric nurse practitioners or psychologists at Social Service Offices (SSOs) to diagnose and refer undiagnosed mental patients for follow-up? Many such mental patients also need other social assistance and thus SSOs can facilitate that simultaneously.

I know that there is a Community Mental Health Team set up by the Institute of Mental Health (IMH) to provide psycho-social rehabilitation for people suffering from mental disorders in the community. However, the purpose of the team is to facilitate patients to be discharged from and not to be re-admitted to IMH. I am concerned in this respect, as there are already too many undiagnosed and untreated mental cases in the community. Will it be better for IMH to discharge such patients to community hospitals or psychiatric nursing homes instead? I really hope IMH is not so psyched up to prematurely discharge patients without considering the overall implications.

Non-compliance has been a problem, especially for mental patients, to the detriment of the patients themselves and the community. Will MOH consider an "outpatient commitment" law, similar to Kendras' Law in the US, where there is some restrictive form of commitment for a mentally ill individual, whereby the individual is free to live in the community, provided he is subject to close monitoring by a physician or agency?

Ms Tin Pei Ling: Madam, I have been speaking up on mental healthcare issues in this Parliament for many years now. And I would say that Singapore has made progress in mental healthcare over the years; I have seen it. There is greater awareness, better intervention and more support. I would also say that few, if any, in our society would dispute the importance of ensuring mental wellness. However, there is still much that we can do. One critical obstacle to effective mental healthcare is the stigma faced by sufferers.

Stigma may be perpetuated by the lack of understanding and media portrayal, but also, by real day-to-day problems that are left unsolved. I have raised examples about this in my speech last year, so I will not touch on it again this year. Together, these threaten to deepen the prejudices that people have of those suffering from mental health issues. The animosity, in turn, makes it more difficult for those suffering from these conditions or even their family members to consider the issue and seek professional help.

Therefore, I would like to ask the Minister, looking ahead, what does the Ministry plan to do to de-stigmatise mental health? Meanwhile, efforts to strengthen community mental healthcare must not stop, so that those who need care will continue to get the care they need. Hence, I would also like to ask: one, whether there is any update on the Community Mental Health Masterplan; two, how are patients who have "graduated" from IMH reintegrated back into the community and workplace; and third, and lastly, some communities have implemented networks involving voluntary welfare organisations (VWOs), Government agencies and grassroots leaders. MacPherson, for instance, has a Community Mental Health Programme supported by AIC, IMH and the South East Community Development Council since 2012.

There has been some positive feedback. At the very least, amongst the volunteers and staff who have to frequently face residents, there is greater awareness of the signs and symptoms which aid early detection, greater appreciation of the challenges people with mental health issues face and greater sensitivity in how to engage them. I am wondering if there are plans to roll this out more extensively to more communities.

Mental Health

Mr Low Thia Khiang (Aljunied): Madam, as our society ages, we have been paying close attention to our healthcare costs as an ageing population. It is also time for us to put more focus on mental health.

Mental illness, while perhaps less understood, is no less real than physical illness. There is also the stigma and lack of understanding which patients and their loved ones combat daily. Some studies estimate that one in six of our population would suffer from mental health issues at some stage of their lives.

Currently, our MediSave, MediShield and MediFund (or 3Ms) framework allows support for mental illnesses, but it is limited. For example, MediSave has a withdrawal limit of $150 per day for inpatient psychiatric treatment, with an annual cap of $5,000. Compare this with a daily limit of $450 for other patients who have been hospitalised.

For MediShield Life, the difference is even greater, with a daily coverage of $700 in a normal ward, but $100 for a psychiatric ward. Mental illness is as real and debilitating as other illnesses. Funding from the 3Ms and other insurance plans should be on par with coverage for other conditions. Companies, too, need to be encouraged to provide equal levels of support and coverage for employees who suffer from mental health issues.

Another equally important issue is how prepared is Singapore to deal with the rising numbers of patients with dementia. It was recently estimated that 10% of us aged above 60 suffer from dementia, with a rise in younger patients being diagnosed.

This may not always be classified as a mental or even physical illness, but the strain on our healthcare costs and infrastructure can be massive. Can the Minister give an update on what has been done in the last few years to ensure our care systems are able to deal with the future increase in the number of dementia sufferers and whether there are plans to expand pilot projects, such as "dementia-friendly" town?

Community Mental Health Framework

Assoc Prof Fatimah Lateef: Madam, mental health is as important as physical health. As there is stigma, many are not coming forward to be diagnosed early enough or for follow-up regular treatments. Thus, it is important to have services and counselling in the community, in a less threatening environment, compared to being in an institution or a ward.

At Geylang Serai, I have got Silver Ribbon sited at my community club (CC) at My Wellness Centre and they do house visits and counselling at the CC as well as the residents' homes. Therefore, we need to have more such programmes. What we do at Geylang Serai is we create awareness of mental health problems. We give talks, organise mental wellness seminars, hold World Mental Health Day celebrations annually, launch suitable books and educational materials, mental health road shows and we even have a Geylang Serai Mental Wellness Taskforce operating for the last several years, comprising 10 partners from the relevant industry. Therefore, we hope that this model can be initiated and replicated elsewhere as well. This is under the initiative of WeCare@geylang Serai.

In fact, this year, we are actively involved in organising and partnering other agencies in The Asia Pacific Mental Health conference in October. My grassroots leaders (GRLs) will be sharing programmes, experiences and initiatives and we need such initiatives in the community. What are MOH's plans to strengthen community mental health support network and framework at the national level? Will we be seeing a new blueprint as well?

Seniors' Mental Health

Miss Cheng Li Hui (Tampines): As we face the silver tsunami, the number of seniors who suffer from dementia is expected to rise. One in 10 people aged 60 and above, and half of those aged 85 and above have dementia. The number is projected to increase from 28,000 in 2012 to 80,000 in 2030.

What preventive measures can we introduce to the public so as to reduce or temper the expected surge in dementia cases? In Mandarin, please.

(In Mandarin): [Please refer to Vernacular Speech.] As we face the silver tsunami, the number of seniors who suffer from dementia is expected to rise. What preventive lifestyle changes can Singaporeans be encouraged to adopt to reduce the risk of getting dementia?

An MOH study shows that the risk of dementia is 25 times higher for housewives and retirees than the working people. This figure deserves our attention. Working and participating in community activities actively may help to slow down brain degeneration. Hence, we should encourage and help more housewives and retirees to stay active and healthy.

(In English): Would the Ministry share with us the latest initiatives for the early detection and treatment of dementia? Also, what is the Ministry's long-term plan to support persons with dementia who are living in the community? Research has shown that allowing them to age-in-place would be less costly to society.

Those who care for dementia sufferers are three times more distressed than other caregivers. Many have to stop work, which may put them in financial situation. What kinds of support schemes are there to help and relieve family caregivers?

Will MOH consider allowing standard health screening, including dementia screening, to be done at private GPs at subsidised rates?

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Dementia-friendly Communities

Dr Tan Wu Meng: Mdm Chair, with an ageing population, we will see more Singaporeans with dementia. Not all will need institutional care; many will still want to live in the community. We must find ways to help our senior Singaporeans with dementia, such as helping them to lead as normal a life as possible, reducing their risk of getting lost or confused during their daily activities, and ensuring they do not become socially isolated because ongoing mental stimulation is healthy for the ageing brain.

These issues will affect all our housing estates, especially mature estates, with many Pioneers, many senior citizens. Can MOH tell us what the Ministry is doing to support Singaporeans with dementia who are living in the community, as well as their caregivers and loved ones?

Community Nursing

Assoc Prof Daniel Goh Pei Siong (Non-Constituency Member): Mdm Chair, it is expected that the demand for palliative care at home will double by 2020 to more than 10,000 patients. However, some reports suggest that the current supply of nurses providing home-based care may not be sufficient to meet the expected increase in demand. Several providers of home nursing care are employing foreign nurses on foreign domestic Work Permits. This could compromise the quality and development of home-based care in Singapore. Furthermore, the 10,000 patients only refer to those needing palliative care.

I would like to raise two suggestions for the Ministry to consider in their efforts to expand home-based care service and raise standards.

First, there were over 5,700 registered and enrolled nurses who were not active in 2014, comprising over 15% of the total number of nurses. This is an existing pool of qualified nurses that can be tapped on if appropriate flexibility, allowances and incentives are given to encourage them to provide home-based healthcare within their neighbourhoods and communities.

I ask the Ministry to consider developing a community nursing core to attract retired, inactive or underemployed nurses to return to active nursing and to cater to existing active nurses who need job flexibility due to family or other reasons, so that they do not leave active nursing. These nurses can be provided with the right training to become professional community nurses attached to hospitals to provide home-based care.

Second, will the Ministry consider developing a comprehensive Hospital and Home Programme modelled on the programme in Australia? Under the Hospital and Home Programme, hospitals will provide inpatient treatment for acute care patients whose conditions allow them to receive treatment in their own homes. This is not limited to seniors or the terminally ill. The community nurses could then act as key care providers, conducting medical check-ups and providing portable medical services to the home-based patients. The community nurses could also make use of telehealth technology to engage in non-site consultations with hospital-based doctors in the homes of the patients.

Homecare

Dr Lily Neo: Mdm Chair, our homecare services are almost non-existent at present. I am repeating my call in this House again to make this service available quickly in order to lessen the need for high-cost stay in the tertiary institutions, especially the acute hospitals. With our ageing population, homecare, where many discharged patients can be looked after in their homes, will be an increasing demand and an important part of our healthcare structure.

Whilst I agree that homecare will incur many medical personnel to visit patients in their own homes, MOH should relook the usage of healthcare workers and consider using not only full-time paid personnel but also family members, community volunteers and so on. Such healthcare workers can be trained in a matter of weeks. In England, it takes only three weeks of intensive training to equip them with the necessary skills. They are certified at the end of their courses, which teach them skills like assisted feeding, catheter care, prosthesis use, simple dressings and simple grooming, as in toenail cutting for non-diabetics using sterile techniques.

There is one pilot homecare model in my constituency supported by MOH and funded by Temasek called Ageing Gracefully At Home. A team of staff and nurses look after the elderly weak and partially disabled seniors with medical conditions in their homes. They assist them with their daily and medical needs in three HDB rental blocks. Some of the healthier senior neighbours are recruited and reimbursed as befrienders to keep watch, befriend and report on weak and sick residents in their charge to the Seniors Activity Centres (SACs) downstairs. I find this scheme useful as it keeps the residents in their own homes for as long as possible, without which, many of them would have invariably ended up in acute hospitals. Perhaps MOH can duplicate such a homecare model in other constituencies, too.

Day Care

Assoc Prof Fatimah Lateef: Madam, as a developed nation, with the challenge of a rapidly ageing population and also a longer lifespan, which means longer duration of chronic illnesses and thus, more potential complications, the need for homes, day care and rehabilitation centres will continue to increase.

For specific problems, specific services will be required, for example, day care rehabilitation, physiotherapy, speech therapy, nursing care and even for mental diseases and dementia as well as mood management services.

How is MOH planning to ramp up some of these services, which means not just the infrastructure but also the needed manpower and trained personnel? For those with significant physical disability and mental health issues, their families need to make arrangements for their care, as the former would have to go out to work. With the call for a later retirement age and also more active employment for our seniors and women, therefore, more day care facilities will be required in the future.

With these centres, we will also have to ensure that care standards are met and the ratio of patient-to-caregiver is acceptable. Here is where I would like to suggest that perhaps we seek and tap on the retired nursing pool as well as train active retirees so that they can help to contribute a few hours a day at least to this required pool.

Home and Community Care Plan

Ms Joan Pereira: Mdm Chair, as our seniors grow frail, they develop multiple health problems and will need varying care needs and repeated visits to various medical specialists and therapists. This can be very tiring for them as well as for their caregivers. It is important that they have access to integrated and holistic care so that they will not end up shuttling from one place to another. What are the Ministry's plans to enable senior-centric care to take place?

An example of an ideal situation would be like this. A senior goes to an SAC daily to take part in activities, socialise and exercise. The staff at the centre are familiar with his general health conditions and problems, and assist him to take his medications. When the elderly exhibits certain health symptoms, they are able to take note and alert his family members or, if he lives alone, to refer him to the appropriate agencies.

When he goes for his medical appointments, the tests and treatments are preferably arranged on the same trip to minimise travelling. In addition, when he needs to move around different departments within the hospital, there will be volunteer guides to help him, especially for an elderly who can only communicate in his vernacular language.

When he grows more frail and has to stay at home, he or his family will be able to get assistance from day/night nurses or part-time care-givers at affordable rates.

With reference to this scenario, I would like to ask the Minister and the Ministry if we will have enough eldercare centres, step-down community hospitals and hospices to cope with an increasing number of seniors. How will we recruit, train and retain enough volunteer carers, volunteer guides, nurses, nursing assistants, professional caregivers and therapists? What kind of support or resources can we provide their families and caregivers, especially if they have long-term patients, to take care of challenges like dementia or depression?

Demand and Capacity for Eldercare

Ms Tin Pei Ling: Madam, with an ageing population, demand for eldercare services and facilities will increase as well. Also, the incidence of dementia will rise, too, making care for our elderly even more challenging as this requires certain care specialisation and adjustments in the communities.

Hence, could the Ministry share the projected demand for eldercare services and facilities, such as day rehabilitation centres, dementia day care centres and home-care? What is the Ministry's plan in meeting this demand? What are the constraints or challenges anticipated, if any?

Also, are there lessons that we can draw from countries more experienced in caring for the aged? For instance, Japan is the world's fastest ageing society and it was said that the "epidemic of dementia" had already arrived. Given that it had to address this challenge much earlier, what can we learn from Japan about the needs of our old, especially those with dementia, and what can we do to address these needs?

Hospice Care

Dr Lily Neo: With an ageing population, demand for palliative care will be expanding. I would like to declare that my daughter is a palliative care doctor with HCA Hospice Care.

Many terminally ill patients prefer to be at home with their family members and staying in their familiar surroundings in their final days. They feel more comfortable compared to being hospitalised. But for hospice care at home, cost is always an issue, besides other factors. Many families are apprehensive about how to cope with their terminally ill family members even though they want to fulfil the final wishes of their loved ones. Thus, they may be more prepared to do so, if they can get more support on hospice care at home.

This is also right siting, compared to occupancy of acute hospital beds by such patients. Thus, could MOH review the subsidies for hospice care? Could MOH expand palliative care with more personnel and facilities? These terminally ill patients need home visits by palliative care doctors to control symptoms, such as pain. They need social workers to support the psycho-social needs of patients and their family members as well as recognising and facilitating the final wishes of the patients. Many patients and their family members also need counselling. The purpose of palliative care is to make life more comfortable for these patients by adding life to their days.

There is an urgent need to expand the number of palliative care doctors, nurses and social workers, as the shortage now will be even more pronounced in years to come with our ageing population. Presently, not many doctors and nurses are interested in palliative care. Increasing numbers of terminally ill patients will also impose an increasing demand on palliative care in-patient beds and services. Hence, we need an expansion in these facilities as well.

Palliative care can be costly and it may be a strain for many patients. Therefore, I urge MOH to consider ways to reduce the burden of patients of hospice care.

Hospice

Mr Low Thia Khiang: Madam, inpatient hospices and palliative care facilities charge patients on a day-by-day basis, and it has been estimated that a month's stay at a hospice will cost about $7,000 before means testing. I understand that patients whose families have a per capita monthly household income of $2,601 and above will not receive any subsidies for inpatient hospice care.

With one in four Singaporeans estimated to be over 60 by 2030, the demand for such specialised care will increase. The additional factors of increases in healthcare material costs and remuneration for healthcare workers will also drive up the costs of hospice and palliative care.

I would like to know what the average length of stay in a hospice was from 2012 to 2015. How many people have benefited so far from the last increase in the income ceiling? And how many have written in to appeal for subsidies for the high costs of inpatient charges at the hospices? In light of the gradual increase in gross monthly income and the increase in cost of living, I would like to know if the Ministry is considering raising the income ceiling so as to allow more families to benefit.

I would also like to propose that ElderShield be extended for the use of hospice and palliative care. A thorough review of the ElderShield scheme is long overdue and it is perhaps the right time for the Ministry to not only include hospice and palliative care under the scheme, but to also review the adequacy of the subsidies and payout period of the ElderShield scheme.

The Chairman: Ms Kuik Shiao-Yin, you have two cuts, please take them together.

Innovate End-of-life Care

Ms Kuik Shiao-Yin (Nominated Member): I declare my interest as an educator in empathy awareness. According to the 2015 Quality of Death Index, Singapore is the 12th best place in the world to die. Benchmarked against 80 countries, we are sixth in the affordability of care, eighth in the quality of care, and our weakest score was in community engagement at 22nd.

By 2020, more than 10,000 people a year here are expected to need palliative care. Yet, a 2014 survey by Lien Foundation showed that two in three Singaporeans still do not even understand what palliative care is. Only about 20% to 30% of those who pass away each year use palliative care services when research shows that up to 70% to 80% of all deaths might have actually benefited from such care. This lack of public awareness and hospice referral is partly because our doctors and nurses struggle with handling death. A Lien Foundation survey showed that six in 10 doctors and four in 10 nurses said their basic training did not prepare them to handle patients with life-threatening illnesses.

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I can testify to what it is like to encounter such a statistic in real life. A junior doctor that attended to my father in a hospital here exhibited zero empathy in the way he broke the news to us that my dad had terminal cancer. This highly educated, articulate young man told us, "Here is the result, it is not good. You know what that means? You know, right? You know? You know?" I am not kidding. Even when we broke down in front of him, he was completely blank and indifferent, and that is very disturbing to me.

Thankfully, the rest of the doctors I encountered on the journey were much more sensitive. My dad passed away in a hospice and it was a very gentle place for him to die, thanks to the staff there. So, I am deeply grateful to every Singaporean who is involved in palliative care. It is an incredible gift to the dying, as well as the living. My experience made me wish that more families here could experience the mercy of a good death.

So, I have just two simple requests: one, keep up the good work of making palliative care even more accessible and affordable; two, make socio-emotional awareness a core component of training for all healthcare professionals. Training our next generation of doctors and nurses in the art of navigating complex human conversations with humility and kindness should not be treated as less important than technical training.

Madam, innovation is not just about investment in expensive technologies, data and subsidies. Those are necessary. But sometimes, innovation can also be found in simply going back to mastery of the basics. In the case of healthcare, it is the art of treating people beyond the science of treating disease.

Renowned surgeon, Dr Atul Gawande, contends in his ground-breaking book "Being Mortal" that courageous doctors who help patients explore these three questions achieve far better outcomes for end-of-life care. One, what is more important to you than living longer? Two, what are you scared of? And three, what are you willing to give up to get the life you want in the time you have left?

Madam, many of our young doctors and nurses today will get the extraordinary power to write something in the last chapters of our own lives. May we give them the ability to write something that is worth remembering?

Provide Holistic Support for Caregivers

Second, support for caregivers. Much has already been said by other Members of this House before about legislating caregiver leave and giving financial support, so I will not dwell on that but focus on issues of emotional and psychological support. Navigating a fragmented landscape of caregivers' subsidies and services can be frustrating and intimidating to an average Singaporean, let alone one who is already acutely stressed by caregiving or limited in their English language proficiency.

Currently, AIC plays intermediary between caregiving bodies and care receivers. Could AIC consider having a team of AIC coordinators who can journey with our caregivers, especially those from the lower-income bracket, from start to end? These coordinators can serve on two fronts.

First, making sense of the system. Caregivers need practical help to figure out where to start and how to end. Just trying to make sense of the system might compound the emotional stress they are already under. Frustrated caregivers might not have time or space to explore their options objectively. When they randomly cobble together their own solutions, they end up providing haphazard and even inappropriate care for their own loved ones. So, they do need someone experienced in the system to come alongside, help them coordinate their piecemeal needs to ensure the full range of needs of both caregiver and care receiver are adequately met.

Also, though there is a good range of formal care services already being offered in the landscape, from home therapy to adult day care, a Ministry of Social and Family Development (MSF) survey of 20,000 caregivers shows that usage of these services is surprisingly still very low. The coordinators' intervention can not only help to increase the take-up rates, it can also investigate the real reasons why utilisation remains low in the first place.

Second, monitoring psychological well-being. The Organisation of Economic Cooperation and Development (OECD) 2011 report found that long-term caregivers were 20% more likely than non-caregivers to suffer mental illness. That same MSF survey discovered that spousal caregivers and caregivers of lower socio-economic status are more likely to be badly impacted by caregiving. Under siege, these caregivers may slip into depression or even some form of extreme behaviour like abuse of patient or abuse of self.

An AIC coordinator can spot early signs of caregiver mental or physical breakdown and provide timely intervention. If we believe family should be the first line of support, we must keep finding ways to better support the very people trying their utmost to live out that value, especially those who are far less financially privileged than us.

Jobs and Career Opportunities

Ms K Thanaletchimi (Nominated Member): Mdm Chair, I declare my interest as the President of the Healthcare Services Employees' Union. I would like to touch on the topic of progressive wage and career model.

In 2012, the National Nursing Taskforce (NNT) was set up by MOH to look into strengthening the development of the nursing profession to better meet the population's healthcare needs. This helped to push for better career progression for the nurses and helped overcome many issues. We acknowledge that the review of non-nursing staff group, Admin, Ancillary and Allied Health, is currently ongoing at the various cluster levels and would like MOH to play a larger role in the coordination and implementation of Progressive Wage/Career Model for the Admin, Ancillary and Allied Health Workers across the healthcare clusters in the public healthcare sector.

On the jobs of the future and being future-ready, as our economy transforms itself against the cyclical headwinds and structural changes, jobs need to be redesigned and keep pace with technology. The questions I have are: what are the jobs that will be at risk in the healthcare sector as a result of automation, robotisation and job redesign? How can we better manage the foreseeable challenges to protect the interest of workers who will be affected? What kind of programmes will be rolled out to assist affected workers to transit to other roles within and outside the industry? What measures are taken and which policies are refined to attract more Singaporeans to work in the Intermediate Long-term Care (ILTC) sector?

In order to raise the overall standards of the healthcare industry, there is a need to refresh and refine the industry as a whole. As our healthcare model evolves, the ILTC services will play a larger role. Hence, there is a need to make sure that this sector's services step up, transform and grow so that the standards of healthcare can also improve dramatically over a short period of time.

Through our interactions with healthcare workers in the ILTC sector, we know that there are locals who have switched careers to the ILTC sector and found meaning in their work. However, as their income and career pathways are not as clearly defined compared to those in the mainstream hospitals, some have struggled to sustain with these incomes and eventually left the industry. I would like to urge MOH to support the aspirations of our locals who want to carve a meaningful career in the growing industry by enhancing their skills and career progression pathways and providing wage support.

From my involvement in the Healthcare Cluster Tripartite Workgroup, I have seen how collaboration on productivity improvement projects has brought benefits to the hospitals, employees and patients. I believe that closer collaboration amongst the ILTC organisations, MOH and healthcare union will help raise the level of ILTC industry practices and bring benefits to patients, too.

I would like to call upon the industry to consider forming an association for ILTCs to champion a progressive movement for ILTC organisations. Such an association will help foster an ecosystem for the ILTC community to thrive in and enhance the professionalism of healthcare workers. It will serve to provide a platform for industry players to network, share concerns and challenges, and allow them to collaborate with one another. As a start, MOH, through AIC, could provide manpower and resource support to speed up its formation.

Madam, on flexible work arrangements (FWAs) in public healthcare. To promote FWAs, the Government introduced the Work-Life Grant which provides funding and incentives for companies. As the demand for the healthcare sector rises, more needs to be done to encourage the public healthcare sector to make FWAs more pervasive across all institutions and all job types.

At the same time, there is a need to comply with the legislation and tripartite guidelines. We could share more stories and examples of staff who have successfully converted to FWAs. Increasingly, healthcare workers are facing more challenges to switch to FWAs due to higher expectations and demands at work. FWAs should be one that supports a pro-family environment and staff who decide to request for FWAs should also be accorded an equal level of recognition and opportunity for the work they produce. Whilst the need of the organisation needs to be fulfilled, many are struggling to cope with caring for their families. We need to help them so that they can continue to work and contribute meaningfully to care for our patients.

I would like to touch on the review of the MediSave withdrawal limit. The Chronic Disease Management Programme was first introduced in October 2006 to reduce out-of-pocket cash payment for outpatient bills. It now covers 19 disease conditions. I would like to propose a review of the current MediSave withdrawal limit, especially to help those below 65 years of age, in view of the high costs of medications for managing these chronic diseases. This is particularly critical for those who need advanced care and are treated with non-standard drugs.

During this volatile economic period, many of the mature workers are concerned about the uncertainty of their continuous employment and therefore the fear of losing their employers' medical benefit. Alternatively, MOH could regularly review the list of non-standard drugs to standard drugs to bring down the costs of medication.

Long-term healthcare models in Nordic countries focus on home-care, rather than on hospital-based care for the sick elderly. With reference to this, I would like to ask the Minister if there are plans to study further on these models.

Manpower Challenges

Assoc Prof Fatimah Lateef: Madam, I know MOH is proactively looking at manpower ratios and numbers. We have also now got three medical schools, but the output of doctors will, of course, take time due to training duration. In the various sectors, such as acute and ILTC care, there is an ongoing demand for staffing. I would also go on to say that we have manpower deficits in many departments across many disciplines. Even with our residency programmes, aligning with the US' Accreditation Council for Graduate Medical Education (ACGME) guidelines, we do always have to grapple with explaining our heavy patient load to our site visitor every accreditation year.

Our doctor-to-patient ratio quoted seems to fall within the global range given, as in a previous response to our Parliamentary Questions. But when it comes to work on the shop floor, we are really, really, very busy and very heavily loaded. With the newer institutions being built and the opening of their doors, the manpower competition is from the same central pool and, thus, it is the same warm bodies that we are competing for.

And in healthcare, Madam, the words automation, value chain, productivity and quality will have to take a customised definition. What plans and framework does MOH have to handle this manpower situation?

Manpower for Intermediate and Long-term Care (ILTC) Sector

Dr Chia Shi-Lu (Tanjong Pagar): Mdm Chair, I am glad with the clear intent in the 2020 Masterplan to strengthen the ILTC sector and, like many of the Members here, I would like to ask what measures the Ministry is considering to address the expanded manpower needs as this sector is particularly labour-intensive.

We all know that our nurses play an essential role in the ILTC sector and the National Nursing Taskforce's recommendations for the future of the nursing profession have already been accepted by the Ministry.

Would the Ministry share details about how it will provide our nurses with more career advancement opportunities, greater authority and autonomy, and implement flexible and part-time work arrangements? What can be done to improve their work conditions and remuneration? In addition, what will the Ministry do to protect our nurses from abuse from patients and their family members? This comes about because there was a worrying report in the Annals of the Academy of Medicine that estimated that about seven in 10 of our healthcare workers have suffered from such abuse.

Manpower Challenges in ILTC Sector

Ms Tin Pei Ling: Madam with an ageing population, demand for manpower in the ILTC sector will increase. However, the labour market is already tight across all industries and sectors. There is stiff competition for workers and control over foreign manpower will only get tighter. Moreover, even as we look to leverage technology more, the human touch cannot be replaced in delivering quality care.

Therefore, I would like to ask, firstly, what is the Ministry's plan in tackling the manpower challenges in the ILTC sector. Secondly, how has the response been in terms of attracting mid-career professionals? How does the Ministry intend to attract more? Would scholarships with bonds be helpful? Thirdly, will the Ministry consider requiring and assisting ILTC providers to redesign their processes and systems where necessary, so that more older or retired workers can join to supplement the manpower needs?

The Chairman: Senior Minister of State Heng Chee How.

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The Senior Minister of State, Prime Minister's Office (Mr Heng Chee How): Thank you, Madam. I have the privilege of giving a response to Ms Joan Pereira and Ms Tin Pei Ling for their earlier cuts.

Mdm Chair, Ms Joan Pereira and Ms Tin Pei Ling asked how the Government would promote good health in seniors and how we plan to encourage more seniors to participate in these health programmes. Indeed, health promotion is a key plank of our active ageing initiatives under the Ministerial Committee on Ageing. This is because good health is the basic condition for successful ageing. We will expand our efforts to promote seniors' health both in the workplace and in the community.

Many of our seniors are still gainfully employed and this is a good thing. It is a good thing also in relation to mental health maintenance, as pointed out by many Members earlier. In order to further extend their longevity in the workforce, MOH and the Health Promotion Board (HPB) are bringing health screening and health education to the workplace and going "deeper" by customising the programmes for seniors working in different work environments.

HPB started with a programme at the taxi service centres for taxi drivers of the ComfortDelGro group in June 2014. HPB knows that taxi drivers are always on the road and, therefore, have very little time to attend health-related activities. By observing their schedule, HPB found that taxi drivers need to send in their taxis for servicing every month and the golden opportunity to reach out to taxi drivers is, therefore, during this time when their taxis are being serviced and the taxi drivers are waiting for the taxis to be serviced.

HPB brought health screening to the service centres and stationed health coaches there. Taxi drivers get to check in with the health coaches every month when they send their taxi for servicing. The health coaches will help the drivers understand their health screening results and customise a health action plan with specific health goals, working together with the taxi drivers.

The programme was extended subsequently to bus captains and it was customised to address other issues that are pertinent to bus captains, such as hydration, ergonomics and stress management. As the bus captains have even more challenging work schedules, HPB and the National Transport Workers' Union (NTWU) had to organise the health screening at bus depots very early in the morning with the active support of the Public Transport Operators, namely, SBS Transit and SMRT. I was there at one of these screenings, at 4.00 in the morning and I saw for myself the bus captains coming in, reporting for work. They were excited about getting screened so that they could know about their health status. After that, we followed up with a series of workshops and coaching at bus interchanges over a few months in order to improve their health outcomes.

This sustained effort paid off. Mdm Chair, I am pleased to share that in less than two years, some 15,000 mature workers in the transport, retail, cleaning and security sectors have participated in this series of workplace health programmes. More importantly, it is not only about activities, it is also about outcomes. The outcomes, in terms of their health screening results, have improved. Almost half of the bus captains with abnormal screening results initially showed at least one improvement, either in their blood pressure, blood glucose or cholesterol at their second health screening which was about eight months after the first one. And of these, about half achieved normal health status in all aspects of their health screening.

We are very encouraged that many of our mature workers have made a real transition into a healthier lifestyle. An example is Mr Loh Ah Tee. An SMRT bus captain who has been driving buses for the last 32 years, he took part in HPB's "Healthier Workers, Happier Workers" programme in June 2015. Following a first screening where he found out that he had borderline high blood pressure and a high body mass index (BMI), Mr Loh was followed up upon by his polyclinic doctor and he attended health coaching sessions at the bus interchange almost every month. From doing little exercise, he progressed to performing about 30 sit-ups and 40 push-ups every morning. Mr Loh and his wife have also made changes to their diet, swapping for wholemeal options and reducing their food intake. Over a period of eight months, Mr Loh has already lost 4.5 kilogrammes, which was a big step towards a healthier BMI. At the recent health screening in January 2016, Mr Loh's blood pressure returned to normal.

We will continue to customise workplace health programmes for mature workers in other sectors, such as healthcare, logistics and education. Our target is to reach out to 120,000 mature workers in seven sectors by 2025.

Next, about the efforts in the community. In the community, we are systematically promoting seniors' health education via the People's Association's (PA's) Wellness Programme. In particular, we want to multiply and expand the access to health education programmes by leveraging the PA's existing community and social nodes. We hope that more seniors will be encouraged to participate in preventive health and health education activities, if these are just a few steps from where they live. So, bring it closer, make it more convenient and, at the same, really urging our seniors to come and participate.

In several communities, we are bringing preventive health and seniors' health education right down to the Resident's Committee (RC) centres. For example, in Bedok, a "Wellness Time" has been set aside each week in each of the four RCs in Bedok. Seniors are invited to come to the RC regularly to take part in workshops run by community organisations on caregiving tips, mental wellness, preventive health and chronic disease management. This is the seniors' personal wellness time and they also build strong friendships and provide peer support to one another.

For example, Ms Celia Teo, a retired teacher who lives in Bedok, lives alone and often found herself staying at home feeling restless. Since starting to attend the Happy Kopitiam programme as part of the Sunflower RC's Wellness Time on Fridays, Ms Teo has gained a better understanding of various health-related topics, including dementia. She also says that she feels happier because she has something to look forward to every week at the RC, and the RC is close to her home.

Beyond physical health, cognitive activity and social interaction are also important for overall health and wellness amongst our seniors. In Tampines Central and several other locations, we have started a weekly news sharing programme done in collaboration with journalists from the Singapore Press Holdings. These journalists from Lianhe Zaobao and Lianhe Wanbao volunteer their time to drop by the Neighbours' Hub which is a cosy corner in the void deck every Friday. They go there to read news articles from the newspapers to our seniors and to engage our seniors in discussions over current affairs.

In addition, MOH partners organisations to bring preventive health services to the doorstep of our seniors. We are experimenting with putting health checks, vaccination, dental, eye and foot checks and even hearing tests on wheels so that they can come to locations closer to our seniors in the community. For instance, many seniors find it inconvenient to travel to SOCs to get a proper hearing test or for the fitting out of hearing aids, even though the Seniors' Mobility and Enabling Fund subsidises such hearing aids.

The National University Health System has thus retrofitted two Hearing Buses to bring audio checks to different neighbourhoods instead. This mobile Hearing Bus has started its journey of screening hearing for our seniors in Yuhua, Bukit Panjang, Nee Soon Central, Whampoa and Tampines West as a pilot and we will see how that goes.

An example of an integrated system of preventive health, health education and social wellness activities have also been rolled into one at Paya Lebar. PA has worked with The Goodlife Cooperative (TGLC) in Paya Lebar to integrate preventive health services with social outreach and wellness programmes. Seniors can access basic health monitoring services weekly at the Paya Lebar Wellness Centre where retired volunteer nurses provide health advice and help seniors take their blood pressure, monitoring their blood glucose level, their height and weight measurements. Therefore, they know their BMI.

TGLC actively reaches out to the community to encourage them to drop by to check their health. This is complemented by daily programming and interest groups at the Paya Lebar Wellness Centre to encourage seniors to take part in physical exercise whilst keeping in touch with neighbours and friends.

Mdm Chair, the best way to enable seniors to age well is to enable them to stay healthy. This is a meaningful effort that can succeed only with the support of everyone – community-based organisations, grassroots, healthcare providers, family members, employers, unions and, most of all, our seniors themselves. By working together in every workplace and in every neighbourhood, we can and will build a nation for ages.

Debate in Committee of Supply resumed.

[Mdm Speaker in the Chair]

Head O (cont) –

Women and Diabetes

Ms Tin Pei Ling: Madam, women play multiple roles at home, at work and in the community. It is, therefore, easy for women to neglect their own health.

Diabetes is a common chronic disease and it is only becoming more common. It adversely affects a patient's life and can lead to complications. Being a chronic disease, the long-term medical financial burden can be high, too.

Hence, we need to actively help women, especially pregnant women, prevent diabetes. This is because many children of mothers who had gestational diabetes mellitus (GDM) while pregnant are at higher risk of suffering obesity and diabetes later on in life. Studies have been reinforcing this finding. Therefore, whether it is for the well-being of women or our young, we must step up our efforts to actively manage and prevent diabetes.

In this regard, I would like to ask what is the Ministry's plan in promoting better women health and preventing diabetes, especially gestational diabetes, in women.

Women's Health

Assoc Prof Fatimah Lateef: Madam, women play a crucial role in the health of our Singaporean families. They are usually the central figure in families, taking charge of the cooking, health appointments, caregiving activities and childbearing as well. It is thus important to ensure our women stay healthy and happy. They are also the gender with the longer lifespan, which means they may also face the brunt of the complications of chronic illnesses.

For those who are working, there will be, of course, added responsibilities to prioritise their commitments. Can I ask MOH what is the role of the Women's Health Advisory Committee and also on the following issues which, hopefully, can be reviewed?

First, a more integrated package for women's health screening at subsidised rates and more publicity as well. Two, tracking and monitoring our Singaporean women's health statistics which can be shared openly. I hope that this can be a motivational element for our ladies to see the positive changes. Thirdly, more education and outreach for our ladies with diabetes since we are all on a war path against diabetes. The prevalence is high and even higher amongst some ethnic groups.

As mentioned, our women play important roles and we do not want them to be prematurely debilitated by the complications of diabetes. The other group to assist will be our women with gestational diabetes and a proportion of them, we know, do go on to become pre-diabetic or overt diabetic. Therefore, I think a proactive approach to handle this will be necessary.

The Chairman: Dr Tan Wu Meng, you have two cuts. Please take them together.

Primary Care and Family Doctors

Dr Tan Wu Meng: Mdm Chair, in countries like the UK, patients see the same family doctor for many years, building a deep doctor-patient relationship: holistic care, individual touch, a doctor knowing the patient well, walking together for years in sickness and in health. It helps the doctor make better decisions, because they understand the patient over months and many years.

A familiar face is often key to changing lifestyle and fighting chronic disease. A smoker is more likely to stop when it is a familiar face who has known him for many years asking him to quit. A diabetic patient is more likely to comply with medication when it is an old friend explaining why the medication is needed to save his life and to save his limbs and his organs in future.

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Yet, today, there is still doctor-hopping. There is still a culture of patients going from doctor to doctor, often within the course of a single illness. Sadly, this means no single doctor may have the full picture of the patient's condition and no single doctor may have understood the patient's illness over time. This can lead to delays in diagnosis and treatment. It does not help the patient. It does not help the doctor. It does not help our control of chronic diseases.

Our family physicians have a very important role to play and it is crucial that MOH supports family medicine and primary care, including enhancing primary care subsidies. These subsidies, in addition to being enhanced, can also be structured and communicated, so that patients have peace of mind and are not afraid to be screened for chronic diseases.

I look forward to MOH sharing its vision for primary care and how we can empower our doctors and support our patients.

Primary Care Infrastructure

Madam, our population continues to age. With more seniors, and even with the best preventive efforts, we can expect more chronic diseases in the years to come. The demand for primary care is going to continue increasing.

We already see this in Clementi where I serve: the Clementi polyclinic is very busy. I was informed that their headcount of chronic disease patients has increased: 32,600 in 2012; just over 35,070 in 2015; a 7% increase in three years. The nearby Family Medicine Centre sees chronic disease cases, too, and they are also very busy. Indeed, Madam, I am told that the Clementi Polyclinic has the highest patient attendance per gross floor area (GFA) in the National Healthcare Group (NHG) chain of polyclinics. They hope to expand, but there is a shortage of available HDB tenant space elsewhere in the block. Clementi, I am sure, is not the only town facing these challenges. Mature, built-up estates have fewer greenfield sites, and this constrains how easily an existing polyclinic can expand.

As such, it will be important for MOH to work together with other agencies to set aside space for polyclinic expansion in our mature housing estates. I am sure the agencies are all working hard on this very important issue and I look forward to whatever updates MOH can provide in this Committee of Supply debate or at a later date.

Enhanced Primary Care

Assoc Prof Daniel Goh Pei Siong: Mdm Chair, primary healthcare at GP clinics should be seen as a form of preventive healthcare to arrest the development of illnesses before they escalate to the needs for costly hospitalisation. Costly, that is, to the public purse and the public, given universal hospitalisation insurance or MediShield Life.

The monthly household income per member capped to qualify for CHAS subsidies should be raised from $1,800 to the prevailing median monthly income from work for an individual which stands at $3,900 in 2015. This is so that retirees who live with their working children, who are themselves parents, are not excluded. This would also provide some relief for the children of the retirees, who belong to the sandwich middle-income group. Another benefit is that this would provide support for and promote multigenerational households, where the elderly would not be disincentivised to live with the children and grandchildren.

Primary Care Services Enhancement

Assoc Prof Fatimah Lateef: Madam, primary care has been on MOH's radar for a while and there are initiatives being planned. However, there are still some gaps that need to be addressed.

One area is the need for service and its siting. For example, in the eastern part of Singapore, the polyclinics are very heavy in terms of patient load. Bedok, Geylang East and the newly renovated and opened Marine Parade polyclinics are all very busy clinics, besides the Clementi one that I just heard about. The waiting times, too, are affected by this. I am sure we know.

Some seniors tell me they have to place an item or stand in line from as early as 6.30 in the morning. I tell them to make an appointment because we know that it is a lot easier and more efficient. Can MOH consider having another polyclinic in the Geylang, Eunos, Haig Road and Ubi vicinity to meet the needs of the patients there? The need and demand for Government primary care services will continue to rise, especially with the introduction of the PG Package, the CHAS programme and other subsidy schemes.

The Senior Minister of State for Health (Dr Amy Khor Lean Suan): Mdm Chair, population ageing presents a unique opportunity for us to redefine ageing and make Singapore an icon of successful ageing. Ms Joan Pereira asked about our Ministry's detailed plans under the Action Plan for Successful Ageing. We have planned a suite of initiatives along two directions.

First, going beyond healthcare to health by investing more in health promotion and active ageing to help seniors live longer and live well. Second, going beyond hospital to home and community by building up a good system of home and community-based care that can provide person-centric care for our seniors. Let me elaborate on each of these.

Health is wealth. I always tell my seniors that they need to achieve three "wellness" for successful ageing: physical wellness, mental wellness and social wellness.

Under the Action Plan, we will step up efforts to promote seniors' health education at different levels: at the national level, in the community and at workplaces. At the national level, MOH and HPB will embark on a series of public education campaigns on seniors' health issues this year. HPB will roll out campaigns on topics, such as Seniors' Nutrition, Falls Prevention and Dementia, to raise awareness among seniors on how they can keep healthy.

We will launch a new National Seniors' Health Programme which is a set of "healthy ageing 101" programmes on health issues important to seniors, such as nutrition, exercise, mental wellness and chronic disease management. Seniors will be encouraged to go through this series of six basic health workshops as a start and then they can attend other additional workshops depending on their interest.

This set of programmes will be delivered in the community and that was elaborated earlier by Senior Minister of State Heng Chee How.

To enable seniors to be cognitively and socially active as well, MOH has worked with MOE to establish a new National Silver Academy to enable seniors to pursue learning in diverse areas according to their interest.

The Academy is not a physical campus, but made up of a network of education institutions and VWOs offering courses in various fields to seniors. I am pleased to announce that the National Silver Academy will offer over 10,000 learning places across 500 courses this year and that seniors aged 50 and above can start to register for courses from next month onwards. The Academy will offer new learning opportunities for seniors in three areas.

First, Singaporeans will be able to take selected courses offered by the Institute of Technical Education (ITEs), polytechnics and universities without taking exams. The post-secondary education institutions are making selected modules from their full qualification courses available for seniors to attend without being assessed, for a token fee. Seniors will be able to sit in the same classroom and learn together with the regular students attending the course.

Second, seniors can now receive subsidies for short courses offered by these post-secondary education institutions as well as VWOs that cover a whole range of topics. Today, such courses offered by the post-secondary education institutions are largely unsubsidised by the Government. Under the Academy, Singaporeans aged 50 and above will receive a subsidy of up to 50% off the course fee.

Third, seniors can look forward to a wider range of courses. The Academy will not only include courses from educational institutions, including the two art colleges LaSalle and NAFA, but also those from community-based organisations and other ad hoc learning opportunities as well. For instance, seniors can also attend intergenerational learning programmes conducted by students in school after school hours on topics, such as technology and music.

We hope that the Academy can not only fulfil seniors' aspirations to keep learning, but also help shape a new mindset regarding ageing. I think having seniors learn with younger students in the same classroom will foster intergenerational interactions and also, at the same time, inspire our younger generation that learning does not stop at any age.

Mdm Chair, together, we can give health and wellness to more seniors and extend the health span of Singaporeans even as their lifespan increases. But when our seniors grow frail eventually, we need a comprehensive range of care options to enable seniors to age in place. Assoc Prof Fatimah Lateef, Ms Tin Pei Ling and Ms Joan Pereira asked about ramp-up plans for eldercare services. In the past five years, as my Minister has noted earlier, we have expanded home and community care capacities to 6,900 home-care places and 3,500 day care places today.

We will continue to work hard to develop more infrastructure and manpower needed to grow our services and we are on track to meet the projected demand of 10,000 home care and 6,200 day care places by 2020.

I agree with Assoc Prof Fatimah Lateef that beyond capacity, we need to continually enhance the quality of care. We introduced the Guidelines for Home and Centre-based Care last year and are committed to supporting providers in working towards these Guidelines. In addition to training courses and capability building programmes, AIC is also developing a voluntary baseline assessment framework based on the Guidelines to help our providers understand how they can improve.

MOH and AIC regularly engage the sector on various fronts, such as in the development of these Guidelines and the Enhanced Nursing Home Standards, in our manpower and quality improvement councils for the sector, as well as through dialogues, such as with the Association of Private Nursing Home Operators.

We will study ways to further strengthen our tripartite partnerships, including the suggestion by Ms K Thanaletchimi to set up an ILTC association.

Dr Tan Wu Meng and Ms Joan Pereira also spoke about delivering home and community care in an integrated manner. Indeed, this is one of our key strategies going forward. MOH will pilot a number of new initiatives under a new Home and Community Care Masterplan this year to better support seniors to age at home.

First, we want to train and assess a new "corps" of domestic elder carers so that they can anchor good care for seniors at home. We have introduced a Foreign Domestic Worker Grant and lowered the concessionary levy so that it is more affordable for caregivers of frail seniors to hire foreign domestic helpers. But some caregivers still find it difficult to obtain domestic helpers who are proficient in eldercare.

MOH will launch a new "Eldercarer" pilot to provide comprehensive training to domestic helpers before they are deployed to the families' homes. The new training programme, developed in consultation with experienced nurses from nursing homes and community hospitals, includes four days of classroom learning and on-the-job training. Trainers will go to the homes to observe the domestic helpers at work and check that they can perform the required eldercare tasks competently. These pre-trained elder carers can then be deployed to families in need. Existing employers who want to send their domestic helpers for this in-depth training can also contact AIC.

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Second, we will complement domestic maids with informal caregivers in the community. Dr Lily Neo and Ms Joan Pereira spoke about befriending and support for seniors at risk of isolation. MOH piloted a community befriending programme a year ago where seniors are paired with befrienders living in the neighbourhood who can visit them often, keep an eye on their condition and help them with their needs.

Since the start of the programme, some 15 communities have come on board with over 230 befriendees and almost 90 befrienders. These befrienders are given a small token to cover the costs of their befriending work. Our target under the Action Plan for Successful Ageing is to grow the befriending movement to 50 communities by 2020, which means more than 1,000 befrienders and some 3,000 befriendees.

Third, we will further strengthen our community-based home and day care services. To serve the needs of seniors more holistically, MOH has worked with some providers to pilot new Integrated Home and Day Care packages that bundle both home and centre-based care services together. Today, we have such a combination and that is the Singapore Programme for Integrated Care for the Elderly (SPICE) programme for frail seniors. We are now expanding the original SPICE package to pilot three or more new care packages which offer different combinations of care services to meet the needs of seniors with a wider range of frailty.

Let me illustrate this with an example. Mdm Lim Miau Chew has multiple health conditions, including Parkinson's disease, which makes it challenging for her to walk, perform activities of daily living as well as keep track of her multiple medications.

During the day, Mdm Lim attends the Peacehaven Bedok Multi-Service Centre, where she receives rehab and nursing care and does recreational activities. The centre will also help her pre-pack her medications. On days when she is feeling unwell, the centre's staff will check on her at home. They will also arrange for basic housekeeping services and meals delivery for her during the weekends, which are additional add-on services not included within the current SPICE. All these services will be conveniently bundled within a single, comprehensive care package for Mdm Lim.

Some three eldercare providers will be offering these packages with a capacity of over 300 places in the pilot phase. If successful and well received by caregivers, we will scale up the packages. We will also test a new tool to capture seniors' needs – functional, cognitive and social – holistically, for better matching with services.

Fourth, we will build more and better centres to support the new care services. Under the Action Plan for Successful Ageing, MOH is working with HDB to pre-build larger spaces within new Build-To-Order HDB developments to serve as "Active Ageing Hubs" or AAHs. These are one-stop centres for seniors that can serve a range of needs, from active ageing programmes for ambulant and healthy seniors, to day care and rehab services for frail seniors, to "assisted living" services, such as grocery delivery.

The size of these AAHs will depend on the space available in the developments but can be up to twice as large as the eldercare centres today. We launched the first Request-For-Proposal (RFP) for operating two AAHs at Kallang-Whampoa last month. At least 10 future HDB housing developments will have these AAHs by 2020.

Fifth, to close the last mile, we need to improve the system of transportation to care services. In the past year, AIC piloted a programme with ComfortDelgro to engage taxi drivers to send seniors from home to their care centres. The effort is off to a promising start with 25 taxi drivers on the scheme. More than 130 seniors have benefited from the service, and we hope to expand the service to serve 200 more seniors this year.

Sixth, Regional Health Systems are piloting new programmes to strengthen their support for frail patients in the post-discharge period. For instance, SingHealth is piloting a new system of deploying its nurses to provide home nursing care to its patients living nearby, starting with Bukit Merah.

Finally, we are investing in research and innovation to pioneer new models of home and community care. We have set up a National Innovation Challenge (NIC) on Active and Confident Ageing to support research and innovation in ageing-related issues, including the use of technology. Last year, MOH made two grant calls under NIC to seek innovative ideas to improve manpower productivity of home-care services and enhance dementia care in the community. We received close to 100 proposals and we will select the best ideas to be implemented on the ground.

Ultimately, home and community care must work together with good residential care options to form a robust system of care for our seniors. Thus far, we have largely tendered out our aged care facilities individually or in pairs. Going forward, we need to better integrate different forms of aged care services so that seniors can receive continuous, seamless and person-centric care even as their care needs evolve. To give integration of care a bigger push, MOH will pilot a new Integrated Operator (IOP) scheme this year. MOH will launch Request for Proposals (RFPs) to appoint operators for bundles of "three-in-one" care facilities and services, comprising nursing homes, eldercare centres and home-care, within the same area. Under this new IOP scheme, the sector may see up to 500 nursing home beds, 240 day care places and 150 home-care places, within one tender.

There are a few objectives to this IOP scheme. First, we want to encourage a single operator to integrate residential and non-residential aged care services into patient-centric care options.

Second, we hope that these large tenders will enable us to grow bigger players with the economies of scale to provide better and more affordable care for our seniors.

Third, by packaging different care services in a region into a single tender, we hope to develop strategic partners who can then partner our Regional Health Systems to provide integrated and seamless care from the acute sector to community hospital to long term care, for Singaporeans.

IOPs will need to demonstrate that they are able to achieve higher standards of care. They are also expected to do more in terms of workforce development, that is, to train and build up the manpower capabilities in this sector. We will start with an RFP for one bundle – for the South region – later this year, but subject to market conditions.

I assure Members that even while we roll out IOP bundles, we will continue to call smaller tenders with individual facilities and services to cater to providers who may prefer to specialise in a particular care setting. Our eventual aim is to develop a sizeable, diverse and resilient sector. We will continue to support all players, both big and small, in developing their capabilities in this sector.

MOH and AIC have partnered SPRING Singapore to reach out to the private sector aged care providers and enable them to tap on the Capability Development Grant to embark on new manpower development or productivity initiatives.

Beyond individual services, we need to better integrate the programmes, services and resources within each community to build a strong "community of care". And it is for this reason that we are piloting community networks for seniors, as mentioned by Assoc Prof Fatimah Lateef and Ms Tin Pei Ling. Let me elaborate more on this new initiative and the Ministry's role in this.

The aim of the community network for seniors is to enable more systematic collaboration between Government agencies and community-based stakeholders, enabling them to leverage each other's strengths and resources to jointly support our seniors. A small group of staff from different agencies will work together to drive the development of this network and there are three objectives of this community network.

First, we want to expand outreach. The Government agencies will coordinate our efforts with local VWOs and grassroots so that we combine forces and collectively reach out to a bigger pool of seniors, rather than visit the same seniors a few times over. For instance, PGAs can inform the Pioneers of relevant active ageing and social activities in the community, as part of their current house visits to explain Government schemes.

Second, we want to link the programmes and services across Government agencies, VWOs and grassroots organisations together so that we can serve our seniors better. For instance, we can join up the healthcare services provided by Regional Health Systems with the social care provided by community-based organisations to support our vulnerable seniors better in the community.

Third, we want to engage stakeholders and recruit more resident volunteers in a particular community, to help their fellow elderly neighbours. As part of this pilot, MOH wants to work with different partners in the community to recruit and train more neighbour carers that can include the more able and active elderly, as suggested by some Members, who can be paired with the seniors living alone in the community.

With Community Networks for Seniors, we hope to build kampungs for all ages, where our seniors can age happily, healthily and actively in place, for as long as possible. If we build up strong community networks over time, caregivers will also have greater peace of mind that their elderly loved ones will have many caring neighbours and agencies on the ground looking out for them.

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Assoc Prof Fatimah Lateef, Dr Chia Shi-Lu and Ms Tin Pei Ling asked about our plans to grow the healthcare workforce. In the midst of a more uncertain economic climate, the growth in the healthcare sector will provide good job opportunities and meaningful new careers for Singaporeans. MOH is stepping up efforts to attract fresh school leavers and mid-career professionals to join the healthcare industry. For instance, we are enhancing information and outreach through career talks and exhibitions, engaging the education and career guidance (ECG) counsellors to secondary school students.

We will also continue to support providers to recruit nurses, allied health professionals and care staff for the aged care sector. We launched the online ILTC Careers Portal in 2013 and a branding campaign earlier this year to raise awareness of opportunities in this sector. We have facilitated the recruitment of 107 locals through our job fairs over the past one year.

MOH has also provided funding support to enhance the pay competitiveness of healthcare workers in VWO providers, in tandem with the pay increases in the public healthcare sector. We will do even more this year, to enhance recruitment for the aged care sector.

Assoc Prof Daniel Goh suggested recruiting retired nurses to deliver home and community care. Today, some of our home-care providers are already doing so. To better attract non-practising local nurses back to work in the growing aged care sector, we have enhanced the Return-To-Nursing scheme in April this year. We have strengthened training in areas, such as geriatric and palliative care, in a three-month refresher course and enhanced the training allowances. There will also be a new one-time Community Care Placement Bonus at $3,000 for Enrolled Nurses and $5,000 for Registered Nurses who join the aged care sector.

There is also an increasing need for professionals, managers, executives and technicians (PMETs) who can take on management and supervisory positions in new aged care facilities. We have, therefore, launched a new Senior Management Associate Scheme to attract mid-career talents with supervisory or managerial experience, who are interested to explore a career switch to the aged care sector. We aim to recruit 10 mid-career talents per year. They will undergo three months of training with AIC to understand the sector before taking up senior positions like Centre Directors in the institutions. MOH will provide funding support to the institutions for the remuneration and benefits given to these mid-career talents.

Even as we explore more initiatives to grow local workforce participation in the sector, there is still a need to bring in foreign healthcare workers to augment our local supply. We will continue to help these workers adapt to our practices and working environment, so that they can be effective members of our teams. Assoc Prof Daniel Goh spoke about home nursing providers who bring in foreign nurses under foreign domestic worker permits.

Let me clarify that providers can only deploy nurses registered under the Singapore Nursing Board (SNB) to deliver home nursing services. The providers Assoc Prof Daniel Goh mentioned are employment agencies who bring in care aides to assist senior clients and they hold foreign domestic worker permits.

In parallel with efforts to grow the workforce are efforts to deepen skills and build new capabilities. To date, more than 7,000 ILTC staff have undergone various training, from care skills training to leadership programmes under the AIC Learning Institute.

Under the national SkillsFuture initiative, we will introduce the Healthcare Skills Future Study Awards to support skills upgrading of the healthcare workforce. The $5,000 study awards will support learning and development in the areas of aged care, healthcare IT, analytics and healthcare system design, organisation and delivery, and will benefit 50 healthcare staff this year. The awards will be opened for application from June this year.

MOH will also champion initiatives within the public healthcare sector to make our healthcare institutions age-friendly and enhance the longevity of our older experienced staff. Our healthcare institutions will be systematically introducing mechanisation to take away the physical strain of healthcare jobs. We will also redesign jobs, introduce FWAs and provide retraining to create more opportunities for older Singaporeans to work in the healthcare sector.

For instance, NUH has started a flexi-work pilot for Singaporeans to help ward nurses with basic care duties, so that the nurses can focus on clinical nursing work. NUH targets to have up to 50 of such Basic Care Assistants and has already hired 16 under the pilot phase.

Ms Thanaletchimi and Dr Chia Shi-Lu will also be pleased to note that all healthcare clusters today have FWAs in place to help workers balance work and personal demands. These include part-time employment, compressed work week, flexible work schedules and hours.

Last year, four hospitals piloted new FWAs for nurses in selected wards, where the timing of the afternoon shift was brought forward to allow the nurses to spend more time with their families and friends after work. MOH is currently working to facilitate electronic rostering systems, so that more FWAs for nurses can be scaled up to all public healthcare institutions.

Our healthcare institutions will also strengthen workplace health programmes and introduce new retirement planning programmes for their mature workers. These include pre- and post-retirement workshops, to guide older healthcare workers through career transition issues.

In short, despite the current economic uncertainty, the health and aged care sector is expanding and will be able to offer many different good jobs to Singaporeans of all ages.

Assoc Prof Fatimah Lateef and Ms Tin Pei Ling asked for an update on community mental health. Last year, I updated the House that we will systematically strengthen our community mental health efforts in a few ways and I am pleased to report that we are making steady progress.

First, to enhance the mental well-being of Singaporeans, HPB has rolled out initiatives to equip the public with knowledge and skills to keep mentally well and seek help early, if needed. For example, their "Working Minds" talks and workshops in workplaces impart skills on managing stress and developing resilience so that employees can perform at their best and 4,500 employees from 90 small and medium enterprises (SMEs) have participated in these workshops since they started in 2013.

Second, to help detect and support the treatment of mental health patients in the community, AIC has trained and partnered over 100 GPs and set up six specialist-led community-based teams to guide our primary care providers in managing patients with more complex issues. Six allied health-led community teams have also been set up to support GPs by providing counselling and psycho-education to clients and caregivers. This is an increase from the 70 GP partners and nine specialist and allied health-led teams last year. As at end-2015, these teams have seen over 7,000 clients, an increase from 4,700 in the previous year.

Third, we have reached out to 36 constituencies; 16 in the past one year alone. Over 800 grassroots leaders, volunteers and community partners have been trained in basic mental health knowledge and symptoms of mental illness, which allows them to identify, respond and support residents with mental health challenges. Again, this is an increase from the 400 trained in 2014. AIC has also trained over 500 staff from the ground agencies, such as HDB, Town Councils, the Singapore Police Force (SPF) and Family Service Centres.

In addition, advisors in all 89 divisions have been given a single AIC contact point for easier referral to assist residents with suspected mental health issues. AIC will be the first responder and lead in coordinating further assessment and care. To address Dr Lily Neo's suggestion, SSOs today can refer persons with suspected mental health issues to AIC for assessment, as well as help provide the necessary support if needed, as part of the overall care plan.

Fourth, IMH is strengthening its after-care services to better support clients post-discharge, so that they could be better managed and supported to continue to live in the community. Together with AIC, IMH is piloting an integrated model of after-care case management for clients with moderate to complex social and healthcare needs. Case managers assigned to these clients will assist in their transitional care upon discharge and link them to community support partners. These after-care teams have reached out to over 150 clients since 2015.

IMH is also enhancing its capability to monitor higher risk patients post-discharge and ensure that they comply with follow-up treatment. If a patient refuses or defaults on treatment, IMH will work closely with family members, caregivers and other community partners to engage the patients. Currently, the Mental Health (Care and Treatment) Act does not provide for enforced treatment of psychiatric patients in an outpatient setting. We can study Dr Lily Neo's suggestion on whether to compel outpatient mental health treatment, taking reference from overseas models, such as Scotland, England and Australia.

Nonetheless, the experience of these countries is mixed so far, and there is no robust evidence to show that community treatment orders are effective in achieving key outcomes, such as reduced hospital re-admissions, improved medication adherence and patients' quality of life. Even as we study such an approach, it is important that we continue to enhance access to mental health services and continuity of care.

We share Mr Low Thia Kiang's concern about funding for mental health, and take a calibrated approach in ensuring comparability in coverage. Patients requiring inpatient treatment can enjoy Government subsidies similar to other medical treatments.

The MediShield Life claim limit and MediSave withdrawal limit for psychiatric treatments are lower, as Mr Low has said, because its bill size is generally lower as well. The median post-subsidy bill per day in 2014 was $60 for psychiatric treatment, compared to $350 for non-psychiatric treatment.

Taken together, the MediShield Life and MediSave limits were sufficient to cover seven in 10 subsidised inpatient psychiatric bills. MediFund assistance is also available for those who are unable to afford treatment, even after subsidies and MediSave and MediShield. Patients requiring outpatient mental health treatment can receive Government subsidies at our SOCs and polyclinics, which were recently enhanced for lower- to middle-income patients, who also enjoy CHAS subsidies at CHAS GP clinics.

Pioneers can receive special subsidies at SOCs, polyclinics and CHAS GPs. All patients can also use MediSave for psychiatric conditions under the Chronic Disease Management Programme (CDMP) and our seniors can further tap on Flexi-MediSave.

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We recognise the stresses of caregiving, as highlighted by Miss Cheng Li Hui and Ms Kuik Shiao-Yin, and have enhanced support for caregivers to make it easier for them to navigate our care system.

Caregivers can approach AIC's AICarelinks at AIC's office and our hospitals. These are one-stop points to get information and advice on the appropriate services for their loved ones. They can also contact AIC's Singapore Silver Line for support on all matters relating to mental health and eldercare services. Besides the four major languages, there are dialect-speaking agents available for seniors who are more comfortable speaking in their native dialects. We have also put in place programmes to help patients and their caregivers transit more smoothly from the hospital to home.

Since 2008, AIC has care coordinators who helped patients look for services required after discharge and follow up with them to provide further support post-discharge through phone calls, home visits or both. To ensure their well-being, we have also made respite care more accessible for caregivers and enhanced subsidies to help defray the costs of caregiving. AIC also works closely with community touch points to look out for caregivers who may be stressed and render assistance where needed.

As noted by Mr Low Thia Kiang, Miss Cheng Li Hui and Dr Tan Wu Meng, the focus for our community mental health efforts going forward will be on dementia. With a fast-ageing population and a dementia prevalence rate of about 10% amongst seniors aged 60 and above, we can expect the number of seniors with dementia in Singapore to grow with time.

We are strengthening community-based support for persons with dementia and their caregivers. We have three home intervention teams to support caregivers in managing challenging behaviours of their loved ones with dementia at home, which have reached out to close to 200 clients and caregivers to date. The 10 outreach CREST teams have also reached out to more than 39,000 seniors at risk islandwide. We are also expanding capacity of dementia care services in the community. By 2020, we will have 3,000 dementia day care places, 1,970 dementia nursing home beds and 160 eldercare sitters.

Mdm Chair, we need to rally the whole Singapore kampung to play a part in supporting seniors with dementia and their care-givers within our communities. Last month, I launched an effort to build a Dementia-Friendly Community in Hong Kah North, after the first such community was launched at Chong Pang. We are working with other divisions, such as MacPherson, Queenstown and Bedok, to embark upon this initiative, too.

Under this initiative, we will build up networks of Dementia Friends who are trained to recognise and provide assistance where necessary to persons with dementia. We will also pilot a safe return system for lost seniors and step up efforts to raise public awareness, such as through AIC's dementia toolkit. We hope to encourage more communities to come together to build a dementia-friendly Singapore.

Moving on to women's health issues, I am pleased to update that I will be chairing a revamped Women's Health Committee to focus on three key health issues among women. These are increasing cancer screening uptake, promoting bone health and, of course, women cannot be left out of the war on diabetes. So, the third focus will be on fighting diabetes, particularly diabetes linked to obesity and gestational diabetes, which Ms Tin Pei Ling and Assoc Prof Fatimah Lateef asked about.

Specifically for gestational diabetes, the Committee will complement the work of the diabetes task force and look into providing support for women with gestational diabetes to reduce the risk of complications during pregnancy and risk of Type 2 diabetes and cardiovascular disease for the child.

Promoting bone health is also important for women who are at higher risk of osteoporosis than men. The Committee will also encourage women to promote good health in our families, such as by breastfeeding our infants, which may reduce the risk of obesity and, hence, diabetes for them later in life, provide them with the best possible nutrition and protect them against illnesses and allergies.

Mdm Chair, the Action Plan for Successful Ageing is our blueprint to prepare for rapid population ageing. A Nation for "All Ages" has to be built by all Singaporeans together. With many hands and many hearts, I am positive that we can face population ageing confidently and successfully.

The Chairman: Ms Tin Pei Ling.

Keeping our Young Healthy and Fit

Ms Tin Pei Ling: Madam, childhood obesity has been described by WHO as "one of the most serious public health challenges of the 21st century". It is also on the rise in Singapore. A major concern is that obese children are more at risk of suffering from chronic diseases and stroke later on in life.

However, this can be prevented if intervention is done right and early. We must keep our young healthy and fit, for their own sake and for the sake of a healthy Singapore. Hence, what is the MOH's plan to address childhood obesity? What is the Ministry's plan also in promoting and supporting our young to stay healthy?

Mental Resilience and Well-being of Youths

Mr Darryl David (Ang Mo Kio): Mdm Chair, I would like to speak on the mental well-being of youths. Mdm Chair, young students today face many different challenges.

First, they have to deal with the pressures of school. Assessment and homework are followed by more assessment and homework. Then, you have enrichment classes and tuition and everything culminates in examinations at the end of primary and secondary school.

They are also increasingly exposed to the digital world. While infocommunication technology can be a great learning tool if employed correctly, this digital world also presents its own set of challenges, such as the exposure to too much unfiltered knowledge. And the pervasiveness of social media also means that these young students sometimes find themselves the victims of cyber-bullying.

Such issues used to be typically associated with teenagers, but we have to acknowledge that pre-teen students are facing these challenges as well. I have personally spoken to a few parents of children from this age group who are seeing psychologists to help their children deal with the stress. In fact, some parents feel that they should see a psychologist as well.

On the risk of falling into mental health problems, it is usually precipitated by experiencing simultaneous multiple stressors in life. In addition to those stressors mentioned above, these could also arise from problems in their family and personal relationships.

I would like to ask what the Ministry is doing to help students build up their mental resilience and mental well-being to better prepare them to cope with these stressors in life. Also, would the Ministry consider having a decentralised community-based mental wellness facility not just for students, but for others, too?

Children's Mental Health

Miss Cheng Li Hui: Madam, last July, in a written answer to a question by Assoc Prof Fatimah Lateef, Mr Tan Chuan-Jin shared that, "For children above the age of six, KKH and NUH provide diagnostic services for a range of developmental disabilities, such as autism and speech and language delays, while IMH provides assessment for Autism and Attention Deficit Hyperactivity Disorder (ADHD). In 2014, the average waiting time for subsidised patients was between one week and two months." I would like to ask how are the children identified for these tests and how many of them were assessed in the last three years.

IMH runs two Child Guidance Clinics located at Buangkok Green and Outram Road. I heard about the good team of doctors and staff in these premises and I thank them for their passion in caring for their clients. I understand that children with mood and anxiety-related concerns, including eating disorders and relationship problems, may be referred there for therapy. Would the Ministry also provide figures on the number of children and youths below age 18 seeking treatment at Buangkok Green?

Our conservative society still exerts considerable social stigma to the family and children suffering from autism and other mental health issues. Will the Ministry consider relocating the Buangkok Green unit to our heartlands or start new units in other locations to strengthen support for mental wellness?

Dengue Vaccination and Zika Prevention

Ms Tin Pei Ling: Madam, the rise in dengue cases in recent years and the spread of Zika in other parts of the world are worrying. While the Government is proactively working to prevent mosquito breeding, it is not foolproof. Singapore is an international hub. The risk of an infection brought in by an unsuspecting foreign carrier is always present. We, therefore, need to look at other prevention methods.

Could the Ministry share whether there are plans to integrate dengue vaccination with other dengue control and healthcare strategies in Singapore? Could the Ministry also share whether it will invest in research into Zika, its treatment and vaccination?

The Chairman: Dr Chia Shi-Lu, you have two cuts, please take them together. Take the first two cuts, and take the third one, when I indicate so.

Protection from Emerging Diseases

Dr Chia Shi-Lu: Yes, Mdm Chair. While we are understandably concerned about the impact of chronic diseases on the population, such as diabetes, which we have been hearing about, we must remain vigilant to the continued threat of infectious diseases, in particular, new and emerging ones.

Our experience with severe acute respiratory syndrome (SARS) at the turn of the millennium has shown us the devastating impact of a previously unrecognised infectious disease and the immense human, social and economic cost.

More than a decade later, the world continues to be besieged by the threat of emerging infectious pathogens: bird flu, swine flu, Middle East respiratory syndrome (MERS), Ebola and, more recently, the Zika virus. MERS remains a threat in the Middle East and had a devastating though fortunately limited outbreak in South Korea last year. Ebola cut through entire populations in West Africa and infected close to 30,000 people worldwide and claimed over 11,000 lives worldwide.

Now, we face the spectre of Zika, which is not fatal but behaves in a far more sinister fashion, affecting unborn babies and potentially condemning them to a lifetime of mental disability. I commend the Ministry on how it has increased our preparedness to deal with such threats since the SARS epidemic, and Singapore has thus far been spared similar crises, through a combination of vigilance, border controls and perhaps through a measure of good fortune.

I would like to ask the Ministry to provide an update on its plans to protect Singapore from the threat of infectious diseases, such as the new and emerging ones which I have just mentioned, and also persistent ones like dengue and resurgent ones like tuberculosis.

Transparency in Healthcare Delivery

Madam, I am glad that, over the years, the Ministry has been actively pursuing greater transparency with regard to issues related to healthcare and healthcare delivery. Results of quality-of-care reviews, patient satisfaction surveys, average costs of hospitalisation for common procedures are readily available, and patients can now access their personal health information online.

I would like to ask what further steps the Ministry is taking to allow even better transparency across the whole chain of healthcare delivery. Can this added transparency be harnessed to improve healthcare delivery, in terms of efficiency, quality and also cost containment?

Healthcare costs are on the rise. Does MOH have any plans to enhance transparency of healthcare fees or to introduce fee guidelines to help contain healthcare inflation?

MediShield Life now provides comprehensive and universal hospitalisation coverage, but about two-thirds of Singaporeans still have integrated insurance plans (IPs) that cover them for medical services by private healthcare providers.

Many are concerned about the cost of private healthcare and also of IP premiums, notwithstanding the recently announced Standard B1 plans that aim to provide a reasonable benchmark for IPs. What is the Government doing to manage rising charges in the private healthcare sector?

The Minister of State for Health (Dr Lam Pin Min): Mdm Chair, with your permission, may I display some slides during my speech?

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

Dr Lam Pin Min: Thank you. MOH remains committed to reinforcing the core pillars of a quality healthcare system for our population. This encompasses taking a closer look at the fundamentals of our healthcare system, including developing better preventive health services for our young and strengthening primary care.

There is a rising prevalence of chronic diseases amongst our population. One in four Singaporeans aged 40 and above has at least one chronic disease. We are concerned about this increasing prevalence, as these conditions can lead to serious complications if not well-managed. For example, complications faced by poorly-controlled diabetic patients include kidney failure, stroke, heart attack, blindness and even lower limb amputations.

The risk of chronic diseases in general can be lowered through simple lifestyle changes. Choosing to live healthily is a habit that we should inculcate from a young age. As pointed out by Ms Tin Pei Ling, it is vital that we go upstream and enhance preventive health services that encourage the formation of healthy habits in our children and youths, even as we continue to step up our efforts in promoting health screening among older adults. All of us have a role to play in keeping our young healthy and fit, especially parents and caregivers. They role-model healthy living, nurture a healthy home environment, influence and guide children to form healthy habits, which, hopefully, will continue through adulthood.

In Singapore, we have had a comprehensive school health service since 1921, which underpins the good public health achieved today. The HPB's current strategies and close collaboration with the schools in encouraging students to adopt a healthy lifestyle have served us well. For example, trained professional nurses are stationed full-time in selected secondary schools and post-secondary institutions under the Student Health Advisor (SHA) programme, to provide advice on weight management and smoking cessation.

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One successful story is that of Ms Tan Su Kheng. For many years, Su Kheng put up with jokes and comments about her weight, which affected her self-esteem. Last year, she joined her school's weight management intervention programme, which helped to kick-start her journey towards a healthier life. On top of receiving many practical tips on healthy living, Su Kheng found additional support through her SHA, who taught her how to incorporate exercise into her busy student life. Apart from exercising thrice a week, she walks home and takes the stairs every day, instead of taking the bus and using the lift respectively.

The journey to staying healthy can be challenging. However, I am inspired by what Su Kheng relates to us about her experience. And I quote, "Whenever I feel like giving up, I will tell myself that although I may not be there yet, I am one step closer to success than yesterday." I am happy to share that with her perseverance and encouragement from her SHA, Su Kheng has lost over 20 kilogrammes in just one year. I hear that family and friends have even started approaching her for tips on healthy living. My heartiest congratulations to Su Kheng!

Despite these efforts, it worries me that we still see the proportion of overweight children and youths increasing over the past five years. Studies have shown that childhood obesity is likely to persist and progress into adulthood. This results in individuals being at higher risks of developing chronic diseases, such as diabetes and hypertension. An overseas study revealed that those with childhood obesity are four times more likely to be at risk of developing hypertension in adulthood when compared to their non-obese peers. It is, therefore, critical that we curb the rising rates of childhood obesity.

A local survey showed that most students are engaging in less physical activities and becoming more sedentary. More than 80% of the students surveyed exceeded the recommended screen time of no more than two hours a day. This is exacerbated by inadequate physical activity. Based on past surveys, only about 10% of mainstream or ITE students and 20% of polytechnic students had sufficient physical activity.

In addition, the prevalence of myopia in our children is one of the highest in the world. More than 60% of our Primary 6 students have myopia today. This is undesirable as poor eyesight from myopia can impact learning. And as the condition progresses, it may result in sight-threatening complications as well.

We have also found that about half of all our Primary 1 students have dental caries. Poor oral health affects the nutrition, growth and development of our children. We are concerned and are keen to tackle the pervasion of these trends among our young. Apart from their physical growth and development, we will also further strengthen our efforts to help our young to build up their mental resilience to better cope with the stressors of life.

Mr Darryl David raised concerns on the mental resilience and well-being of our youths. To comprehensively address the multifaceted aspects of student mental health concerns, we have adopted a three-pronged approach, comprising knowledge and skills-building, facilitating access and referral to mental health services, and parental engagement.

MOE and HPB have introduced programmes to provide educators with basic knowledge on common issues faced by our youths. Educators are also equipped with the ability to detect early warning signs and skills to provide appropriate support and referrals to services and resources in the school setting. These programmes have also groomed youth opinion leaders on health, by arming them with knowledge on health and well-being, mental health concerns and youth advocacy.

Mr Darryl David also suggested having community-based mental wellness facilities. As Senior Minister of State Amy Khor mentioned earlier, we are steadily building up our mental health services and support networks within the community to identify and help persons with mental health concerns.

It is important for us to work upstream to lay strong foundations for our young to lead healthier and more productive lives, starting from those as young as two years old. To this end, I will lead an inter-agency NurtureSG Taskforce with Minister of State for Education Dr Janil Puthucheary. The task force comprises representatives from various Ministries, HPB, Sport Singapore and the ECDA, as well as medical professionals and academics. It will guide the development of the NurtureSG Plan to enhance the health outcomes among our young.

The NurtureSG Taskforce will focus on three main areas. First, we will look into developing new strategies and strengthening existing programmes to address salient health issues and negative trends among children and youths. Next, we want to reinforce health promotion efforts at the tertiary institutions so that young Singaporeans will maintain healthy habits beyond the school-going age and well after entering the workforce. Last but not least, we aim to bring health promotion for the young beyond the school and into their families and the community.

We will launch a public consultation later this month to seek ideas on how we can encourage and enable our young to adopt and maintain healthy lifestyles. In particular, we will engage students, educators, parents, caregivers and even the private sector, such as food establishments, to create a healthier environment for our children.

To Miss Cheng Li Hui's comments, children are referred to the hospitals for both developmental and mental health conditions by polyclinics, GPs, paediatricians, primary schools and REACH, which stands for Response, Early Assessment and intervention in Community mental Health teams. Besides the Child Guidance clinics at Buangkok View and Outram Road, mental health services for children and youths are also available in other hospitals, such as NUH, Singapore General Hospital (SGH) and KK Hospital.

These services typically include assessment, diagnosis and multidisciplinary management of patients up to the age of 18, but may continue to follow up with them beyond this, where appropriate. The subsidies for these services are in line with existing SOC subsidies. From 2013 to 2015, there were about 50,000 psychiatric SOC attendances for patients up to 18 years old, of which two-thirds were seen in IMH.

Empowering and teaching our young to lead healthier lives are only one part of the equation. As our population ages and healthcare needs continue to rise, we must reshape the way we approach healthcare.

Primary care is the foundation of any healthcare system. We aim to strengthen its place in our healthcare system, to be the first and continuous line of care. Dr Tan Wu Meng asked about the role of the family doctor. My response is encapsulated in our vision "One Singaporean, One Family Doctor".

Overseas studies have shown that care continuity by a regular family doctor results in better care outcomes for patients. These include decreased hospitalisations and emergency department visits. Our family doctor can be our partner in helping us stay healthy and in providing us with good and affordable care close to us. Many Singaporeans see a doctor when we come down with an illness, such as a bad cold. With a regular family doctor, such visits can develop into a strong doctor-patient relationship over time. As our family doctor develops a holistic understanding of our family's medical profile and health needs, they will become our health advocate in identifying risk factors and can offer more targeted, timely and individualised advice and plans to manage our health.

For those with chronic diseases, we can manage our condition better by having a family doctor who understands our condition well and supports us with quality management and treatment. Our family doctor must also have some understanding of our family, social and work situation to advise us on making lifestyle changes and adhering to treatment. They can also refer us appropriately if we require more specialised medical attention and help coordinate our care with other providers.

I would like to share a story of a family doctor being one's trusted health partner. Mr Tan Heok Lim has been seeing his family doctor, Dr Leong Choon Kit, for the past 14 years. He feels comfortable with Dr Leong's care and has continued seeing him for his medical needs. This enables Dr Leong to care for Mr Tan holistically – from health screening to diagnosis and management of chronic conditions, such as hypertension.

With deeper understanding of the family, Dr Leong has recommended suitable health screening for Mr Tan's wife, who has a strong family history of diabetes. Mrs Tan was found to be borderline diabetic and Dr Leong was able to intervene early through advice on lifestyle modifications, to prevent the progression of diabetes. Currently, Dr Leong manages the chronic conditions of Mr Tan, his wife and his son. And I am happy to hear that both Mr Tan and his son have also successfully quit smoking, with encouragement from their family members and Dr Leong.

I believe that there are many such positive stories to illustrate the benefits of having a regular family doctor. However, only two in five Singapore residents aged 18 to 69 have a regular family doctor today. We want to call on Singaporeans, especially those with chronic conditions, to take the first step in identifying and sticking with a regular family doctor.

To facilitate this, we will review our policies to help strengthen doctor-patient relationships in primary care. As we progress on the journey to realise our vision of "One Singaporean, One Family Doctor", we will continue to engage our GP and polyclinic colleagues to co-create the future primary care landscape, in particular, to achieve better chronic disease management in the community.

We are mindful to ensure sufficient primary care capacity with the ageing of the population and a growing chronic disease burden. Our polyclinics will continue to play a key role, especially in the management of complex chronic diseases. In recent years, we have announced the development of new polyclinics and redevelopment of existing ones.

Since 2012, we have also strengthened partnerships with private GPs to provide subsidised care to Singaporeans. Today, the CHAS provides lower- to middle-income Singaporeans and all Pioneers access to subsidised care at private GP and dental clinics, and 900 GP clinics and 650 dental clinics islandwide have signed up for CHAS. We value their partnership.

We have also developed new models of primary care, such as the Family Medicine Clinics or FMCs, since 2013. The FMCs are multi-doctor practices, with onsite nurses and other allied health professionals, delivering comprehensive team-based care, especially for chronic disease management.

As part of our continual efforts to better serve our residents, we have been redeveloping existing polyclinics. The new polyclinics in Punggol and Jurong West will open in 2017. I am pleased to announce that we will build another polyclinic in Eunos, in response to Assoc Prof Fatimah Lateef's query on new primary care facilities. The new polyclinic is expected to be operational by 2020 and will be designed to cater for future primary care needs.

Today, there are seven FMCs in operation. By early 2017, we will develop two more FMCs: one in Tampines and another one in Keat Hong. We will continue to review and evaluate FMC development as part of our efforts to strengthen and improve primary care.

With these range of developments, we have tried to support the growing needs in primary care. To address Dr Tan Wu Meng's concerns, residents in the West can look forward to three new facilities – the new polyclinics in Jurong West and Bukit Panjang, as well as a new FMC in Keat Hong. These will help to relieve the load in existing polyclinics in the West, such as Clementi Polyclinic.

We will continue to review the regional primary care needs of our population and work closely with the Urban Redevelopment Authority (URA) and HDB to review and ensure the adequacy of the space needed for primary care facilities in HDB estates.

A good primary care system can help to reduce costly interventions in the hospital setting. To keep primary care affordable, CHAS and PG cardholders at the FMCs and CHAS clinics receive Government subsidies for their care. Dr Tan Wu Meng and Assoc Prof Daniel Goh commented on enhancing subsidies for primary care. Since 2012, we have significantly enhanced CHAS so that more Singaporeans can benefit. In 2013, we raised the income criterion from per capita monthly household income of $1,500 to $1,800. In 2014, the age floor of 40 years was also removed. These changes have helped more Singaporean households to benefit from CHAS.

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I thank Assoc Prof Daniel Goh for his suggestion to change the qualifying criteria for CHAS. Assoc Prof Goh suggested that we change the per capita household income criterion of $1,800 to an individual's prevailing median monthly income of $3,900. The current CHAS income criterion of $1,800 ensures that lower- to middle-income Singaporeans, or Singaporeans in about half of all resident households, can qualify. This means that a household of four, with the breadwinner earning $7,200, is eligible.

A household-based approach ensures that subsidies are equitably distributed to extend more benefits to individuals with more dependants. In determining our income criterion, we will need to strike a balance, bearing in mind the need to target subsidies at those who need it most and Government budget availability. We will review CHAS regularly and enhance the scheme where needed to ensure that care remains affordable.

Dr Chia Shi-Lu asked for measures to improve transparency in the charging of healthcare services. We have implemented various measures to this end. Hospitals are required to provide financial counselling to patients to ensure that they are informed of the charges likely to be incurred for their treatment. For outpatient care, patients are also provided with information on estimated charges for consultation.

Since 2013, hospital bill sizes for common conditions and procedures at both public and private hospitals have been progressively published on the MOH website. In 2014, the publication of "Total Operation Fees" for common procedures in public hospitals was introduced.

I am pleased to announce that the publication will be expanded to cover "Total Operation Fees" for private hospitals later this year. There will be further breakdown of the "Total Operation Fees" into "Surgeon Fees", "Anaesthetist Fees" as well as "Facility Fees". The expanded publication will provide added transparency on the private hospital bill components attributed to performing the procedure and serve as a point of reference for both healthcare professionals and the general public.

Safeguarding public health is another fundamental aspect of maintaining population health. Even as we tackle the increasing prevalence of chronic diseases, we need to remain cognisant of our external environment.

In line with the Minister's call for us to remain vigilant, we need to constantly improve our public health system to promote health, prevent diseases and prolong life among our population. Dr Chia Shi-Lu asked about the measures that we are taking to protect Singapore against emerging diseases. We have adopted a three-pronged approach to external public health threats, namely, reducing the risk of importation, early detection and containment.

We perform local and global surveillance to ensure situational awareness for endemic diseases, such as tuberculosis and influenza, and emerging diseases overseas, such as MERS and Zika. We also fund research to evaluate the effectiveness of surveillance and response plans to infectious diseases. These include looking at potential areas for collaboration with the relevant institutions on Zika virus diagnostics, transmission and its association with microcephaly and Guillain-Barre Syndrome. We conduct regular preparedness exercises to practise our responses and identify potential areas for improvements. We also maintain a surge capacity for isolation beds and a national stockpile of personal protective equipment.

In the community, we work with about 640 GP clinics which have volunteered as Public Health Preparedness Clinics, or PHPCs, to help manage public health emergencies, such as haze and influenza pandemics. While all GPs play important roles to provide care in such situations, PHPCs take on additional roles, such as providing subsidised care for conditions related to the public health emergencies.

Coordinated efforts across multiple Government agencies, as well as with other countries and international organisations, are also vital in protecting Singapore against external public health threats.

In relation to Ms Tin Pei Ling's query regarding dengue vaccination, HSA has received the regulatory filing for Sanofi's dengue vaccine in March 2016 and is expediting the review, given the dengue situation in Singapore and recognising that this is the first dengue vaccine available.

The key focus in the Health Sciences Authority's (HSA's) review is to ensure that the vaccine is safe, of good quality and is effective for use in our local population, taking into consideration the local prevalent strains of dengue and its potential risks and adverse effects. Nonetheless, there is currently no vaccine that confers 100% protection against all known strains of the dengue virus.

If it is found to be efficacious locally and subsequently introduced, dengue vaccination should be coupled with other dengue control and healthcare strategies in Singapore, such as having a strong disease surveillance system and maintaining effective vector control measures, to keep the mosquito population low. All of us still have a part to play in staying alert and fighting dengue.

Mdm Chair, we see an increasing need to shift the focus from healthcare to health. However, we cannot do this alone. Let us encourage one another, including our children and youths, to adopt a healthy and active lifestyle to keep chronic diseases at bay. Our regular family doctor shall be our trusted health partner throughout the different stages of our lives.

At the same time, we introduce further measures for greater fee transparency at the hospitals. Not forgetting our vulnerabilities in an increasingly connected global community, we will remain vigilant in responding to public health emergencies. On this note, I urge Singaporeans to partner us in building strong foundations for better care and better health.

The Chairman: Dr Chia Shi-Lu.

Taxes for Unhealthy Eating

Dr Chia Shi-Lu: Mdm Chair, according to a recent study that was published in the Lancet, which is a very well-respected medical journal, there are more than 640 million obese people globally. The threat of severe obesity noted in this paper was considered too severe to be tackled with medications or by exercise alone. The study recommended taxing foods that are high in sugar or that are highly processed. WHO has also recently come out in support of such a move.

The level of obesity, as we have just heard, is also rising in Singapore. Our adult obesity rate increased from 6.9% in 2004 to 10.8% in 2010. It is probably higher today.

Obesity increases the risk of diabetes, heart disease, stroke, joint problems, high blood pressure, high cholesterol and certain types of cancer. Not only does obesity have a negative impact on personal well-being; it is costly to the nation. We have to spend more money on obesity-related healthcare. And an unhealthy workforce is also likely to be less efficient, affecting our economic productivity.

We should certainly not sugar-coat this problem. Hence, I would like to renew a call I first made in 2011 that the Ministry consider implementing increased taxation on unhealthy foodstuffs, such as those containing excessive fat or sugar, to discourage their consumption.

Other nations have imposed taxes on sugared beverages and on food which is high in saturated fats. I understand that such general taxes will raise prices and may disproportionality affect Singaporeans with lower incomes who spend a greater part of their income on food. Unfortunately, unhealthy, processed food is often cheaper and more affordable.

But just as taxes on alcohol and tobacco have nudged people into reducing their consumption, taxes on unhealthy food should be effective as well. Sugar is arguably as significant a threat to public health as alcohol or tobacco, if not more.

My rudimentary understanding of military strategy informs me that a key to winning a battle is to cut off the supply lines to the enemy and as we have just declared war on diabetes, I think such a move is tantamount to cutting the supply lines to the enemy, which is diabetes.

Finally, I would also like to suggest that healthy food, such as fresh fruits and vegetables, be made cheaper through targeted subsidies. By making healthier food cheaper than unhealthy food, hopefully, our people would start to change their eating habits.

Sugar Content Labelling

Assoc Prof Daniel Goh Pei Siong: Mdm Chair, the harmful effect of excessive sugar consumption has led to Britain recently introducing a sugar tax. Singapore, like the UK, is experiencing an ageing population and the prevalence of obesity and heart disease. There are also local characteristics to the problem as Asians are at a higher risk of developing Type 2 diabetes. In fact, over 10% of adult Singaporeans are currently diabetic and it is the second highest proportion in the developed world. It will, therefore, appear that we should seriously consider a sugar tax.

However, the effectiveness of the sugar tax is questionable, at least in Singapore, as it will likely turn out to be a requisite tax on vulnerable Singaporeans. We should focus instead on empowering Singaporeans towards making healthier choices and adjustments to their lifestyle. I request the Government to consider mandating the labelling of free-sugar content in processed foods where the calories and percentage of daily intake of free-sugar need to be prominently displayed on food packaging.

The sugar content should also be colour-coded with green, amber and red. Labelling should be in line with WHO guidelines of cutting free-sugar consumption to less than 10% of daily calorie intake. This can be rolled out in phases, starting with canned and packet drinks. For example, a can of Coca Cola contains added sugar amounting to 80% of the current WHO guidelines and should be labelled red.

Health warnings that read "Drinking beverages with excessive added sugar contributes to obesity, diabetes and tooth decay" should be attached to drinks that are labelled red. Studies to track whether labelling has resulted in consumers making better choices should be conducted to improve the labelling and gauge its success before we even consider a sugar tax.

ElderShield

Dr Lily Neo: ElderShield is a severe disability insurance scheme with the purpose of providing basic financial protection to those who need long-term care, especially during old age. This is an important insurance scheme nowadays and will be even more so down the road in view of our ageing population.

However, in its present form, the ElderShield which was introduced in 2002 is not adequately addressing the long-term needs of the severely disabled for which it was intended. This is the 10th time I am speaking on ElderShield in this Chamber since 2002. I have raised ElderShield inadequacies even then. Mdm Halimah Yacob had also raised ElderShield 12 times in this Chamber before. I hope MOH will review ElderShield and make it more relevant towards addressing the long-term care of the severely disabled.

Cash payouts of $300 are paid to non-upgraders for up to a maximum period of five years, and $400 are paid, for upgraders, for up to a maximum period of six years to patients who are unable to perform at least three out of six activities of daily living (ADL). These activities are washing, dressing, feeding, toileting, mobility and transferring.

It is obvious that such patients are totally dependent on others for their daily living. They need full dependent-care. Therefore, how will $300 to $400 be enough to care for such patients in one month? Even having a domestic helper to assist them will cost more than double in one month.

I am concerned for those patients, especially the elderly, who do not have savings or family members who can afford their dependent-care costs. Some families take the option of sending their dependent members to hospitals or overstaying in acute hospitals even when they do not require to be hospitalised anymore. Their actions not only deprive other patients who need hospital care, but they also incur tremendously high hospital costs. The patients may not feel the burden of the higher costs in acute hospitals, but it is to be noted that the bills are usually being paid by MediShield or MediFund for needy patients.

The tenure of ElderShield payouts of a maximum of five to six years is also not adequate. These patients with three ADLs, especially those as a result of old age, are unlikely to get back to normal since they have reached the stage of inability to perform the daily activities. Even for other sick patients with severe disabilities due to illnesses, such as stroke or cancer, reaching the stage of inability to perform daily activities, it will usually mean that their illnesses are too severe for them to regain normal activities again. Thus, the insurance coverage of five to six years will leave them in a lurch at the end when their conditions could have deteriorated and should they require even more dependent-care at higher costs.

Presently, ElderShield excludes those aged 70 and above in 2002 and those with existing illnesses. These are the groups who are more likely to get severe disability. They are badly in need of ElderShield but are not eligible for this insurance. For those aged 60 to 64, the annual premiums payable to join ElderShield are from $1,000 to $3,000 respectively. These are unaffordable premium amounts for many seniors and, therefore, many seniors are not in the scheme.

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One of the main reasons for people to take insurance is for peace of mind, knowing that finance is available should eventuality strike. Thus, I hope MOH will review ElderShield to give better protection and assurance to the insured.

MediShield Life had been revamped to give that assurance with its many improved features. Maybe, now, MOH will consider revamping ElderShield to ElderShield Life, similarly as MediShield was improved to MediShield Life. The many new features of MediShield Life had been well thought out and they are very good. Will MOH consider adopting these good features for ElderShield Life as well? I shall mention a few examples.

Lifelong coverage like MediShield Life is essential to give people the reassurance of coverage when they need the insurance most. Patients usually reach their inability to perform ADL towards the end of their lives. Therefore, it is good not to have the age limit on claims.

The risk pool feature of MediShield should be adopted for ElderShield to make ElderShield more viable with non-opt out and as a comprehensive national scheme. I hope our Government will also give subsidies to those who cannot afford the premiums.

Presently, ElderShield is being administered by three private insurers. It will be better if CPF board takes over the role as in MediShield Life.

Increasing ElderShield Payout Period

Mr Louis Ng Kok Kwang (Nee Soon): Madam, with increased cost of living and added healthcare cost, I am concerned that the poor and vulnerable elders in Singapore will fall through the cracks. While MediShield Life is a good measure to cover all Singaporeans, it does not help with their living expenses when they are in recovery or out of the hospital.

This is where ElderShield comes in. However, there are some improvements that I would like to suggest. The premium costs are high for the lower-income families and the process to file claims may be overly burdensome, especially for the elderly. Does the Ministry have plans to review the premiums and also simplify the claim process? Can the Ministry also tap on the PG Office (PGO) to reach out to the other 35% of the resident population who are currently not covered by ElderShield?

Lastly, while the payout period has been extended to 72 months, will the Ministry consider extending the payout period for ElderShield to end of life instead, since there is no reason to assume that care needs would decrease after 72 months?

Information Technology in Healthcare

Dr Tan Wu Meng: May I declare first that I am a doctor who has served in the public and private sectors.

Medical records are essential to good patient care. Better information means better quality diagnosis, more timely treatment and better patient safety. Yet, today, when patients move around across public hospitals, private hospitals, polyclinics and their local GP clinics, it can take time to get a full picture of the patients' medical records. Even within the same public or private hospital, information can be spread between paper and digital, sometimes in multiple digital databases, and not all databases are in the National Electronic Health Record (NEHR). Sometimes, it can be almost like opening a different web browser app to view each different website.

We should look at ways to enhance the use and user-friendliness of information technology (IT) in healthcare to improve productivity and patient safety everywhere.

The Chairman: Minister of State Chee Hong Tat.

The Minister of State for Health (Mr Chee Hong Tat): Mdm Chair, with an ageing population, it is not feasible for Singapore to meet future healthcare demand by simply building more and more hospitals, hiring more and more healthcare workers and providing more and more subsidies. We must also focus on developing a sustainable healthcare system. If we shift too far to the right, we will not be doing right by our fellow Singaporeans. If we overspend and shift too far to the left, our children will have nothing left in the future.

Today, I shall talk about three areas to develop a sustainable healthcare system. First, promoting healthy living. Second, transforming our care models by bringing care beyond hospitals into the community. Third, enhancing value through innovation and productivity improvements.

Let me start with initiatives to promote healthy living and to reduce diabetes prevalence. To fight diabetes, we need a supportive environment to encourage Singaporeans to eat healthily and exercise regularly. Under the Healthy Living Master Plan, we introduced healthier dining options and provided more exercise options in the community, workplaces and schools.

One such initiative is the Healthy Community Ecosystem, which has been implemented in six neighbourhoods since 2014, including my own Group Representation Constituency (GRC) in Bishan-Toa Payoh. Group exercises are held in 40 community spaces, with an average of 1,000 residents participating each week. Lifestyle modification programmes have reached 14,000 residents in these neighbourhoods.

To benefit more Singaporeans, we will be extending the Healthy Community Ecosystem programme to nine more neighbourhoods this year, including Jalan Besar, Pasir-Ris Punggol and West Coast.

Eating right is key to fighting diabetes. Excessive consumption of sugar and refined carbohydrates can lead to weight gain and cause spikes in blood sugar levels. Such spikes increase the risk of developing Type 2 diabetes, if they happen frequently over time.

Dr Chia Shi-Lu asked about measures to discourage consumption of unhealthy food products. Assoc Prof Daniel Goh asked if we could introduce colour-coded labels for sugar content in processed food and drinks. I thank Dr Chia and Assoc Prof Goh for their useful suggestions. We will study their proposals as part of the fight against diabetes.

Many food manufacturers already practise back-of-pack nutritional labelling. HPB's Healthier Choice Symbol (HCS) helps consumers make healthier purchases, through an identifiable front-of-pack symbol. There are currently 2,500 HCS products across 70 food categories. These products contain less sugar, saturated fat or salt. A 2015 consumer survey showed a high level of awareness of HCS products. Nine in 10 said they recognised these products as healthier options and eight in 10 said they use HCS to guide their food purchases.

HPB has worked with close to 240 supermarkets on in-store promotions, such as lucky draws, food sampling and cooking demonstrations. I am glad to know that HCS products are gaining market share. Sales of HCS products are growing at 9% annually. Our target is to increase the total market share for HCS products to 25% by 2020, up from the current 17%.

Some Members are concerned that healthier food may be more expensive. I understand these concerns. We need to work together with industry partners to provide affordable healthy options for Singaporeans. As of March this year, we have 52 food and beverage partners participating in the Healthier Dining Programme involving nearly 1,600 food stalls. Under the programme, we collaborated with restaurants to offer lower calorie meal options and to incorporate healthier ingredients, such as whole grains, fruits and vegetables, as part of their core menu offerings. Major food court chains, including Kopitiam, Koufu and NTUC Foodfare, offer at least one dish below 500 calories at each stall. They also promote reduced-sugar drinks. The number of lower calorie meals sold has doubled from 7.5 million in 2014 to 15 million last year.

I am encouraged by the industry's efforts to produce versions of staple foods, like bread and noodles, which are healthier and taste just as good. Gardenia, for example, uses finely textured wholemeal flour to retain the health benefits of whole grains, while keeping its bread soft and easy to chew.

Besides eating right, we need to encourage Singaporeans to exercise regularly. The recommendation is to have at least 150 minutes of physical activity per week. These 150 minutes can be achieved through simple daily activities like walking to the bus stop, using the stairs instead of the lift, doing household chores or taking a brisk walk at the park.

In 2013, one in four Singaporeans between the ages of 18 and 69 did not meet the 150 minutes per week target, and this was an increase from one in five in 2007. We need to reverse this trend. Leading an active lifestyle can be simple and inexpensive. It is also something we can enjoy with our family and friends.

Mdm Jessie Jee is a Pioneer and one of HPB's Health Ambassadors. She is a regular participant at our Sundays at the Park programme. Every Sunday morning, she joins others in workout classes at the Firefly Park near her home in Clementi. We hope to encourage more Singaporeans, including our seniors, to adopt active lifestyles like Mdm Jee. To support this, HPB will double the number of exercise sessions available in the community and workplaces from the current 100 to 200 by the end of this year.

Another initiative is the National Steps Challenge. Through the use of wearable technology and simple data analytics, users can receive feedback on their daily progress and also receive rewards when they reach certain milestones.

The National Steps Challenge has been well-received since its launch in November 2015. One in three participants have clocked 10,000 steps a day on average. In addition, 70% of previously inactive participants now average more than 7,000 steps per day.

This is a good start, as studies have shown that walking at least 7,500 steps a day can contribute to lower blood pressure and cholesterol levels and help those with diabetes keep their blood sugar levels in check.

Mr Mohd Aidil Bin Sufyan found the Steps Tracker easy to use and a good way to motivate him to stay healthy. He now takes the stairs more often and alights one bus stop earlier to walk home. He also brings his children for weekend walks. Praising the National Steps Challenge as a good initiative, Mr Aidil said he hopes this programme can be extended to more Singaporeans. Thank you, Mr Aidil, for your support and active participation. We are preparing for a second season of the National Steps Challenge. So, akan datang.

Apart from eating right and exercising more, it is important for Singaporeans to go for evidence-based health screening at recommended intervals. Under HPB's Screen for Life programme, Singaporeans 40 and above are recommended to be screened for diabetes once every three years and, very importantly, to follow up with their family doctors after the screening.

Early detection and treatment are important in the fight against diabetes, to keep the disease under control and prevent serious complications. Individuals with diabetes can benefit from lifestyle changes to prevent their condition from worsening. In addition, pre-diabetics could lower their risk of getting diabetes if they detect the problem early and improve their diet and lifestyle.

We plan to reach out to certain groups of Singaporeans below 40. For example, those who are obese and those whose immediate family members have diabetes. They face a higher risk of getting diabetes and may need to start the screening at an earlier age.

We will extend our screening outreach at the workplaces to bring diabetes screening to more workers. These include those who may find it difficult to schedule screening appointments due to the nature of their jobs. We will also review ways to strengthen post-screening follow-up to initiate early treatment and care when needed.

Next, I will touch on efforts to move care beyond hospitals into the community. MOH has co-located several community hospitals with acute hospitals to facilitate care integration for patients. We are helping patients to shorten their stays at community hospitals and return home earlier. For example, by allowing them to do their rehabilitation follow-ups at day rehabilitation centres. This is what many of our patients prefer. They do not want to stay in the hospitals longer than necessary.

As our population ages, it is inevitable that some of us will become frail and disabled and require support in activities of daily living. For some, this may be a few years before they pass on. For others, the duration could be longer, as Dr Lily Neo and Mr Louis Ng highlighted.

I thank Dr Lily Neo, Mr Low Thia Khiang and Mr Louis Ng for their suggestions on ElderShield. There were also earlier proposals from the People's Action Party (PAP) Seniors Group. MOH will study these suggestions carefully, as part of our ElderShield review.

Mdm Chair, one point I wish to highlight is that increasing the payouts and coverage of ElderShield will require, in the end, higher premiums for the scheme to remain viable. So, this higher cost will, ultimately, be borne by everyone, whether directly through ElderShield premiums or indirectly through tax-funded subsidies.

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Hence, there is a need to balance enhancements in ElderShield with the potential cost increases, so that the scheme can remain affordable for all Singaporeans. ElderShield payout is one important source of payment but it is not the only source. Pioneers, for example, can receive Pioneer Generation Disability Assistance Scheme (PioneerDAS) on top of ElderShield. So, we will look at different ways of helping our seniors, especially those who are disabled.

Other important issues for the review include whether ElderShield should be made mandatory for every Singaporean. It is now an opt-out scheme, as some Members have pointed out, and how do we provide coverage for older cohorts of Singaporeans who, today, may not have ElderShield?

Similar to how we enhanced MediShield into MediShield Life, MOH will need to carefully review ElderShield in consultation with experts and key stakeholders. Our end in mind is to provide Singaporeans with peace of mind when we grow old, while keeping the scheme affordable for all.

Mdm Chair, ageing well also means having access to affordable end-of-life care. MOH is working in partnership with the palliative care sector under the National Strategy for Palliative Care. Since 2014, we have ramped up capacity and improved the quality of palliative care in Singapore.

Dr Lily Neo asked for better provision of hospice care, including training of hospice care personnel. We have introduced guidelines for the palliative care sector and will work with the Singapore Hospice Council to encourage industry players to adopt these guidelines.

Dr Lily Neo and Mr Low Thia Khiang asked about the financing framework for hospices. MOH regularly reviews funding for the palliative care sector to ensure end-of-life remains affordable for patients and sustainable for providers.

In July 2012, we raised the threshold for per capita household monthly income to cover up to two-thirds of Singaporean households, up from half previously. This has benefited more than 1,000 additional patients. We will continue to review and adjust the income threshold, like what we have done before.

We have also enhanced financial support for hospice care services. In 2014, we improved funding for home palliative care providers. Last year, we increased the MediSave withdrawal limit for inpatient hospice and home palliative care. Just last month, we increased subsidies for eligible inpatient hospice patients and introduced subsidies for day hospice care.

Overall, with coverage from Government subsidies, charity assistance and MediSave, most patients do not face out-of-pocket payments for hospice and palliative care. Let me share some data for FY2011 to 2015 on the length of stay. For inpatient hospice, the median length of stay is 15 days. For home palliative care, the median care period is around two months. And in terms of affordability, for inpatient hospice, eight in 10 patients have zero out-of-pocket payments and for home palliative patients, nine in 10 did not have to make out-of-pocket payments. Last year, MOH received three appeals on hospice care costs.

Later this year, MOH will further enhance financial support for palliative care by extending the $2,500 MediSave lifetime withdrawal limit for home palliative care to include day hospice services. Similar to home palliative patients, day hospice patients diagnosed with terminal cancer or end-stage organ failure will not be subject to this withdrawal limit if the claim is made from the patient's own MediSave account.

I agree with Ms Kuik Shiao-Yin that it is important for end-of-life care to be provided with empathy. We do have training for our healthcare professionals in this area and will look at ways to further improve and do better. In addition, MOH is supportive of other efforts to improve the quality of our end-of-life care, for example, Assisi Hospice's new facility, where the design of wards resembles a home rather than an institution. Outdoor gardens and green spaces are also included as part of the development.

VWOs play an invaluable role in the end-of-life care sector to provide quality and affordable care. We want to preserve this strong community support and involvement.

Programmes by volunteers also help patients to live their last days fully. This includes befriending and psycho-social support for patients and their families. We will support innovations in palliative care and will continue to work with providers, like Assisi Hospice and others, to pilot new ideas that can benefit patients and caregivers.

Mdm Chair, allow me to now respond to cuts from Mr Dennis Tan and Mr Pritam Singh. Mr Tan asked whether existing private patients in SOCs are allowed to switch to subsidised care without a polyclinic referral. Let me explain what our policy is.

If a private SOC patient wants to switch to subsidised care, a medical social worker will assess his request. These assessments are done on a case-by-case basis. This is to ensure that we target our subsidies at patients with the greatest financial need.

For new patients seeking subsidised specialist care, they will first go through a primary care doctor to assess if they need specialist care services. This can be done at a polyclinic or CHAS GP clinic, if he is a CHAS or PG card holder.

We know there are some private SOC patients who choose to be discharged from private SOC and go through this route to switch to subsidised SOC, instead of going through a medical social worker at the hospital. Strictly speaking, this is not part of the policy for patients to downgrade from private to subsidised SOC. This is perhaps why Mr Tan pointed out that the arrangement is not very neat and tidy. However, our hospitals want to be flexible and they have accommodated these private patients, so that they are not treated differently from new patients who go through the polyclinic.

Taking a broader view, our priority is to transform the way we care for patients, by bringing it beyond the hospital into the community. I shared about how we are integrating care between acute and community hospitals. In addition, MOH is piloting new models where specialists work closely with polyclinics and GPs to co-manage patients who have chronic conditions and need ongoing care. We are also building up primary care so that more SOC patients who are stable can be discharged and cared for by the polyclinics or GPs. This is a more impactful and sustainable way to have a win-win arrangement for everyone.

Mr Pritam Singh asked about Integrated Shield Plans, or IPs. These are private insurance plans which work together with MediShield Life.

IP premiums have two components: there is a MediShield Life component, which is sufficient for basic, subsidised healthcare services, and there is an additional private insurance component. MOH sets the premiums for the MediShield Life component and we will keep MediShield Life premiums affordable for all Singaporeans.

The private insurance premiums are decided by insurers based on commercial and actuarial considerations. They will review and adjust these premiums based on factors, such as claims experience. If claims were to increase significantly over time, the insurers will likely increase their premiums, as some have recently done so with the premiums for riders. Singaporeans who want to keep their insurance premiums affordable, including at older ages when premiums tend to go up, should carefully consider if you want to purchase private insurance like IPs and riders. Some of my residents in Bishan-Toa Payoh told me that they think MediShield Life is adequate to provide them with good quality subsidised care. It is an individual choice.

I agree with Mr Pritam Singh that it is important to guard against over-consumption and over-charging. These will exert upward pressure on healthcare costs and insurance premiums over time, a concern that was shared by Dr Chia Shi-Lu. This is why MediShield Life and all IPs have co-payment features. We will work with insurers to review existing features in private insurance schemes to mitigate the risk of over-consumption and over-charging, while providing sufficient coverage and peace of mind for policyholders.

Other important initiatives to keep healthcare costs and premiums affordable include: promoting healthy living and active ageing because we know prevention is better than cure; finding ways to improve productivity in the healthcare sector; encouraging appropriate care to reduce over-treatment or over-prescription; and, providing more information on fees and charges to help patients decide which hospital and doctor they want to visit.

Mr Pritam Singh also asked to increase the MediSave Additional Withdrawal Limits, or AWLs, to be sufficient for Standard IP premiums at all ages.

MediSave is sized for basic healthcare expenses. MediShield Life premiums can be fully paid for by MediSave. Singaporeans who wish to purchase private insurance can use their MediSave to pay for the additional private insurance component, up to the AWL. We need to set a limit for the use of MediSave for private insurance, including the Standard IP, so that Singaporeans will have sufficient MediSave balances to support their healthcare needs when they grow old.

Mdm Chair, let me now touch on the final area of enhancing value in healthcare through innovation. MOH will work closely with our healthcare institutions and the Healthcare Services Employees' Union to encourage and support ideas that can enhance patient care and service quality, improve the work environment for our healthcare workers and make our healthcare system more productive and sustainable.

Dr Tan Wu Meng asked about enhancing the use of information technology, particularly in the sharing of medical records. I agree with Dr Tan that this will help to improve productivity and patient care.

We rolled out NEHR in 2012 for participating healthcare institutions to view their patients' events and summary health records. As at March 2016, there are more than 900 healthcare institutions with access to NEHR and we would like to include more healthcare institutions over time.

Technology is a key enabler to improve the work environment for healthcare workers. When I visited NUH, I saw their pilot project to remotely monitor patients' vital signs. With this system, the time nurses spend monitoring patients' vital signs has reduced by half.

I am also very happy to know that there are other areas where we can support such technology, including a chair that I saw. It is a portable toilet from Japan. It looks like a normal chair but when you use it, and if you press a button, it will automatically wrap and seal the waste products. So, this makes it easier for the nurses and caregivers, as there is no unpleasant smell and the waste disposal can be done more conveniently.

Ms Thanaletchimi asked about the training for healthcare workers as we implement automation and robotics. The public healthcare employers are committed to redesigning jobs and supporting our workers to gain new skills so that they can stay employable. In fact, through technology and productivity improvements, we want to enable healthcare workers to remain longer in service by making the work less physically demanding for them. This is a win-win arrangement – workers can continue working for more years, while patients can benefit from their service and experience.

Jamiyah Nursing Home is a good example. They partnered the AIC to do a job redesign and, through the various changes they have made, the staff were able to save up to 20% of their time. They also introduced FWAs so as to allow staff more flexibility in managing their work hours.

Our healthcare workers play a pivotal role in supporting productivity initiatives and we appreciate and recognise their efforts.

Ms Thanaletchimi suggested extending the Progressive Wage Model which we currently have in the healthcare system to other groups of healthcare workers. I fully support her proposal. MOH will work with the union on this. We want to retain our healthcare workers and upskill them to provide quality care for our patients.

Mdm Chair, we have made steady progress over the years to provide quality healthcare for all Singaporeans. This is reflected in the improvements in our life expectancy and health outcomes. Credit must go to our committed healthcare workers, who have put in a lot of dedication and hard work to care for their patients. They do it with a caring heart. We must continue to show appreciation for their efforts, support them in their work and also stand by our healthcare workers during difficult times.

For future generations of Singaporeans to continue having affordable, accessible and quality healthcare, we need to transform our care models and keep our healthcare system sustainable.

To succeed, it will require the involvement of all Singaporeans − from individuals, families and the community. It will require changes in habits and behaviours. And, most importantly, it will require all stakeholders to work together in close collaboration and partnership.

The Chairman: We have a bit of time for clarifications. Dr Chia Shi-Lu.

Dr Chia Shi-Lu: Mdm Chair, I have three clarifications. The first concerns the Health Products Act. As I understand it, it now regulates medical devices and cosmetic products and I also understand there have been some public consultations on this about whether it is possible to transfer the control of other pharmaceutical products under this Act. Could I ask the Minister for an update on the status of this transfer and whether it is likely that we will see an amendment to the Act in the near future?

The second clarification concerns this threat of infectious diseases, and it is directed to Minister of State Dr Lam Pin Min. In view of the potential cost of an epidemic, should it occur, do we have provision for a fund to deal with the cost of tackling the epidemic and also the resultant economic cost?

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If we look at the US, for instance, they set up a fund to combat Ebola. Now that the threat has passed, they are porting some money over to combat the threat of Zika and expanding on that fund. So, I am just wondering whether we have a provision for a fund to tackle such public health crises.

The final clarification is with regard to my cut on transparency. I thank the Minister of State for his answer.

The Chairman: Dr Chia, can you keep your clarification short.

Dr Chia Shi-Lu: Yes. Could I just ask if there are any more concrete steps that we can take to, perhaps modulate the cost of private healthcare?

Mr Gan Kim Yong: Madam, let me just address the first clarification on the Health Product Act. Dr Chia is right that we are looking at health product regulations and looking at the pharmaceutical products that are currently regulated under the Medicines Act.

Pharmaceutical products will be ported over to the Health Products Act to be regulated under the Health Products Act as therapeutic products, in addition to the medical devices and cosmetic products that are already under the Health Products Act. This is in line with our plan to update our legislation and to consolidate the regulation of health-related products in one Act for greater clarity.

We have conducted extensive stakeholder engagement. We held two rounds of public consultation recently. The feedback has been supportive and we hope to be able to finalise the review shortly and to bring over the therapeutic products into the Health Products Act by the end of this year.

The Chairman: Mr Low Thia Khiang.

Dr Lam Pin Min: Sorry, Mdm Chair, can I answer the other two questions asked by Dr Chia Shi-Lu?

The Chairman: Yes, please.

Dr Lam Pin Min: I would like to thank Dr Chia Shi-Lu for the two clarifications. I would like to say that we do not have a big war chest fund like in the US. Having said that, MOH does build in contingency requirements into our service contracts to respond to health emergencies. And in the event of a disease outbreak, MOH will reprioritise our budget to ensure that we are able to implement all these control measures.

In addition to that, like I have mentioned in my reply, we do stockpile medical equipment and supplies like our personal protective equipment, anti-microbials and even vaccines, if necessary. I would like to reassure Dr Chia that we take a whole-of-Government approach to tackle disease outbreaks and, if additional funds are needed, we will definitely work with MOF to ensure that there will be sufficient funding support to implement our efforts.

With regard to the second clarification on the control of costs in the private sector, in my speech, I did mention that we have published the professional fees on our MOH website which include total hospitalisation fees both in the public and private sector, the total operation fees in the public sector. And most recently, like I have just announced, we will be publishing the total operation fees of the private hospitals, and this will actually serve as a point of reference for both the healthcare professionals as well as the general public, so that they can make an informed decision.

Minister Gan Kim Yong has also announced the setting up of ACE, and this agency will evaluate the clinical and cost effectiveness of health technologies and all the different expensive treatment modalities.

Thirdly, our healthcare insurance financing features like co-payment and deductibles are built into our MediShield Life as well as some private healthcare plans and this will, hopefully, discourage the "buffet syndrome".

Last but not least, which is the most important, is that I would like to remind all doctors that we are bound by the Singapore Medical Council and Singapore Dental Council's ethical code and ethical guidelines and that we should not abuse the doctor-patient relationship for our own personal gains.

The Chairman: Mr Low Thia Khiang.

Mr Low Thia Khiang: I would like to ask the Minister whether he will require hospitals to publish on their website waiting times for SOCs by medical speciality.

Mr Gan Kim Yong: Madam, we will take onboard the suggestion and study what are the implications. There are pros and cons. From the patients' point of view, whether the data is meaningful or not, is something we need to consider. From the patients' point of view, what we do for SOC services is to prioritise their needs and fix their schedule according to the seriousness of their conditions. For those who have more serious and time-sensitive conditions, we will give them priority.

The published wait time may not mean a lot to them and may create more confusion, because some of them may have to wait longer than the median wait time because their conditions are less critical, and some may have earlier appointments because of their serious conditions. From the patients' point of view, we have to be careful with the data we publish. But we do monitor the wait times at our SOCs for our hospitals. Whether they are published or not, it is a performance indicator that we keep track of.

The Chairman: Ms Tin Pei Ling.

Ms Tin Pei Ling: Madam, I have four clarifications. The first one, just now, Senior Minister of State Amy Khor had mentioned and provided some explanation about the community networks for seniors. I would like to register my very strong interest to have it piloted in MacPherson and, if yes – please say yes – I hope, I would like to ask if there is any room for the local grassroots to be involved in the set up so that we can provide the local context to customise the scope of work for the community network.

At the same time, I am just wondering if the Ministry will also consider establishing something like an eldercare relationship management system so that there is a more systematic way for the different stakeholders to integrate our efforts and to synchronise in how we can reach and better care for our elderly.

Second, I would like to ask whether there is any plan to leverage more on technology to enable ageing-in-place so that our elders in their retirement can live in a more independent manner.

The third query is on the Trim and Fit (TAF) programme. I understand that, in the past, in the schools, there is the TAF programme to encourage the young to be healthier. So, just wondering why this has been discontinued and what is the reason for that.

Lastly, on Zika, just yesterday, there was news from the US that it is worse than it has been previously thought. It affects the entire pregnancy period and so this is quite worrying. I would like to ask what are the measures in place to better protect pregnant women in Singapore. Also, I fear that awareness about Zika in Singapore is still very much lagging, especially compared to dengue.

The Chairman: Ms Tin, can you keep it trim and fit, please?

Ms Tin Pei Ling: Thank you, I will. So, may I ask the Ministry what is it going to do to increase awareness towards Zika?

Dr Amy Khor Lean Suan: I will take the first two. Firstly, on community networks, I would just like to explain that we will be piloting this in about three areas across the island, different regions and also looking at slightly different demographic profiles as well as socio-economic status so that we can learn from the pilots before scaling up. We will try and look at what the gaps are and so on.

With regard to the Member's suggestion about getting grassroots involved, indeed, community networks will involve all stakeholders in the community. It is just that it will be facilitated by a small team of staff together with the various Government agencies, the VWOs, community-based organisations and, of course, including grassroots.

Because we are piloting the project, we will certainly take into account the Member's strong interest in setting up a community network. Let us pilot it and learn from it before we can scale up.

Regarding eldercare relationships, in fact, this is what we have been doing under the Action Plan for Successful Ageing. After learning from implementing the many ground-up ideas, we have put it into a guide and sent it to all the divisions. When we learn through the community networks, we can also put up some of these as guiding principles for use.

Technology for eldercare, certainly. That is why I have said in my speech earlier that there is a National Innovation Challenge where we have made two grant calls and we will be calling for more. The first two are on new models of home-care and enhancing care for dementia.

Along with these, we will be looking at technology, too. In fact, there are some pilots, with regard to technology, say in Marine Parade, where they are piloting a home-monitoring system to monitor the health as well as the lives of the elderly to make sure they are taken care of. If something happens, they can actually alert the senior care centres.

Dr Lam Pin Min: Mdm Chair, I would like to thank Ms Tin Pei Ling for the two clarifications. On the issue of the TAF programme, it was implemented in 1992 and discontinued in 2007. Ms Tin is probably young enough to have either personally experienced the TAF programme or have witnessed her classmates going through it. The objective of the TAF programme is to enable all our overweight and obese students to achieve a healthy weight and while it showed success in reducing obesity rate from 14% to about 9.8% in 2002, MOE did receive quite a number of feedback, both from parents as well as students, that some of the students felt stigmatised by this programme.

Since it was discontinued in 2007, MOE replaced it with a different programme called the Holistic Health Framework (HHF) which is a more holistic approach towards health, rather than just focusing on weight alone. It addresses other aspects of physical health as well as mental and social health. So, that is the reason and the answer to the Member's first clarification.

For the second one on Zika, just like any emerging diseases, including Zika, MOH adopts a three-pronged approach which I have mentioned in my reply. One, to reduce the risk of importation; two, early detection; and three, containment. In reducing the risk of importation, MOH issues travel advisories on affected countries for Singaporeans who are travelling out of Singapore. Even for women who may get pregnant, they are advised strongly not to travel to these affected countries unless there is a strong reason to do so.

To enhance early detection, we have enhanced vigilance amongst our healthcare providers as well as public healthcare institutions. We also have to step up public education amongst the general public about this disease.

If we do have a first case of positive Zika infection, then isolation will be necessary to prevent its spread through the bites on this infected person by the Aedes mosquito. So, we try to contain it. But, of course, not forgetting the good old effective vector control. I think all of us have a part to play in performing the 5-step Mozzie Wipeout routine.

To manage pregnant patients who may be affected by Zika, MOH has also set up a clinical advisory group on Zika virus infection and pregnancy and it comprises obstetricians, public health specialists as well as infectious disease specialists who advise MOH on the different aspects of management of a pregnant patient who may be suspected of being infected with Zika.

So, I want to reassure Ms Tin Pei Ling that MOH will closely monitor the development of Zika infection overseas as well as the development of other potential treatment modalities including vaccines.

The Chairman: Ms Thanaletchimi.

Ms K Thanaletchimi: I have four clarifications to make.

The Chairman: Keep it short, please, since you have four questions.

Ms K Thanaletchimi: Sure, Madam. On healthy living and preventive health, could I check with the Minister if there are any plans to roll out the holistic electronic health record of a Singaporean from birth to school, work and through retirement in a holistic way?

The second clarification is on promoting healthy eating habits. How can we help low-wage and vulnerable workers eat healthily, to have better healthy options for choice, if the cost of healthy choice options is rather high at workplaces or in industry sectors?

The third clarification is whether the Minister would consider reviewing the MediSave withdrawal limit, especially on flexi-MediSave capped at $200, so that those affected patients who are seeking specialist treatment can better manage their chronic disease or illness.

3.30 pm

Lastly, would MOH revive or further explore the possibility of a portable medical benefits scheme which employers can offer workers in the early stage of employment so that workers can carry with them the medical benefit plan even if they were to be retrenched or lose their jobs?

The Chairman: Please keep replies short and succinct as well. Thank you very much. Who is going first?

Mr Gan Kim Yong: Madam, yes, I will try to keep it short. I had been working with the unions and the employers' group when I was in the Ministry of Manpower, to look at the portable medical benefits, and I continue to do so after I have moved over to MOH. I am very supportive of these portable medical benefits and I think it is a great thing. The most portable medical benefit is really MediShield Life. I would encourage employers to think about helping their employees with their MediShield Life, either by topping up their MediSave so that they can use their MediSave top-up to pay for the MediShield Life premiums, or purchase IPs for their employees. These are possibilities, and we do have tax incentives for them. They can claim up to 2% tax deductions for the cost of the portable medical benefits.

I will now ask my colleague, Minister of State Chee Hong Tat, to talk about MediSave withdrawal limits that the Member has asked about, as well as healthy eating habits, how to help the low-wage workers.

On the health records from birth to school, adult and retirement, we have introduced an app called "My Health Hub" which draws data from your personal health records, including your screening and vaccination records from birth to the end of life. So, I would encourage you to download this app which you can carry in your handphone and it is available to you 24/7 all the time. It is something that we are working on and we will continue to enhance this app. This is just a pilot application and it is still at the beta stage. We encourage you to download it, use it and let us have your feedback on how it is working and we will continue to enhance its features to make it useful for individuals. We want to use this to empower our individuals to lead a healthy lifestyle.

Mr Chee Hong Tat: Mdm Chair, I will answer the question on how to encourage our workers to eat healthily, especially our low-wage workers, and also the other question about MediSave.

First, on eating habits. Indeed, we have to find ways to make healthier food options affordable. There are different ways of doing this. In some of the institutions and companies, in their cafeteria or canteen, they do offer healthier options. When I visited Khoo Teck Puat Hospital, they were showing me the food court. They do a few things. First is pricing. If you eat brown rice, it is cheaper than if you eat white rice. It Is not the case in all places, but at the food court in Khoo Teck Puat Hospital, that is the pricing incentive that they give to encourage people to eat healthily. They also give a discount if you order drinks with less sugar. If you order kopi-C, it is more expensive than if you order kopi-C xiu dai, and it is more expensive than if you order kopi-C kosong. So, they try to find different ways to nudge people to eat healthily.

They also use design to try and place the different food items. So, this is not just pricing. It is also about how you encourage good behaviours, eating habits. The economic rice stall, for example, they will put the healthier options at the beginning of the queue, so that when you choose these options, by the end of the queue where some of the less healthy foods are, your plate would be full and, therefore, you may not have as much incentive, desire or temptation to order the less healthy food.

Through this combination of ways, they are trying to help the visitors, patrons and also their own staff to eat more healthily. We need to work with employers. We also need the help of the unions and our Labour Movement to help us to work together to try and encourage all Singaporeans, including our workers, to eat healthily.

Ms Thanaletchimi also asked about MediSave. Today, we have a withdrawal limit of $400 per person for management of chronic diseases. In 2014, when we looked at the amount, it was sufficient for the majority of patients. For eight in 10 patients, this amount was sufficient. But in certain cases where the need may be greater, they can actually share with their spouse. So, it is not just your own individual account. You can use it to help your spouse. This also gives greater flexibility in cases where they need a little bit more.

Very importantly, while we look at ways to provide more flexibility through the use of MediSave, we must also bear in mind that MediSave, at the end, is also used for long-term healthcare needs when we grow old. It is used to pay for our healthcare costs and to pay for our insurance premiums, including MediShield Life premiums. So, there is a need to strike a balance. But we will look at ways to try and make it flexible for people to use and to keep the cost affordable for chronic disease management.

The Chairman: Mr Leon Perera.

Mr Leon Perera: Madam, just two brief clarifications and I will keep it short. One, for the Minister, is whether the Ministry will consider the suggestion I made to publish the waiting times separately for walk-in versus appointment for polyclinics, and to lower the key performance indicator from 100 minutes to 45 minutes.

My second clarification point is to Minister of State Chee Hong Tat regarding the outreach efforts to companies through health talks and healthy living promotion. One of the best ways to reach out to adults is through their employers. I know HPB does programmes, such as screening and talks, with large employers. But the SMEs often get left out. What more will HPB be doing to reach out to SMEs to conduct this kind of programmes, perhaps working together with the trade associations and chambers?

Mr Gan Kim Yong: Madam, I may take a little bit longer. Usually, I try not to reject ideas and suggestions, so we will consider Mr Leon Perera's suggestion carefully and see whether we could enhance our indicators and publish the wait times for both appointments and walk-ins.

In saying that, I should also clarify that in the primary sector, such as polyclinics that the Member was referring to, we have more critical issues at hand because we are in the process of restructuring the whole primary care sector, as Dr Lam has outlined. Over time, we should look at primary care not just between polyclinics and GPs. In primary care, polyclinics and private GPs should work together. We have also introduced Family Medicine Clinics which are still in the pilot phase. We have six or seven of them and we hope to expand and have more. They play a very important role.

We are in the process of restructuring and revamping the primary care sector. Our indicators and performance targets have to be in line with the new model that we are evolving. We will take on board the Member's suggestion and study very carefully but, at the same time, bear in mind that the sector is going through a transformation.

This is not just between polyclinic and GPs. We are also trying to integrate SOCs with primary care, so that we minimise the need to refer cases to the SOCs and to also facilitate discharge of SOC patients to primary care, so that they can be taken care of in a primary care setting.

One example is orthopaedics. In orthopaedics today − I think Dr Chia Shi-Lu would be very familiar with − primary care and polyclinic patients cannot have direct access to physiotherapy without being referred to orthopaedic specialists because we are concerned about the missed-diagnosis. But we have developed protocols to facilitate primary care doctors to make a preliminary diagnosis and, in many cases, you do not require the services of a specialist and you can refer patients directly to a physiotherapist.

This is still at the pilot stage. We want to try it out to see whether this works well for us. If it does, we will encourage more in the primary sector to take on this responsibility.

In doing so, you will find that between GPs and polyclinic, between primary care and specialist care, it is going to be more and more integrated. The indicators that we use will also have to take that into account. How do we measure the outcome, not in a segmented way, each individual department's or setting's performance, but an integrated performance measurement? It is something that is evolving, and we will consider the Member's suggestions and incorporate some of them.

The Chairman: Dr Lily Neo.

Dr Lily Neo: Mdm Chair, one clarification, please. Madam, may I first declare that my two children are doctors with MOH.

My clarification is on the expansion of healthcare demand which the Minister spoke about earlier. May I ask the Minister whether he will prioritise the traineeship of Singapore Core doctors? Are there sufficient resources given to this area? For long-term benefits and future needs, will the Minister not curtail, for whatever reasons, the specialist training of local doctors? May I also ask how many private specialist doctors are being employed in our public hospitals and is it not better to train our local doctors to fill these positions rather than employing foreign specialist doctors in our public hospitals?

The Chairman: May I remind Members that we only have two minutes left.

Mr Gan Kim Yong: Madam, I will keep it short. Our priority is to train our own doctors, to provide them with opportunities to go into specialist training if they are able to. But we do also want to ensure that there are sufficient numbers of local doctors that go into family medicine because family medicine is going to play an increasingly important role. As I explained just now, family medicine will play a very important role in our review of primary care. Therefore, we want to encourage our doctors to pursue further education, both in specialist as well as family medicine training.

Having said that, despite the expansion in the pipeline, expansion in our training capacity, we will still need to look at the need of supplementing our local manpower with foreign trained manpower. The first part of foreign trained manpower is our own Singaporeans who are trained overseas. We have a lot of programmes to reach out to them, including our Pre-employment Grant (PEG), where we work with our students who are receiving training overseas to attract them back to Singapore to serve in our public sector.

Our greatest allies are the parents because the parents do want their children to return. So, we work with them to bring them back. I have one parent who came to me to say, "Can you please give my son the PEG? I will fund you, but make sure he signs the contract to come back." We do go out of our way to reach out to them, engage them, provide them with the opportunity to return. In between their studies, if there are opportunities, we will also want to bring them back for internship, training and so on, so that they remain connected to Singapore. We hope to be able to do more of this, going forward.

The Chairman: End of clarification time. Do you wish to withdraw your amendment, Dr Chia Shi-Lu?

Dr Chia Shi-Lu: Mdm Chair, I would like to thank all Members who have contributed to the lively and considered debate. I am certain the feedback and suggestions will be useful as we work to strengthen our healthcare system. On behalf of Members, I would like to thank the tireless staff of MOH and, of course, Minister Gan, Senior Minister of State Amy Khor, Minister of State Lam Pin Min and Minister of State Chee Hong Tat for their meticulous replies and clarifications. I would be very happy to proffer them all a cup of teh-O kosong or kopi-O kosong for all their efforts! So, Mdm Chair, I beg leave to withdraw my amendment.

Amendment, by leave, withdrawn.

The sum of $9,202,218,100 for Head O ordered to stand part of the Main Estimates.

The sum of $1,797,678,900 for Head O ordered to stand part of the Development Estimates.

The Chairman: Order. I propose to take the break now.

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

Mdm Speaker: Order. I suspend the Sitting and will take the Chair at 4.05 pm.

Sitting accordingly suspended

at 3.45 pm until 4.05 pm.

Sitting resumed at 4.05 pm

[Mdm Speaker in the Chair]